Texas Renewal Bundle

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The following course content

This Texas License Renewal Bundle meets the Continuing Nursing Education renewal requirements for Texas LVNs and RNs and is accepted for APRNs as well. Upon completion of this course, you will receive a certificate of completion for 20 contact hours of CNE.

This course is accredited and approved by American Nurses Credentialing Center (ANCC) (Provider Number: P0614) and includes multiple interesting topics in one easy course.

The Texas Human Trafficking Requirement is NOT met by this bundle.
The Texas Health and Human Services provides a Board-Approved Human Trafficking course free of charge. This course can be found here.

Course Outline

1. Texas Nursing Jurisprudence and Ethics (Meets TX BON Requirement)
2. Texas Nursing Forensics (Meets TX BON Requirement)
3. End of Life Care for Geriatric Patients (Meets TX BON Requirement) 
4. Key Concepts of Critical Thinking in Nursing
5. Effective Communication in Nursing
6. Ensuring Patient Confidentiality in Nursing
7. Nursing Documentation 101
8. Nursing Ethics
9. Infection Control and Barrier Precautions

Texas Nursing Jurisprudence and Ethics

Introduction - Texas Nursing Jurisprudence and Ethics

The purpose of this course is to review nursing ethics and jurisprudence specifically as these relate to Texas state nursing practice and law (1). Each state nursing board works to promote the safety and welfare of clients in their state by ensuring nurses are competent to practice nursing safely.

As outlined by the Texas Board of Nursing continuing education requirements, Nursing Jurisprudence and Nursing Ethics Board Rule 216.3, all nurses, including APRNs, must complete the required two contact hours of CNE relating to nursing jurisprudence and ethics before the end of every third two-year licensing period. This requirement applies to licensing periods that began on or after January 1, 2014. All new nurses must also pass the Nursing Jurisprudence Exam (NJE) (2,3). 

Requirements also outline that education includes information related to the Texas Nursing Practice Act, the Board's rules, including Standards of Nursing Practice, the Board's position statements, principles of nursing ethics, and professional boundaries. Nurses are named in negligence and malpractice lawsuits that may claim unethical behavior/conduct, practice outside the scope of licensure, or lack of nursing supervision. Nurses must understand their state nurse practice act, scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries to avoid litigation (2). 

The Texas Nursing Practice Act – Overview 

Registered Nurse Scope of Practice 

The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RNs) (4). "Professional nursing" means performing an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves: (4) 

• the observation, assessment, intervention, evaluation, rehabilitation, care, and Counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes. 
• The maintenance of health or prevention of illness. 
• A physician, podiatrist, or dentist orders medication administration or treatment. 
• The supervision or teaching of nursing. 
• The administration, supervision, and evaluation of nursing practices, policies, and procedures. 
• The requesting, receiving, signing for, and distributing prescription drug samples to patients at practices where an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157. 
• The performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059. 
• The development of the nursing care plan. 

The RN accepts responsibility for practicing within the legal scope of practice, is prepared to work in all healthcare settings, and may engage in independent nursing practice without supervision by another healthcare provider. The RN, focusing on patient safety, must function within the legal scope of practice and by the federal, state, and local laws, rules and regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN provides safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs (5). 

Texas Nursing Jurisprudence and Ethics - Board Rules 

Texas Board of Nursing, Chapter 217, Rule §217.11, Standards of Nursing Practice (6) 

The Texas Board of Nursing regulates nursing practice within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted (6). 

• Standards Applicable to All Nurses. All vocational nurses, registered nurses, and registered nurses with advanced practice authorization shall: 
  • Know and conform to the Texas Nursing Practice Act, the Board's rules and regulations, and all federal, state, or local laws, rules, or regulations affecting the nurse's current area of nursing practice. 
  • Implement measures to promote a safe environment for clients and others. 
  • Know the rationale for and the effects of medications and treatments and shall correctly administer the same.

•  Accurately and completely report and document: 
  • The client's status, including signs and symptoms, is as follows: 
  • Nursing care rendered. 
  • Physician, dentist, or podiatrist orders. 
  • Administration of medications and treatments. 
  • client response(s). 
  • contacts with other healthcare team members concerning significant events regarding the client's status. 

• Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information. 
• Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs. 
• Obtain instruction and supervision as necessary when implementing nursing procedures or practices. 
• Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations. 
• Notify the appropriate supervisor when leaving a nursing assignment. 
• Know, recognize, and maintain professional boundaries of the nurse-client relationship. 
• Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nursing Practice Act), Subchapter I, which includes reporting a nurse: 
  • Who violates the Nursing Practice Act or a board rule and contributed to the death or severe injury of a patient. 
  • Whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse? 
  • Whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries. 
  • Whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. 
  • Except for minor incidents (Texas Occupations Code §§301.401(2), 301.419, 22 TAC §217.16), peer review (Texas Occupations Code §§301.403, 303.007, 22 TAC §217.19), or peer assistance if no practice violation (Texas Occupations Code §301.410) as stated in the Nursing Practice Act and Board rules (22 TAC Chapter 217). 

• Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served. 
• Institute appropriate nursing interventions that might be required to stabilize a client's condition and prevent complications. 
• Clarify any order or treatment regimen the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse decides not to administer the medication or treatment. 
• Implement measures to prevent exposure to infectious pathogens and communicable conditions. 
• Collaborate with the client, members of the health care team, and, when appropriate, the client's significant other(s) in the interest of the client's health care. 
• Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care. 
• Be responsible for one's continuing competence in nursing practice and individual professional growth. 
• Make assignments to others that consider client safety and are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made. 
• Accept only those nursing assignments that consider client safety and are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability. 
• Supervise nursing care provided by others for whom the nurse is professionally responsible. 
• Ensure the verification of current Texas licensure or other Compact State licensure privileges and credentials of personnel for whom the nurse is administratively responsible when acting in the role of nurse administrator. 

• Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: 
  • Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: 
    • Collecting data and performing focused nursing assessments. 
    • Participating in the planning of nursing care needs for clients. 
    • Participating in developing and modifying the comprehensive nursing care plan for assigned clients. 
    • Implementing appropriate aspects of care within the LVN's scope of practice. 
    • Assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs. 

• • Shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. 
  • May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. 

• Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: 
  • Utilize a systematic approach to provide individualized, goal-directed nursing care by: 
  • Performing comprehensive nursing assessments regarding the health status of the client. 
  • Making nursing diagnoses serves as the basis for the care strategy. 
  • Developing a plan of care based on the assessment and nursing diagnosis. 
  • Implementing nursing care. 
  • Evaluating the client's responses to nursing interventions. 

• • Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute environments, and Chapter 225, relating to independent living environments for clients with stable and predictable situations. 

• Standards Specific to Registered Nurses with Advanced Practice Authorization. Standards for a specific role and specialty of advanced practice nurses supersede standards for registered nurses where conflict between the standards, if any, exists. In addition to paragraphs (1) and (3) of this subsection, a registered nurse who holds authorization to practice as an advanced practice nurse (APN) shall: 
  • Practice in an advanced nursing practice role and specialty by the authorization granted under Board Rule Chapter 221 of this title (relating to practicing in an APN role; 22 TAC Chapter 221) and standards set out in that chapter. 
  • Prescribe medications in accordance with the prescriptive authority granted under Board Rule Chapter 222 of this title (relating to APNs prescribing; 22 TAC Chapter 222) and standards set out in that chapter and compliance with state and federal laws and regulations relating to the prescription of dangerous drugs and controlled substances. (4) 

The Board's Position Statements 

15.28 The Registered Nurse Scope of Practice (See also the LVN Scope of Practice) (7) 

The Board of Nursing recommends that all nurses utilize the Scope of Practice Decision-Making Model (DMM) when deciding if an employer's assignment is safe and legally within the nurse's scope of practice (8). 

The Texas Board of Nursing (BON or Board) is authorized by the Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely. The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RN) (4, 9).  

The RN takes responsibility and accepts accountability for practicing within the legal scope of practice, is prepared to work in all healthcare settings, and may engage in independent nursing practice without supervision by another healthcare provider. With a focus on patient safety, the RN must function within the legal scope of practice and in accordance with federal, state, and local laws, rules, and regulations. In addition, the RN must comply with policies, procedures, and guidelines of the employing health care institution or practice setting. The RN provides safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs (9). 

This position statement aims to provide direction and recommendations for nurses and their employers regarding the safe and legal scope of practice for RNs and to promote an understanding of the differences in the RN programs of study and between the RN and LVN levels of licensure. The LVN scope of practice is interpreted in Position Statement (9). 

Every nursing education program in Texas must ensure that their graduates exhibit competencies outlined in the Board's Differentiated Essential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgements, and Behaviors. These competencies are included in the program of study so that every graduate has the knowledge, clinical judgment, and behaviors necessary for RN entry into safe, competent, and compassionate nursing care. The DECs serve as a guideline for employers to assist RNs in transitioning from the educational environment into nursing practice. As RNs enter the workplace, the DECs are the foundation for developing the RN scope of practice (9). 

Completion of ongoing, informal continuing nursing education offerings and on-the-job training in an RN's area of practice serves to develop, maintain, and expand competency. Because the RN scope of practice is based upon the educational preparation in the RN program of study, there are limits to expanding the scope. The Board believes that successfully transitioning from one level of nursing practice to another requires the nurse to complete a formal education program. (10) 

The RN Scope of Practice 

The professional RN advocates for the patient and the patient's family and promotes safety by practicing within the NPA and the BON Rules and Regulations. The RN provides nursing services that require substantial specialized judgment and skill. The planning and delivery of professional nursing care are based on knowledge and application of biological, physical, and social science principles as acquired by a completed course of study in an approved school of professional nursing. Unless licensed as an advanced practice registered nurse, the RN's scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. RNs utilize the nursing process to establish the plan of care in which nursing services are delivered to patients. The level and impact of the nursing process differ between the RN and LVN, as well as the levels of RN education (9). 

Assessment 

The comprehensive assessment is the first step and lays the foundation for the nursing process. The thorough evaluation is the initial and ongoing, extensive data collection, analysis, and interpretation. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care (9). 

 Based upon the comprehensive assessment, the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and knowledge synthesis. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determine when reassessments are needed (9). 

Patient Diagnosis/Problem Identification/Planning 

The second step in the nursing process is nursing diagnosis and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team (9). 

The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, make nursing diagnoses, and formulate goals, teaching plans, and outcomes. A nursing plan of care for patients is developed by the RN, who is responsible for coordinating nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and risk factors prevention. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary healthcare team during the planning process (9).  

Implementation 

Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate specific interventions within the care plan for patients within legal, ethical, and regulatory parameters and consider health restoration, disease prevention, wellness, and promotion of healthy lifestyles (9).  

The RN's duty to patient safety when making assignments to other nurses or delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN's scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual's performance and activity. The RN may have to directly observe and evaluate the nursing care provided depending on the LVN's skills and competence, patient conditions, and level of urgency in emergent situations (9).  

The RN may determine when to delegate tasks to unlicensed personnel and maintain accountability for how they perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision depends upon patient conditions and the skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. (10,11) 

Evaluation and Reassessment 

A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions compared to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the care plan are necessary (9). 

Essential Skills Used in the Nursing Process 

Communication 

Communication is an essential and fundamental component used during the nursing process. The RN must communicate verbally, in writing, or electronically with healthcare team members, patients, and their families in all aspects of the nursing care provided to patients. The patient record or nursing care plan must appropriately document these communications. Because RNs plan, coordinate, initiate, and implement a multidisciplinary team's approach to patient care, collaboration is crucial to communication. When patient conditions or situations exceed the RN's level of competency, the RN must be prepared to seek out other RNs with greater competency or other health care providers with differing knowledge and skillsets and actively cooperate to ensure patient safety (9).  

Clinical Reasoning 

Clinical reasoning is another integral component of the nursing process. RNs use critical thinking skills to problem-solve and make decisions in response to patients, their families, and the healthcare environment. RNs are accountable and responsible for the quality of nursing care provided and must exercise prudent and professional nursing judgment to ensure the standards of nursing practice are always met (9). 

Employment Setting 

When an employer hires an RN to perform a job, the RN must ensure that it is safe and legal. Caution must be exercised to stay within the legal parameters of nursing practice when an employer may not understand the limits of the RN's scope of practice and makes an assignment that is not safe. Before engaging in an activity or assignment, the RN must determine whether he or she has the education, training, skill, competency, and physical and emotional ability to carry out the activity or assignment safely. The RN must always provide patients with safe, compassionate, and comprehensive nursing care (9).  

Summary of RN Scope of Practice 

The RN, with a focus on patient safety, must function within the legal scope of practice and by the federal, state, and local laws, rules and regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN functions under his or her license and assumes accountability and responsibility for the quality of care provided to patients and their families according to the standards of nursing practice. The RN demonstrates responsibility for continued competence in nursing practice and develops insight through reflection, self-analysis, self-care, and lifelong learning (9).  

The table below offers a brief synopsis of how the scope of practice for nurses differs based on educational preparation and level of licensure. These are minimum competencies but also set limits on what the LVN or RN can do at his or her given level of licensure, regardless of experience (9). 

Synopsis of Differences in Scope of Practice for Licensed Vocational, Associate, Diploma and Baccalaureate Degree Nurses (10) 

Synopsis of Differences in Scope of Practice for Licensed Vocational, Associate, Diploma and Baccalaureate Degree Nurses (4) 

Nursing board Position Statements are not laws, but they provide direction for nurses on issues of concern to the Board relevant to public protection. These Position Statements are reviewed annually for relevance and accuracy to current practice, the Nurse Practice Act, and Board of Nursing rules. Examples of Position Statements include the following: (9) 

• Nurses Carrying out Orders from Physician Assistants 
• Role of the Licensed Vocational Nurse in the Pronouncement of Death 
• LVNs Engaging in IV Therapy, Venipuncture, or PICC Lines 
• Educational Mobility 
• Nurses with Responsibility for Initiating Physician Standing Orders 
• Board Rules Associated with Alleged Patient "Abandonment" 
• The Role of LVNs & RNs in the Management and Administration of Medications via Epidural or Intrathecal Catheter Routes 
• The Role of the Nurse in Moderate Sedation 
• Performance of Laser Therapy by RNs or LVNs 
• Continuing Education: Limitations for Expanding Scope of Practice 
• Delegated Medical Acts 
• Use of American Psychiatric Association Diagnoses by LVN, RNs, or APRNs 
• Role of LVNs & RNs As School Nurses 
• Duty of a Nurse in any Practice Setting 
• Board's Jurisdiction Over a Nurse's Practice in Any Role and Use of the Nursing Title 
• Development of Nursing Education Programs 
• Texas Board of Nursing/Board of Pharmacy Joint Position Statement on Medication Errors 
• Nurses Carrying Out Orders from Advanced Practice Registered Nurses (APRN) 
• Nurses Carrying Out Orders from Pharmacists for Drug Therapy Management 
• Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long-Term Care Facility (9) 

Principles of Texas Nursing Jurisprudence and Ethics 

Professional Boundaries 

15.29 Professional Boundaries including use of social media by nurses (11) 

The purpose of this Position Statement is to guide nurses regarding expectations related to professional boundaries, including social media, and to provide nurses with guidance to prevent boundary violations (5). 

In keeping with its mission to protect public health, safety, and welfare, the Texas Board of Nursing (BON or Board) holds nurses accountable for knowing, recognizing, and maintaining professional boundaries of the nurse-patient/client relationship. The term professional boundaries is defined as the appropriate limits that the nurse should establish in the nurse/client relationship due to the nurse's power and the patient's vulnerability. Professional boundaries refer to the provision of nursing services within the limits of the nurse/client relationship, which promote the client's dignity, independence, and best interests and refrain from inappropriate involvement in the client's relationships and the obtainment of the nurse's gain at the client's expense (5). 

The National Council of State Boards of Nursing (NCSBN) defines professional boundaries as the spaces between the nurse's power and the patient's vulnerability. The nurse's power comes from the nurse's professional position and access to sensitive personal information. The difference in personal information the nurse knows about the patient versus the personal information the patient knows about the nurse creates an imbalance in the nurse-patient relationship. Nurses should respect the power imbalance and ensure a patient-centered relationship (5). 

Common to the definition of professional boundaries from the Texas Board of Nursing and the NCSBN is that a nurse abstains from personal gain at the client's expense and refrains from inappropriate involvement with the patient or the patient's family (5). 

Duty of a Nurse in Maintenance of Professional Boundaries 

There is a power differential between the nurse and the patient. The patient depends on the nurse's knowledge and relies on the nurse to advocate for the patient and ensure actions are taken in the patient's best interest. The nurse must protect the patient, establishing and maintaining professional boundaries in the nurse-patient/client relationship. Under or over-involvement can harm the patient and may interfere with the nurse-patient relationship. Visualizing the two ends of the spectrum may assist the nurse in knowing, recognizing, and maintaining the professional boundaries of nurse-patient relationships (5). 

Patients each have their own unique needs and abilities. The boundary line for any one patient may change over time and may not be the same as the boundary line for another patient. It is up to the nurse to assess and recognize the patient's needs, adjusting the nursing care accordingly. Every nurse is responsible for knowing, identifying, and maintaining the professional boundaries of the nurse-client relationship (5). 

Boundary Violations 

A violation of professional boundaries is one element of the definition of "conduct subject to reporting [Tex. Occ.Ide Sec. 301.401(1)(C)]. A professional boundary violation is also considered unprofessional conduct [22 TAC §217.12 (6)(D)]. Some of the specific categories of professional boundary violations include but are not limited to, physical, sexual, emotional, or financial boundary violations (5). 

Use of Social Media and the Protection of Health Information 

Social media and other electronic communication are expanding exponentially as the number of social media outlets, platforms, and applications available continues to increase. Nurses play a significant role in identifying, interpreting, and transmitting knowledge and information within healthcare. As technological advances expand connectivity and communication, rapid knowledge exchange and dissemination can pose risks to patients and nurses. While the Board recognizes that using social media can be a valuable tool in healthcare, there are potentially severe consequences if misused. A nurse's use of social media may cause the nurse to unintentionally blur the lines between the nurse's professional and personal life (5). 

Online postings may harm patients if protected health information is disclosed. In addition, social media postings may reflect negatively on individual nurses, the nursing profession, the public's trust in the nursing profession, or the employer and may jeopardize careers. In an NCSBN survey, many responding boards reported receiving complaints about nurses misusing social media sites. The survey results indicated that boards fired by employers have disciplined nurses and are criminally charged for the inappropriate or unprofessional use of social media (5). 

To ensure the mission to protect and promote the welfare of the people of Texas, the Texas Board of Nursing supports the guidelines and principles of social media use by the NCSBN and the American Nurses Association. By the NCSBN guidelines and Board rules, it is the Board's position that (5): 

Nurses have an ethical and legal obligation to maintain patient privacy and confidentiality. When using social media, nurses do not identify patients by name or post or publish information that may lead to patient identification. Limiting access to postings through privacy settings is not sufficient to ensure privacy. Nurses must promptly report any identified breach of confidentiality or privacy (5). 

Nurses maintain professional boundaries in the use of electronic media. The nurse must establish, communicate, and enforce professional boundaries with patients online. Nurses do not refer to patients disparagingly, even if the patient is not identified, or transmit information that may be reasonably anticipated to violate patient rights to confidentiality or privacy or otherwise degrade or embarrass the patient (5). 

Nurses must provide nursing services without discrimination and not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic, or other offensive comments (5). 

Nurses must be aware of and comply with all laws and rules, including employer policies regarding using electronic devices, including employer-owned computers, cameras, and personal devices. In addition, nurses must ensure appropriate and therapeutic use of all patient-related electronic media, including patient-related images, photos, or videos, by applicable laws, rules, and institutional policies and procedures (5). 

The use of social media can be of tremendous benefit to nurses and patients alike, for example, the dissemination of public safety announcements. However, nurses must know the potential consequences of disclosing patient-related information via social media. Nurses must always maintain professional standards, boundaries, and compliance with local, state, and federal laws. All nurses must protect their patients' privacy and confidentiality, which extends to all environments, including social media (5). 

The following are ways to avoid problems when using social media: 

• Never post any healthcare-related images, client information, or even general client information 
• Only use your organization's name or a client or family member's name to post content about or speak for your employer if your organization authorizes you to follow their specific policy and procedures. 
• Never post comments about a client, even if the client is not named. 
• Never post photos or videos of your healthcare organization or clients  
• Never post any comments about your employer or other team members 
• Never use obscenity, profanity, racial slurs, sexually inappropriate comments, homophobic comments, threats, harassing/abusive language, or any other offensive comments. Never post any image that contains the above content. 

Prevention of Boundary Violations 

The ability of a client to rely on employees as concerned and caring individuals who remain objective in their guidance is one of the tents of a safe, therapeutic relationship. The relationship may no longer be objectively therapeutic when staff interacts with patients personally. Accepting gifts, financial transactions, and romantic entanglement could lead to various negative consequences for an organization, employee, or client. Many organizations enforce a non-fraternization policy between employees and current or former clients. While there are exceptions, the expectation is that employees are not to establish a personal relationship with a current or former client. Organizations do recognize that there are times when peers, friends, family, or neighbors of employees seek treatment. In these circumstances, the relationship must remain the nature it was before admission if in the client's best interest, and the treatment plan should address the relationship to best meet the client's therapeutic needs. Employees should also notify a supervisor when an individual with whom he or she has a relationship is admitted for treatment (5). 

Texas Nurses are required to comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 NPA Subchapter I, which include reporting a nurse (11): 

• Who violates the NPA or a board rule and contributed to the death or severe injury of a patient.  
• Whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse?  
• Whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries.  
• Whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.  

The exception is for minor incidents, peer review, or peer assistance if there is no practice violation as stated in the Nursing Practice Act and Board rules (6, 11).  

Organizations also take many precautions to ensure appropriate employee-client relationships, including (13):   

• Criminal background checks of employees 
• Employee, student, and volunteer education regarding therapeutic boundaries and issues and consequences of any violations 
• Mandatory, supportive, and confidential reporting of any violation 

Employee supervision also includes the identification of early signals that an employee may be crossing therapeutic boundaries and the institution of appropriate interventions. Employees educate clients regarding the importance of maintaining a therapeutic relationship and proper boundaries. Organizations work to ensure adequate supervision of staff and appropriate supervision of clients, such as increased observation or same-gender staff working with a client when appropriate (13). 

There must be mandatory reporting by any employee who becomes aware of a boundary violation. The employee should report this immediately to their supervisor, who will evaluate the nature and severity of the claim and initiate an investigation of the situation. In conjunction with Human Resources and Risk Management, the immediate supervisor will determine whether an accused employee should be put on immediate leave pending investigation results and whether mandatory reporting of the allegations to outside agencies is required. Legal Counsel may also be consulted when necessary. An employer may not suspend or terminate employment or otherwise discipline, retaliate, or discriminate against a person who reports, in good faith, or advises a nurse of the nurse's rights and obligations (5, 9, 11, 12).

Unprofessional Conduct - Rule §217.12 

The following unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify behaviors in the practice of nursing that are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (all from 5) 

1.Unsafe practice – actions or conduct including, but not limited to: 

- Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of a minimum acceptable level of nursing practice set out in §217.11 of this chapter. 

- Failing to conform to generally accepted nursing standards in applicable practice settings. 

- Improper management of client records. 

- Delegating or assigning nursing functions or a prescribed health function when the delegation or assignment could reasonably be expected to result in unsafe or ineffective client care. 

- Accepting the assignment of nursing functions or a prescribed health function when the acceptance of the assignment could be reasonably expected to result in unsafe or ineffective client care. 

- Failing to supervise the performance of tasks by any individual working pursuant to the nurse's delegation or assignment. 

- Failure of a clinical nursing instructor to adequately supervise or to assure adequate supervision of student experiences. 

2. Failure of a chief administrative nurse to follow standards and guidelines required by federal or state law or regulation or by facility policy in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible. 

3. Failure to practice within a modified scope of practice or with the required accommodations, as specified by the Board in granting an encumbered license or any stipulated agreement with the Board. 

4. Conduct that may endanger a client's life, health, or safety. 

5. Inability to Practice Safely – a demonstration of actual or potential inability to practice nursing with reasonable skill and safety to clients by reason of illness, use of alcohol, drugs, chemicals, or any other mood-altering substances, or as a result of any mental or physical condition. 

6. Misconduct – actions or conduct that include, but are not limited to: 

- Falsifying reports, client documentation, agency records, or other documents. 

- Failing to cooperate with a lawful investigation conducted by the Board. 

- Causing or permitting physical, emotional, or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing Board. 

- Violating professional boundaries of the nurse/client relationship including but not limited to physical, sexual, emotional, or financial exploitation of the client or the client's significant other(s). 

- Engaging in sexual conduct with a client, touching a client in a sexual manner, requesting, or offering sexual favors, or language or behavior suggestive of the same. 

- Threatening or violent behavior in the workplace. 

- Misappropriating, in connection with the practice of nursing, anything of value or benefit, including but not limited to, any property, real or personal of the client, employer, or any other person or entity, or failing to take precautions to prevent such misappropriation. 

- Providing information, which was false, deceptive, or misleading in connection with the practice of nursing. 

- Failing to answer specific questions or providing false or misleading answers in a licensure or employment matter that could reasonably affect the decision to license, employ, certify, or otherwise utilize a nurse. 

- Offering, giving, soliciting, or receiving, or agreeing to receive, directly or indirectly, any fee or other consideration to or from a third party for the referral of a client in connection with the performance of professional services. 

7. Failure to pay child support payments as required by the Texas Family Code §232.001, et seq. 

8. Drug diversion – diversion or attempts to divert drugs or controlled substances. 

9. Dismissal from a board-approved peer assistance program for noncompliance and referral by that program to the Board. 

10. Other drug-related actions or conduct that include, but are not limited to: 

- Use of any controlled substance or any drug, prescribed or unprescribed, or device or alcoholic beverages while on duty or on call and to the extent that such use may impair the nurse's ability to safely conduct to the public the practice authorized by the nurse's license. 

- Falsification of or making incorrect, inconsistent, or unintelligible entries in any agency, client, or other record pertaining to drugs or controlled substances. 

- Failing to follow the policy and procedure in place for the wastage of medications at the facility where the nurse was employed or working at the time of the incident(s). 

- A positive drug screen for which there is no lawful prescription. 

- Obtaining or attempting to obtain or deliver medication(s) through means of misrepresentation, fraud, forgery, deception and/or subterfuge. 

11. Unlawful practice – actions or conduct that include, but are not limited to: 

- Knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of vocational, registered, or advanced practice nursing. 

- Violating an order of the Board, or carelessly or repetitively violating a state or federal law relating to the practice of vocational, registered, or advanced practice nursing, or violating a state or federal narcotics or controlled substance law. 

- Aiding, assisting, advising, or allowing a nurse under Board Order to violate the conditions set forth in the Order. 

- Failing to report violations of the Nursing Practice Act and/or the Board's rules and regulations. 

12. Leaving a nursing assignment, including a supervisory assignment, without notifying the appropriate personnel. 

There is a Texas State Board of Nursing Disciplinary Matrix that nurses can review to see the process followed when a review of a nurse's conduct is necessary. The Board will consider public safety, the seriousness of the violation, and any aggravating or mitigating factors. Other factors considered include the presence of multiple violations, prior violations, and costs which could result in a more severe disciplinary action. (13) 

Provisions of the Code of Ethics for Nurses 

Provision 1 

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. (1) 

Provision 2 

The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. (1) 

Provision 3 

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. (1) 

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. (1) 

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. (1)  

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. (1)  

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. (1)  

Provision 8 

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. (1)  

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. (1) 

Case Study 

Rachel is a 13-year-old adolescent female client admitted to an inpatient behavioral health unit for bipolar disorder, alcohol and marijuana abuse, and borderline personality disorder. The client has a history of sexual promiscuity, lying, and has alleged abuse and rape by history. Rachel approaches the Charge RN at bedtime, saying that an employee and she "have been having sex" many times over the course of two weeks and that she realizes now that "she should have told someone". The alleged employee is currently on duty.

As Charge RN, using what you learned about Texas Nursing Jurisprudence and Ethics, how would you respond, and what are your next steps?

Conclusion - Texas Nursing Jurisprudence and Ethics

When a nurse is named in a negligence or malpractice lawsuit, it can create stress for the client, the employee, and the employer. A nurse maintaining professional, ethical, and jurisprudent conduct will help to ensure standards of practice are consistently followed. Maintaining appropriate boundaries with clients at all times helps maintain a therapeutic employee-client relationship.

It is important that nurses understand their state nurse practice act, the scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries in order to maintain professionalism, meet performance standards, and avoid a breach of duty, injury, and litigation. 

Resources 

Educational Requirements:
Texas Board of Nursing (2010), Differentiated Essential Competencies (DECs) of graduates of Texas Nursing Programs. (12) 

Texas Occupations Code, Chapter 301 (12) 

Nursing Practice Act (NPA) Section 301.002, Definitions (12) 

Rule 217.11 - Standards of Nursing Practice (12) 

Scope of Practice Position Statements: (12) 

• Position Statement 15.28 The Registered Nurse Scope of Practice Web version for viewing 
• Position Statement 15.14 - Duty of a Nurse Web version for viewing 
• Position Statement 15.14 - Duty of a Nurse - HHSC/DADS/BON poster 

For the complete list of position statements, click here. (12) 

Texas Nursing Forensics

Statistical Evidence 

National Statistics 

According to the Rape Abuse and Incest National Network (RAINN) (1), every 68 seconds someone is sexually assaulted in the United States, and every nine minutes, that victim is a child (1). Only 25 out of every 1,000 perpetrators will end up in prison (1).in less than every 80 seconds, a person is sexually assaulted. In 2015 the Texas Statewide Sexual Assault Prevalence Study found that 33.2% of adult Texans or 413,000 individuals reported having been sexually assaulted at some point during their lives (2).  

Each year in the United States (1):  

• 80,600 inmates are sexually assaulted or raped 
• 60,000 children were victims of “substantiated or indicated” sexual abuse 
• 433,648 people 12 and older were sexually assaulted or raped 
• 18,900 military personnel experienced unwanted sexual contact 
• 1 out of every 6 women have been the victim of attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted) 
• 1 in 3 men have experienced an attempted or completed rape in their lifetime 
• More women and children are sexually assaulted than men, and that girls under 18 years of age are at the highest risk. According to RAINN (1), men and boys, especially college-aged, are also at risk with transgender students at the highest risk of this group. 

Most common locations where sexual assault occurs in the U.S. (1): 

• 55% at or near the victim’s home 
• 15% in an open public space 
• 12% at or near a relative’s home 
• 10% in an enclosed but public area (i.e. parking garage or lot) 
• 8% on school property 

Activities the victims were doing when they were assaulted (1): 

• 48% were sleeping or performing another activity at home 
• 29% were traveling to and from work or school, or traveling to shop or run errands 
• 12% were working 
• 7% were attending school 
• 5% were doing an unknown or other activity 

Sexual Assault on Children (1): 

• 1 in 9 girls and 1 in 20 boys under the age of 18 experience sexual abuse or assault 
• 2 out of 3 victims of sexual assault or rape (under the age of 18) are age 12 – 17 
• Victims of sexual assault or rape under the age of 18 are about 4 times more likely to develop symptoms of drug abuse and PTSD as adults, and about 3 times more likely to experience a major depressive episode as adults 

Texas Statistics 

The latest statistics on sexual assault in the state of Texas were from 2018 and is as follows (2): 

• Total number of reported sexual assault incidents was 19,816, a 9.4% increase from the prior year 
• Of victim-to-offender relationships, 11% were romantic, 14% parental/child, 19% other family, and 55% other. 
• Victims were 88% were female and 12% male 
• Victims who were aged 10 – 14 were the group with highest number of cases 
• Of all victims, 82% were white, 17% black, and 1% American Indian/Alaskan Native, Asian, or Native Hawaiian/Pacific Islander 

Location of sexual assault incidents in Texas in 2018 (2): 

• 16,015 in residents/homes 
• 2,041 in unknown or other areas 
• 657 in a hotel/motel 
• 718 in school/college 
• 710 in a highway/road/alley 
• 506 in a parking lot/garage 
• 268 in fields/woods 
• 185 in commercial/office buildings 
• 176 in drug stores, doctor’s offices, or hospitals 

Forensic Law and Collection Process in Texas Nursing Forensics

The Texas government code 420.031 (9) describes the protocol that must be taken to develop and protect evidence collection in a sexual assault case.  Since a major part of Texas is rural, the code was enacted to protect and care for patients and the evidence in those areas where a SANE nurse is not available.  In those cases, a medical forensic examiner may perform the exam and evidence collection for Texas nursing forensics.   

A medical forensic examiner is described as any practitioner MD, Registered Nurse, Nurse Practitioner, or Physician's Assistant who has undergone a minimum of 2 hours of training in forensic evidence collection.  The law outlines requirements in the collection and preservation of evidence.  In 2019 the code was amended to require written informed consent from the patient or guardian for release of the evidence and must be gained prior to the history and physical.  Obtaining consent also carries important psychological implications after a sexual assault since the patient's right to consent was violated by the assaulter. Sexual assault examination teams should always be involved as early as possible.   

In Texas, there is no statute of limitations on reporting sexual abuse of a child.  For an adult (over 17 years of age) that statute ends ten years after the crime.  However, during the investigation of the offense, if "biological matter" is collected and the matter:  

• Has not yet been subjected to forensic DNA testing; 
  
• Has been subjected to forensic DNA testing and the testing results show that the matter does not match the victim or any other person whose identity is readily ascertained;  
• Probable cause exists to believe that the defendant has committed the same or a similar sex offense against five more victims" there is no statute of limitations. (9) Sexual assault evidence can be found in several areas, including the crime scene, the patient's body, skin, hair, nails and clothing, and other items belonging to the patient (11).  There is a specific kit used to collect this evidence.  As described by RAINN, the kit is best known as a RAPE or Sexual Assault Evidence Kit (SAEK) and is inclusive of the items listed below: 
  -"Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off of the patient while undressing, 
  -A comb to collect evidence from hair, 
  -Forms for documentation,  
  -Envelopes and containers for the evidence 
  -Instructions on use of the kit, documenting guidelines 
  -Blood sampling materials and swabs." (11) 

Types of evidence collected in Texas nursing forensics are usually skin samples, scrapings from fingernails, and oral, genital, and anal swabbing internal and external.  Directions on how to collect this evidence is included in the kit.  The forensic examiner can also use special types of photography to document internal injuries. (11) Personal cameras should never be used.  Remember, it is the law that the patient consent to each part of the exam. 

As described by RAINN, prior to the Texas nursing forensics exam, it is best if the patient has not changed clothes, combed their hair, brushed their teeth, tried to clean the area, showered or bathed, or used a restroom. If needing to use the restroom, a urine sample should be collected, educating the patient not to cleanse the perianal area.  In the event that they have already showered or bathed and have not arrived after the acute assault, emergency personnel needs to educate the patient to keep the clothes they were wearing and any other belongings they had with them at the time of the assault in a paper bag in order to preserve the evidence. (11)  If the patient comes to the emergency department up to 7 days after being sexually assaulted, the exam can still be performed.  After the 7 days, it is at the forensic examiner's discretion whether the exam should be performed. Collection and protecting forensic evidence is a legal, moral and professional responsibility (12) 

Any medical witness who testifies in court is held in the highest regard and as experts in sexual assault. (5)  Courts will closely scrutinize the chain of custody, and if broken, it can cause a conflict in the case and question of validity.  Cases may be heard in criminal, civil, juvenile, military courts, or grand juries.  If a forensics examiner is called to be a "fact" witness, no opinions on the case will be heard. Only the procedures that were performed on the patient will be admitted, and if the testifier is not the professional who performed the examination, they may be questioned regarding SANE protocols.  If called upon to be an expert witness, the SANE nurse not only has knowledge of protocols but can educate and give opinions to the court.   In either case, the necessity for excellent knowledge of SANE protocols is important.  Nurses must be comfortable testifying in court as it is a rigorous and stress-provoking experience.  Working with your organization's lawyers and prosecutors as well as reviewing the case extensively will prepare the nurse to testify in a case. (5) 

Chain of Custody

In order to protect the patient and evidence for the courts, a chain of custody of the evidence must be followed precisely.  Failure to comply does not mean the evidence is not admissible in the courts; however, the more complete the evidence, the better chance of conviction of the assaulter.  Texas A&M's nursing program offers a chain of evidence handbook outlining each step in the collection of evidence.  The information below highlights the collection process from that handbook (8):

"Precise chain of custody must be maintained and well documented through the entire patient assessment and evidence collection process. Chain of custody documents includes the dates and times of each individual who handles every piece of evidence, from the time it is collected to the legal proceedings."

Evidence must also be labeled with the patient's name, date of birth, a unique identifier number from the institution, the examiner's initials, date, and time.  

Chain-of-custody documentation must include:  

1. Receipt of evidence
2. Storage of the evidence 
3. Transfer of the evidence, 
4. Date and time of each transfer
5. The printed name and signature of each person in possession of the evidence 
6. Signatures of all persons transferring or receiving the evidence. 
7. Swab and evidence collection.  

There should be two swabs used from each site. (8) 

Evidence must be kept in sight of the staff person collecting it at all times. After collected,  the evidence must be dried and contained in the SAEK kit and sealed per kit instructions until it can be handed over to the appropriate law enforcement official and opened only by crime lab personnel.  Each emergency department should have a locked storage space to provide temporary custody of collected evidence until it can be transferred to the appropriate persons or lab.  If a patient is transferred to another facility, the chain of custody again must be documented according to the law. 

The law in Texas nursing forensics allows an adult to choose whether to report the assault to law enforcement.  If the choice is to not report, evidence will still be collected and preserved for up to 5 years post-assault.  In the case of child sexual assault, elder abuse (over 65), or disabled persons, all medical personnel must report the case to law enforcement as mandatory reporters.  Texas caregivers are also required to give patients an information sheet describing where to find appropriate services for the sexually assaulted.  This document can be found on the Texas consumer protection website.   

Physical and Emotional Issues Post Assault  

After a sexual assault, patients can experience anxiety and depression, PTSD and turn to alcohol and/or substance abuse.  There may be feelings of fear, denial, guilt, shame, loss of self, loss of control, and anger. (8) Their world has been turned upside down, and they feel life has stopped, and they cannot move forward.  They may feel ashamed and wonder if, in some way, they were responsible.  They may not feel safe in their own space and may lack trust.   

In domestic cases, the patient may be concerned about their attacker.  They may worry that their attacker will be prosecuted and sent away.   Daily life can be disrupted to the point of self-isolation and loss of the patient's job, family, and social life.  A patient may become disabled to the point of homelessness and poverty.  Many will feel the attack is transparent and that others can tell they've been assaulted just by looking at them.  Flashbacks can occur at any time, and they may experience nightmares of being chased or attacked. They may also have constant thoughts of the abuse, causing insomnia and intense anxiety.   

Sexually assaulted patients are more likely to contemplate and attempt suicide than those of other assaults.  These issues can extend into long periods of time, with unknown triggers bringing flashbacks or repeated negative feelings.  Patients need to be educated to understand that all of their feelings are normal to the trauma and understand that these feelings are temporary. Each person heals in different ways and in different timeframes.  Ongoing support and therapy will assist the patient in recovery as well as self-help and group programs.  There are many online, telephone, and in-person programs for victims as well as organizations to assist with ongoing issues.  For example, the RAINN program can be helpful in advocating for patients and guiding them on their journey to recovery.  

 Many psychologists and therapists deal explicitly with sexual assault patients.  The attorney general of the state of Texas website has information and resources for all crime victims.   Having a trained sexual assault counselor at the emergency visit time can be of great assistance with the initial contact and subsequent referrals to professionals.  Compassionate, empathic, and supportive care by emergency nurses at the initial contact can positively impact the patient's road to a safe and healthy recovery.   

Physical injuries must also be considered using clinical assessment, radiology, MRIs, and CT scans when necessary.  Laboratory collection for STDs (sexually transmitted diseases), pregnancy in females, possible HIV, and other illness exposures are also a consideration during the physical exam and history taking.  Follow-up care for these injuries with subsequent laboratory tests and appointments made with appropriate specialists should be made.   

Ideally, the Texas nursing forensics professional could schedule a telephone call with the patient in 2-3 days to assess how they are doing and for continued support and referrals.  At that time, the patient may have more questions or concerns that the nurse can help with and provide for follow-up care and resources.   A list of educational programs and therapists who specialize in sexual assault and support groups should be supplied to the patient at the time of the visit and subsequent phone calls. There is no handbook on how to recover from trauma; it is an individual journey that is experienced solely by each person; however, there are many resources to assist a sexually assaulted patient at the time of the event and long after.  

Conclusion

Sexual assault has become a major and costly health problem in the United States. The state of Texas has implemented a code of laws to identify, protect and collect evidence from patients who have experienced this crisis.  The utilization of SANE nurses is common in major metropolitan area hospitals, but many rural areas in that state are not equipped with the program.  To properly care for these patients and collect and protect evidence appropriately, Texas has mandated education for those emergency department nurses not served by SANE personnel.   

It is imperative that emergency department nurses and other Texas nursing forensics professionals become educated in the use of SAEK kits for evidence collection and chain of evidence protocols. The utilization of the SANE method allows for standardized care that is safe and protective of the patient and the patient's rights.  It protects evidence for investigation while helping to keep costs down.  

End of Life Care for Geriatric Patients

In this course we will discuss some of the major considerations all nurses should be aware of when providing end-of-life care. This course is specific to geriatric patients but can be applied to patients of any age in any setting, as many of the principles remain the same.

What is End of Life Care? 

End of life nursing care encompasses a wide range of aspects of care, to include symptom management, appropriate pain management, ensuring patient and family education and support during the death and dying process, providing culturally sensitive care, and ensuring the decision-making process remains ethical (6). Nurses are an integral part of the end of life process and should be sure to be an active advocate for their patients and families. 

End of Life Care vs. Palliative Care 

End of life care and palliative care are two terms that are used interchangeably, but are two very different things. Palliative care refers to pain and symptom management during “any time in the trajectory of serious illness or injury and does not replace curative interventions” (8). This means that anyone experiencing a serious illness or injury can receive palliative care to manage symptoms, and doesn’t necessarily mean that they are beginning the dying process. Palliative care can be delivered as either a separate service or the primary care team, and can be given in a variety of settings to include intensive care, inpatient wards, outpatient clinics, and long term care or rehabilitation facilities. In contrast, end of life care (also known as hospice care) refers to patient care before and during the dying process. It may be initiated before, during or after curative treatment and is meant to focus on a patient’s comfort rather than a cure (8). End of life care can be provided in the comfort of the patient’s home, in a long term care facility, or in a hospital. 

End of Life Care Considerations 

End of life care should be given to anyone who is “near the end of life and have stopped treatment to cure or control their disease” (13). It can also be considered for those who are undergoing a curative treatment. 

Talking frankly about end of life care planning is important, and should be done often in collaboration with patients and their families. Nurses should be active in this planning phase, ensuring that the patient and all involved family members understand the death and dying process, all available treatment options that have been presented by the health care team, and all the different methods available to control pain and symptoms. Talking about end of life options early is imperative – by broaching the subject before pain and symptom management become an issue, the nurse can ensure that the patient is an active participant in creating their care plan and final wishes.

Types of End of Life Care

End of life care planning can include a few different things: 

Hospice Care

As was mentioned above, hospice care focuses on pain and symptom management during a chronic illness that will ultimately cause the patient to die. Also known as “comfort care,” hospice can be initiated in several instances: 

• During a curative treatment 
• If a patient wishes not to continue with curative treatment 
• The curative treatment has failed 
• The patient wishes not to pursue curative treatment 
• After withdrawal of lifesaving interventions (ventilatory support, vasopressors, etc.) 

Do Not Resuscitate (DNR)/Do Not Intubate (DNI)

A patient has the right to refuse resuscitation or intubation and mechanical ventilation in the event that they would need it, if they are of sound mind and are able to make their own medical decisions. A Do Not Resuscitate (DNR) order is written by a medical doctor and instructs the health care team not to initiate cardiopulmonary resuscitation (CPR) if the patient experiences a cardiac or respiratory arrest. The order is written only after discussion with the patient. If the patient is not able to make medical decisions, a doctor may discuss options with a designated healthcare proxy. A DNR order does not cover any other lifesaving interventions. A Do Not Intubate (DNI) order is also written by a doctor and states that a patient does not wish to have an artificial airway placed should they experience respiratory arrest. It is possible for a patient to be a DNI but still wish to have CPR in the case of cardiac arrest (9). 

Once a DNR/DNI order is in place, if it is at the patient’s request, the family cannot override it. If a patient has requested a DNR/DNI order but then changes their mind, they have the right to revoke it at any time. A DNR/DNI order must be respected, it is a legal, binding document. As such, verbal DNR/DNI requests from family members cannot be honored – the original signed order must be present for care providers to cease resuscitation attempts. 

Advance Directive

An advance healthcare directive, also known as a living will, is a legal document that specifies what a person’s desires are regarding treatments and lifesaving interventions in the event that they become unconscious or are dying (9). A living will can include instructions on: 

• The use of ventilators or other artificial respiratory support 
• Initiation of CPR in the event of cardiac arrest 
• The use of vasoactive medications 
• Dialysis 
• Organ or tissue donation 

The advance directive may also name a health care proxy can make decisions for the patient if they become incapacitated. 

In order to facilitate advance directive planning, nurses may wish to use a document called “5 Wishes.” 5 Wishes is a legal advance directive document that is written in lay language, and helps patients to choose their end of life care and document it appropriately. This document is widely available in hospitals and other care facilities.

The Role of the Nurse in End of Life Planning 

According to the position statement on end of life care from the American Nurses’ Association, nurses “are often ideally positioned to contribute to conversations about end of life care and decisions, including maintaining a focus on patients’ preferences, and to establish mechanisms to respect the patient’s autonomy” (7). Similarly, a statement entitled “The Right to Self Determination” from the Code of Ethics for Nurses with Interpretive Statements also emphasizes the nurse’s role in end of life planning and care: 

“The importance of carefully considered decisions regarding resuscitation status, withholding and with-drawing life-sustaining therapies, forgoing nutrition and hydration, palliative care, and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limits of various advance directive documents. The nurse should provide interventions to relieve pain and other symptoms in the dying process consistent with palliative care standards and may not act with the sole intent of ending a patient’s life” (7). 

What these statements say is that nurses have ethical roles and responsibilities that are fundamental to nursing practice. Nurses should ensure that both patients and family members understand the options and treatments that have been presented to them, and should ensure that the patient’s autonomy is being respected throughout all aspects of their care. Nurses are first and foremost patient advocates, and this is especially crucial during the end of life stage. Nurse advocacy during this time can encompass anything from symptom and pain management, culturally sensitive care provision, and ethical decision making (6). 

Talking to Patients and Families 

Talking to a patient and their family about end of life care can be a huge challenge for nurses. In addition to managing patients’ and families’ emotions, nurses must manage their own emotions and approach the subject with professionalism as well as empathy. 

Often, during the end of life planning phase, patients will go through the five stages of grief, as outlined in the book “On Death and Dying” by Elizabeth Kubler-Ross. The five stages of grief include (6): 

• Denial: Usually a temporary defense, patients may say that they’re fine, or that this is some mistake. 
• Anger: Once the patient is no longer in denial, anger is often the next stage. It may be difficult to care for the patient during this stage, as they may misplace their angry feelings on their caregivers. 
• Bargaining: At this stage, the patient seeks ways to postpone death – often in the form of promising to reform a lifestyle in exchange for more life. 
• Depression: This stage may involve the refusal of treatments or visitors, and the disconnection from people, love, and affection. 
• Acceptance: The final stage, which is not reached by all patients. In this stage, the patient has come to terms with their mortality and has accepted that death will happen. 

It is important for the nurse to understand these five stages, as most patients will be experiencing one or more of the stages during the end of life process. 

Here are some helpful techniques for nurses to use when talking to patients about hospice or end of life planning, according to the American Academy of Family Physicians (10): 

Make sure you have time. 

While this may seem impossible while on a shift when you have other patients, it’s imperative that a nurse allow enough time to have this difficult conversation. This is not a conversation that can be rushed – rushing through the conversation may make a nurse miss important details that the patient has shared. 

Turn off your phone. 

Minimizing distractions during these difficult conversations will ensure that the nurse can get ample information from this patient and family interaction. 

Listen to the patient.  

Above all, listen to what the patient is saying. Begin the conversation by asking what the patient and their doctor have already discussed. Be sure that the plan of care has been reviewed with the doctor prior to this conversation, then have the patient repeat their plan of care as they understand it. If there are major differences in the plan of care and what the patient says, this may warrant further conversation with the health care team to clarify and identify knowledge gaps. 

Learn what the patient’s goals are.  

Active listening is crucial during the conversation phase of end of life care planning. Once the nurse has determined that the patient understands the options that have been presented, it is vital to ask them what their goals are for palliative and comfort care. Understanding a patient’s goals can help identify what resources will be best suited for their individual needs. 

Conversations surrounding end of life care should happen as soon as possible. Do not wait until the patient is no longer able to participate in the discussion. Encourage the presence of family members, but be sure to respect the patient’s wishes regarding who is involved in the planning process. Other members of the healthcare team that should be included in the planning process include social workers, patient navigators (if applicable in that setting), and any primary and specialist physicians involved in the patient’s care.  

Caring for an End of Life Patient

Transitioning to End of Life Care

There may come a point during a patient’s hospital stay where it becomes evident that curative or life-supporting measures are no longer effective, thus necessitating the transition from curative treatment to comfort/end of life care. Of course, it is preferable that comfort care be initiated during the curative treatment – this makes the transition to end of life care somewhat easier, since the conversation and planning were ideally initiated before treatment began, and with the collaboration of the healthcare team, family and patient. 

Social Considerations

When preparing a patient and family for the end of life process, a nurse should be sure to consider several social perspectives of both the family and the patient: 

Patient and family education: This is crucial to ensuring that the end of life process goes smoothly for both the patient and any involved family members. It is imperative to assess the patient’s level of understanding of their diagnosis and all treatment plans. If a knowledge gap is identified, consider calling a meeting of the healthcare team to review the plan of care. The nurse should be present at as many planning meetings and patient conversations as possible. This way, the information is getting passed firsthand and nothing is lost in translation. 

Physical location: What are the patient’s wishes for where they want to be when they die? If the patient wishes to leave the hospital, every effort should be made to accommodate their wishes, should their clinical status allow it. At this point, social workers should be involved to coordinate home hospice care or transfer to an appropriate hospice facility. 

Advance directives: If the patient has an advance directive in place, what are their wishes? If the patient can participate in discussions surrounding end of life care, their autonomy should be respected. If the patient wishes to create an advance directive, the nurse should be sure to confirm the patient’s and family’s understanding of available options. 

Clinical Considerations

Medically ineffective interventions: This can also be called “futility of care.”  According to the American Medical Association’s Code of Medical Ethics (11), these interventions may be requested by family members but are deemed inappropriate by the physician. According to the AMA, the following steps should be taken by the physician when dealing with a futility of care situation: 

1. “Discuss with the patient the individual’s goals for care, including desired quality of life, and seek to clarify misunderstandings. Include the patient’s surrogate in the conversation if possible, even when the patient retains decision-making capacity. 

2. Reassure the patient (and/or surrogate) that medically appropriate interventions, including appropriate symptom management, will be provided unless the patient declines particular interventions (or the surrogate does so on behalf of a patient who lacks capacity). 

3. Negotiate a mutually agreed-on plan of care consistent with the patient’s goals and with sound clinical judgment. 

4. Seek assistance from an ethics committee or other appropriate institutional resource if the patient (or surrogate) continues to request care that the physician judges not to be medically appropriate, respecting the patient’s right to appeal when review does not support the request. 

5. Seek to transfer care to another physician or another institution willing to provide the desired care in the rare event that disagreement cannot be resolved through available mechanisms, in keeping with ethics guidance. If transfer is not possible, the physician is under no ethical obligation to offer the intervention.” 

The above steps are not limited to physicians. While nurses cannot make ultimate treatment decisions for the patient, they can ensure that the patient and family understand what the physician has explained. Furthermore, the nurse can act as an advocate for the patient. This kind of advocacy ensures that the patient’s wishes are being respected and that the care they are receiving is ethical. 

How to Prepare a Family for End of Life Care

Physical signs of end of life: When the dying process starts, it is important that the family members present understand what is happening. The following are common signs of the end of life: 

• Increased sleeping 
• Loss of appetite 
• Labored breathing 
• Decreased urine output 
• Confusion 
• Hallucinations 
• Decreased heart rate 
• Irregular breathing patterns (Cheyne Stokes respirations) 

When you’re not a medical professional who has experienced the dying process with a patient, it can be jarring – especially when it’s your family member. Put yourself in the family members’ shoes and explain what is happening. Knowledge can be comforting for most but may not be in every case. Talk to the family members and assess how much they know and how much they would like to know. Be empathetic but do not dance around the subject. Use terms such as “die” instead of “pass away.” Using alternative terms for death and dying may leave it open to interpretation, and in some cases may give family members or patients false hope.  

Family Support 

Along with assessing the patient’s needs, the nurse should also frequently assess the needs of the family. Providing emotional support to the family member of a dying person is incredibly important, both during the dying process and afterwards (12). Be sure to involve social work if you identify any potential need for continued support for the family, i.e. support groups.

Conclusion

Nurses are an integral part of the end of life process, both in the planning and active phases. Among the biggest responsibilities for the nurse during this difficult time is the assessment of understanding of the treatment plan and goals, as well as ensuring that the patient’s autonomy and dignity are respected at all times. The healthcare team should work together as a whole to ensure that the dying process is as comfortable as possible for the patient and their family.

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. 

Nursing Ethics

Introduction   

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

History 

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

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

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

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

Professional Ethics 

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

Nursing Ethics, Principles and Values 

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

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

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

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

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

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

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

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

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

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

Foundations of Nursing Ethics 

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

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

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

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

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

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

Application 

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

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

• Traditionalists or Silent Generations (1922- 1946):  

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

- Many have delayed retirement (8). 

• Baby Boomers (1946- 1964): 

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

• Generation X (1965-1977): 

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

• Generation Y (1978-1991): 

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

• Generation Z (1992- 2010): 

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

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

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

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

End-of-Life 

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

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

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

The ANA Code of Ethics 

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

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

Conclusion 

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

Infection Control and Barrier Precautions

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

Introduction   

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

Element I

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

Element I Objectives

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

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

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

Statements from Relevant Professional and National Organizations

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

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

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

Implications of Professional Conduct Standards

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

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

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

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

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

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

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

Methods of Compliance

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

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

Element II 

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

Element II Objectives

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

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

Definitions

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

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

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

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

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

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

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

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

Overview of Components of the Infectious Disease Process

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

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

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

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

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

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

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

Factors Influencing the Outcome of Exposures

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

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

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

Pathogen or Infection Agent Factors

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

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

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

Methods to Prevent the Spread of Pathogenic Organisms in Healthcare Settings

Standard Precautions

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

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

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

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

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

For Patients Infected with Organisms other than Bloodborne Pathogens 

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

Control of Routes of Transmission 

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

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

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

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

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

Use of Appropriate Barriers

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

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

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

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

How to Put On (Don) PPE Gear

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

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

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

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

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

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

      5. Put on face shield or goggles.

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

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

   7. Healthcare personnel may now enter patient room. 

How to Take Off (Doff) PPE Gear

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

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

Appropriate Isolation/Cohorting of Patients with Communicable Diseases

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

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

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

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

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

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

Host Support and Protection

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

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

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

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

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

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

Environmental Control Measures

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

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

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

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

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

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

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

Element III

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

Element III Objectives

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

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

Definitions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Evaluation or Surveillance of Exposure Incidents

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

1. Identification of who is at risk for exposure
2. Identification of what devices cause exposure 
3. Education for all healthcare employees that use sharps. This would include that ALL sharp devices can cause injury and disease transmission if not used and disposed properly. Specific focus would include the devices that are more likely to cause injury such as:  

• Devices with higher disease transmission risk (hollow bore)
• Devices with higher injury rates (“butterfly”-type IV catheters, devices with recoil action)
• Blood glucose monitoring devices (lancet platforms/pens)

1. Identification of areas/settings where exposures occur
2. Circumstances in which exposures occur
3. Post exposure management - See Element VI

Engineer Controls

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

1. Evaluate and select safer devices 
2. Passive vs. active safety features 
3. Mechanisms that provide continuous protection immediately 
4. Integrated safety equipment vs. accessory devices:  

• Properly educate and train all staff on safer devices 
• Consider eliminating traditional or non-safety alternatives whenever possible 
• Explore engineering controls available for specific areas/settings

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

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

Work Practice Controls

General Practices

• Hand hygiene including the appropriate circumstances in which alcohol– based hand sanitizers and soap and water hand washing should be used (see Element II). 
• Proper procedures for cleaning of blood and body fluid spills: 
• Initial removal of bulk material followed by disinfection with an appropriate disinfectant. 
• Proper handling/disposal of blood and body fluids, including contaminated patient care items. 
• Proper selection, donning, doffing, and disposal of personal protective equipment (PPE) as trained [see Element IV]. 
• Proper protection of work surfaces in direct proximity to patient procedure treatment area with appropriate barriers to prevent instruments from becoming contaminated with blood-borne pathogens. 

Preventing Percutaneous Exposures

1. Avoid unnecessary use of needles and other sharp objects. 
2. Use care in the handling and disposing of needles and other sharp objects:  

• Avoid recapping unless absolutely medically necessary. 
• When recapping, use only a one-hand technique or safety device. 
• Pass sharp instruments by use of designated “safe zones.” 
• Disassemble sharp equipment by use of forceps or other devices. 
• Discard used sharps into a puncture-resistant sharps container immediately after use. 

Modify Procedures to Avoid Injury

1. Use forceps, suture holders, or other instruments for suturing
2. Avoid holding tissue with fingers when suturing or cutting
3. Avoid leaving exposed sharps of any kind on patient procedure/treatment work surfaces
4. Appropriately use safety devices whenever available:  

• Always activate safety features. 
• Never circumvent safety features. 

Element IV

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

Element IV Objectives

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

• Describe the circumstances that require the use of barriers and personal protective equipment to prevent patient or healthcare worker contact with potentially infectious material
• Identify specific barriers or personal protective equipment for patient and healthcare worker protection from exposure to potentially infectious material

Definitions

Personal protective equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard. 

Barriers: Equipment such as gloves, gowns, aprons, masks, or protective eye wear, which when worn, can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials.

Types of PPE or Barriers and Criteria for Selection

Per OSHA guidelines, employers must provide employees with appropriate PPE that provides protection from any potential infectious pathogen exposure (1). PPE includes gloves, cover garb, masks, face shields and eye protection. All PPE is intended to provide a barrier between the healthcare worker and potential contamination, whether from a patient, object, or surface. 

Gloves are intended to provide coverage and protection for hands. There are several types of gloves to choose from and the type of patient care or activity should guide choice. 

• Sterile – to be utilized when performing sterile procedures and aseptic technique 
• Non-sterile – medical grade, non-sterile gloves may be used for general patient care and clean procedures (such as NG tube insertion) 
• Utility – not medical grade and should not be used in patient care
  

Choice in material for gloves is often is dictated by cost and facility preference. When given a choice, considerations should be made as to the types of material being handled. 

• Natural rubber latex – rarely used in facilities due to allergen risk 
• Vinyl – made from PVC, lower in cost, provides protection in non-hazardous and low-infection environments 
• Nitrile – more durable, able to withstand chemical and bio-medical exposure (2) 

An appropriately sized glove fits securely over the fingertips and palm without tightness or extra room. If a glove develops a tear or is heavily soiled, it should be replaced immediately. 

Cover garb is a protective layer to wear over scrubs or clothes to protect garments and skin. These include laboratory coats, gowns, and aprons. As with gloves, consideration should be given to size, sterility, type of patient care involved, and material characteristics of the gown. 

• Fluid impervious – does not allow passage of fluids 
• Fluid resistant – resists penetration of fluids, but fluid may seep with pressure 
• Permeable – does not offer protection against fluids 

Masks are intended to provide protection to the wearers mouth and nose, with respirators providing an extra layer of protection to the respiratory tract against airborne infection pathogens (1).

Goggles are designed to protect the eyes from splashes and droplet exposure, while face shields offer additional protection to the entire face. It is important to note that face shields are not designed to be a replacement for masks. 

The choice of PPE is based on the factors that are reasonably anticipated to occur during the patient care encounter. Potential contact with blood or other potentially infectious material can occur via splashes, respiratory droplets, and/or airborne pathogens. The type of PPE chosen will be based on standard or transmission-based precaution recommendations. Follow your facility policy and procedures for guidance on appropriate choice. The nurse will also need to anticipate whether fluid will be encountered, such as emptying a drain or foley collection device. In situations where a large amount of fluid is likely to be encountered, it would be wise to choose a higher level of protection, such as an impermeable gown, if available, and to wear eye protection to ward off splashes. 

Choosing Barriers or PPE Based on Intended Need 

Barriers and PPE is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. 

Patient Safety 

Barriers, PPE, and hand hygiene is aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. This includes, but is not limited to: 

Sterile Barriers for Invasive Procedures

During invasive procedures, such as inserting a central line or during a surgery, staff directly involved performing the procedure or surgery must maintain sterility. Appropriate sterile PPE will be selected based on the type of procedure and the patient will be draped in sterile fashion according to recommended guidelines.  

Both the patient and caregiver should wear a mask during central line changes, with the caregiver adhering to aseptic technique (1). Specific policies of the organization should be referred to on the selection and donning and doffing of sterile protective equipment during surgical procedures.   

Masks for Prevention of Exposure of Droplet Contamination

Patients in droplet precautions pose a significant risk to healthcare workers and visitors. The patient, as well as anyone inside the patient's room, should wear a mask for the most effective prevention of transmission (1). The patient and patient's family must be educated on the importance of adhering to these guidelines while visitation is appropriate. During transport of a patient under droplet precautions, the patient should wear a mask, placed over the top of any oxygen delivery device, if needed.  

Employee Safety

Employees must ensure that they are evaluating the types of exposure that is likely to occur during patient care. Selection of PPE and appropriate barriers should consider the following: 

Barriers for Prevention of Contamination

Per the CDC, "use of PPE is recommended based on the anticipated exposure to blood, body fluids, secretions, or excretions" (3). The following are CDC guidelines based on the expected type of exposure or precaution; however, clinical judgement should be used based on the situation (all from 5): 

Standard precautions are to be used with any potential exposure to blood, mucous membranes, compromised skin, contaminated equipment or surfaces, and body fluids. Barriers may include gloves, gown, and eye and face protection. 

Employees must be judicious in identifying any precautions that are placed on a patient (ie. Contact, droplet, airborne) and following recommended PPE guidelines for protecting themselves and other patients.  

PPE should be donned prior to going into a patient room and doffed upon exit. PPE must never be worn in the halls or when going from one patient room to the next. All gloves must be changed in between use and hands washed or sanitized upon removal of gloves. 

Additionally, whenever possible, social distancing of 6 feet should occur within the work environment. When not possible, adherence to mask guidelines is sufficient.  

Masks for Prevention of Exposure to Communicable Disease

With the onset of Covid-19 across the globe, masks are an essential tool in preventing the transmission of communicable disease. At a minimum, medical masks should be donned during all patient care. During procedures or surgery, surgical masks are to be utilized.  

N-95 masks are reserved for patient care with known or suspected Covid-19, if airborne precautions are ordered, or during procedures that may aerosolize (such as during intubations and certain endoscopy procedures). The CDC recommends reserving surgical N-95 masks for healthcare providers "who are working in a sterile field or who may be exposed to high velocity splashes, sprays, or splatters of blood or body fluids".  Standard N95 respirators are recommended for all other care involving confirmed or suspected Covid-19 patients (5).

Guidance on Proper Utilization of PPE or Barriers

Proper fit is required for PPE to be effective. Gowns and gloves chosen should fit well, allow movement, and neither be too baggy or too tight. For particulate respirators, the CDC recommends the following regarding proper fit and use of particulate respirators: 

All workers who are required to wear tight-fitting respirators (e.g., N95 respirators, Elastomerics) must have a medical evaluation to determine the worker’s ability to wear a respirator, and if medically cleared, a respirator fit test needs to be performed using the same model available in the workplace (3, 4). 

Prior to donning PPE, it should be inspected for any anomalies, tears, or vulnerable spots. PPE that is compromised should be disposed of and a new garment selected. Nurses must give careful consideration to the selection of PPE to ensure that it is the correct type for the job and anticipate any circumstances where splashes or saturation of fabric is likely to occur. 

The PPE provided by the employer may be single use or re-usable. Always verify with manufacturer guidelines and facility policy on the correct usage and processing of worn garments. It is the facilities responsibility to ensure that re-usable gowns are laundered according to State guidelines. 

In order to prevent cross contamination, OSHA offers the following guidelines: 

• Personal protective equipment must be removed prior to leaving a work area 
• Garment penetrated by blood or other potentially infectious material must be removed immediately or as soon as possible 
• PPE must be discarded in “. . . an appropriately designated area or container for storage, washing, decontamination, or disposal” 
• Employers must ensure that proper hand washing is taking place after the removal of PPE
  

Healthcare facilities have a legal duty to protect their workers. Per OSHA, “One way the employer can protect workers against exposure to blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS, is by providing and ensuring they use personal protective equipment, or PPE. Wearing appropriate PPE can significantly reduce risk, since it acts as a barrier against exposure. Employers are required to provide, clean, repair, and replace this equipment as needed, and at no cost to workers” (5). 

Employers and healthcare workers must understand the balance of cost versus benefit ratio in PPE selection and use. While it is important to be good stewards with resources, always erring on the side of caution and choosing PPE based on anticipated exposure risk is the most effective way to protect yourself and your patients. 

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

Element V

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

Element V Objectives

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

• Define cleaning, disinfection, and sterilization 
• Differentiate between noncritical, semi critical, and critical medical devices 
• Describe the three levels of disinfection (i.e., low, intermediate, and high) 
• Recognize the importance of the correct application of reprocessing methods for assuring the safety and integrity of patient care equipment in preventing transmission of blood-borne pathogens 
• Recognize the professional’s responsibility for maintaining a safe patient care environment in all healthcare settings 
• Recognize strategies for, and importance of, effective and appropriate pre-cleaning, chemical disinfection, and sterilization of instruments and medical devices aimed at preventing transmission of blood-borne pathogens.

Definitions

Contamination: The presence of microorganisms on an item or surface. 

Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object 

Critical device: An item that enters sterile tissue or the vascular system (e.g., intravenous catheters, needles for injections). These must be sterile prior to contact with tissue. 

Decontamination: The use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles. 

Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. 

High level disinfection: Disinfection that kills all organisms, except high levels of bacterial spores, and is affected with a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA). 

Intermediate level disinfection: Disinfection that kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a “tuberculocide” by the U.S. Environmental Protection Agency (EPA). 

Low level disinfection: Disinfection that kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA. 

Noncritical device: An item that contacts intact skin but not mucous membranes (e.g., blood pressure cuffs, oximeters). It requires low level disinfection. 

Semi critical device: An item that comes in contact with mucous membranes or non-intact skin and minimally requires high level disinfection (e.g., oral thermometers, vaginal specula). 

Sterilization: The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. 

Universal Principles

Instruments, medical devices, and equipment should be managed and reprocessed according to the recommended and appropriate methods regardless of a patient’s diagnosis, except for cases of suspected prion disease. 

Due to the infective nature and steam resistant properties of prion diseases, special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD] or Bovine spongiform encephalopathy [BSE]). Consultation with infection control experts prior to performing procedures on such patients is warranted. 

Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions must be made available for each instrument, medical device, and equipment reprocessed. The CDC recommends that critical medical and surgical devices and instruments that would be expected to enter a system through body fluids, blood, or tissue be sterilized prior to use on each patient. (1).   

Potential for Contamination

The type of instrument, medical device, equipment, or environmental surface creates variables that are more likely to be a source of contamination. External contamination may be caused by the presence of hinges, crevices, or multiple interconnecting pieces. If able, these devices should be disassembled. Endoscopes provide a particular challenge for both internal and external contamination, due to their lumens as well as the crevices and joints present. The disinfectant must reach all surfaces and assurance that there are no air pockets or bubbles to impede penetration (2). These devices may be made of material that is not heat resistant, preventing sterilization. In these instances, chemicals must be utilized to provide disinfection. 

Once rendered sterile, there are multiple opportunities for potential contamination due to the frequency of hand contact with the device or surface. Packaging may be over handled and breached, or the item may come into contact with potential contaminants via poor storage, improper opening, or environmental factors. 

The efficacy of sterilization and disinfection is dependent upon the number and type of microorganisms present. There are several types of pathogens that carry an innate resistance, making successful decontamination more challenging (2). Most infections are caused by bacteria, followed by viruses, fungi, protozoa, and prions (3).  Due to the nature of their outer membranes, spores and gram-negative bacteria have a natural barrier that prevents the absorption of disinfectants. Bacterial spores are especially resistant against chemical germicides, as are the following pathogenic organism types (all from 2): 

• Coccidia – i.e., Cryptosporidium 
• Mycobacteria – i.e., M. tuberculosis 
• Nonlipid or small viruses – i.e., poliovirus, coxsackievirus 
• Fungi – i.e., Aspergillus, Candida 
• Vegetative bacteria – i.e., Staphylococcus, Pseudomonas 
• Lipid or medium-size viruses – i.e., herpes, HIV 

The number of microorganisms that are present on a medical instrument, device or surface affects the time that must be factored into disinfection and sterilization efficacy. As stated by the CDC, “Reducing the number of microorganisms that must be inactivated through meticulous cleaning, increases the margin of safety when the germicide is used according to the labeling and shortens the exposure time required to kill the entire microbial load” (2) 

In general, used medical devices are contaminated with a relatively low bioburden of organisms. Inconsistencies or incorrect methods of reprocessing can easily lead to the potential for cross-contamination (1). 

Steps of Reprocessing

Reprocessing medical instruments and equipment is completed sequentially dependent upon the instrument and the process chosen. 

Pre-cleaning is the process of removing soil, debris, lubricants from internal and external surfaces through mopping, wiping, or soaking. It must be done as soon as possible after use to lower the number of microorganisms present on the object. 

Cleaning may be accomplished manually or mechanically. Manual cleaning relies upon friction and fluidics (fluids under pressure) to remove debris and soil from inner and outer surfaces of the instrument. There are several different machines used in mechanical cleaning including ultrasonic cleaners, washer-disinfectors, washer-sterilizers, and washer-decontaminators. Studies have shown that automated cleaning is more effective than manual; however, the frequency of fluid changes must follow manufacturer guidelines to eliminate the risk of contaminating debris (1). 

Disinfection involves the use of disinfectants, either alone or in combination, to reduce microbial count to near insignificant. Common disinfectants used in the healthcare setting include chlorine and chlorine compounds, hydrogen peroxide, alcohols, iodophors, and quaternary ammonium compounds, among others. These products are formulated and then approved by the Environmental Protection Agency and Food and Drug Administration for specific uses. 

Sterilization is used on most medical and surgical devices that are utilized in healthcare facilities. This requires sufficient exposure time to heat, chemicals, or gases to ensure that all microorganisms are destroyed.   

Choice/Level of Reprocessing Sequence

The choice or level of reprocessing is based on intended use: 

• Critical instruments and medical devices require sterilization 
• Semi critical instruments and medical devices minimally require high level disinfection 
• Noncritical instruments and medical devices minimally require cleaning and low-level disinfection.
  

Manufacturer recommendations must always be consulted to ensure that appropriate methods, actions, and solutions are used. There is a wide variability of compatibility among equipment components, materials, and chemicals used. Rigorous training is required to appropriately to understand equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing. Failure to follow manufacturer recommendations may lead to equipment damage, elevated microbial counts on instruments after reprocessing, increase risk for infections, and possibly patient death.   

Effectiveness of Reprocessing Instruments, Medical Devices, and Equipment

Pre-cleaning and cleaning prior to disinfection is one of the most effective ways to reduce the microbial count. This is only effective when completed prior to disinfection. Disinfection relies upon the action of products to eliminate microbial count. Depending on the medical instrument or device design, the product may only be required to cover the surface. However, due to the lumens of scopes, crevices, or hinges on certain instruments, immersion products and dwell times may be required (4). 

The presence of organic matter, such as blood, serum, exudate, lubricant, or fecal material can drastically reduce the efficacy of a disinfectant. This may occur due to the presence of a barrier or the organic material acting as a barrier.  It may also occur from a chemical reaction between the organic material and the disinfectant being utilized. 

Biofilms pose a particular challenge and offer protection from the action of disinfectants. Biofilms are composed of microbes that build adhesive layers onto the inner and outer surfaces of objects, including instruments and medical devices, rendering certain disinfectants ineffective. Chlorine and Monochloramines remain effective against inactivating biofilm bacteria (1). 

Per the CDC, “. . . a given product is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read labels carefully to ensure the correct product is selected for the intended use and applied efficiently” (1). The label will indicate the sufficient contact time with chemical solution to achieve adequate disinfection. 

After disinfection, staff and management must adopt a system of record keeping and tracking of instrument usage and reprocessing. Reprocessing equipment must be on a schedule to be maintained and regularly cleaned, according to manufacturer guidelines. 

There are several methods of sterilization used such as steam sterilization (autoclaves), flash sterilization, and more recently, low-temperature sterilization techniques created for medical devices that are heat sensitive. Selection depends upon the type of instrument, material, ability to withstand heat or humidity, and targeted microbes. 

There are several methods of ensuring that sterilized instruments are processed and tracked appropriately. Indicators or monitors are test systems that provide a way of verifying that the sterilization methods were sufficient to eradicate the regulated number of microbes during the process. These safeguards include: 

• Biologic monitors 
• Process monitors (tape, indicator strips, etc.) 
• Physical monitors (pressure, temperature gauges) 
• Record keeping and recall/ tracking system for each sterilization processing batch/item 

Studies have shown that the best-practice of handling and storage of reprocessed medical equipment and instruments uses a system of event-related shelf life, rather than time-related. The rationale for this lies in the theory that the sterile items are remaining sterile as long as the packaging is not compromised (2). Factors that are considered event-related include internal or external contamination such as damage to packaging, humidity, insects, vermin, open shelving, temperature fluctuations, flooding, location, and the composition of packaging material 

Standards for handling must also focus on protection of workers from health issues.   

Recognizing Potential Sources of Cross-Contamination in the Healthcare Environment

• Surfaces or equipment which require cleaning between patient procedures/treatments 
• Practices that contribute to hand contamination and the potential for cross-contamination 
• Consequences of reuse of single use/disposable instruments, medical devices, or equipment   

Factors that Have Contributed to Contamination in Reported Cases of Disease Transmission

At any point in reprocessing or handling, breaks in infection control practices can compromise the integrity of instruments, medical devices, or equipment. Specific factors include: 

• Failure to reprocess or dispose of items between patients 
• Inadequate cleaning 
• Inadequate disinfection or sterilization 
• Contamination of disinfectant or rinse solutions 
• Improper packaging, storage, and handling 
• Inadequate/inaccurate record keeping of reprocessing requirements   

Expectations of Health Professionals Based on Setting and Scope of Practice

Professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical devices is performed elsewhere (e.g., in a dedicated Sterile Processing Department) are responsible of understanding these core concepts and principles: 

• Standard and Universal Precautions (e.g., wearing of personal protective equipment) 
• Cleaning, disinfection, and sterilization (Sections III and IV above) 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended 
• Verify with those responsible for reprocessing what steps are necessary prior to submission of pre-cleaning and soaking
  

Professionals who have primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (e.g., Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) are responsible for understanding these core concepts and principles: 

• Standard and Universal Precaution 
• Cleaning, disinfection, and sterilization described in Sections III and IV above 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended
  

Facilities must be fastidious in developing appropriate reprocessing practices that follow regulatory guidelines. When selecting appropriate methods, consideration must be given to the antimicrobial efficacy, time constraints and requirement of these methods, as well as compatibility.  Compatibility among equipment/materials includes the corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity. 

The toxicity of the products used can pose occupational and environmental hazards to staff and patients. Facilities must adopt policies and procedures to reduce exposure to harmful substances, monitor for harmful exposures, and train staff on reprocessing cleaning and chemicals. To reduce potential exposure to harmful substances, OSHA mandates that training for workers prior to use include (all from 5): 

• Health and physical hazards of the cleaning chemicals 
• Proper handling, use, and storage of all cleaning chemicals being used, including dilution procedures when a cleaning product must be diluted before use 
• Proper procedures to follow when a spill occurs 
• Personal protective equipment required for using the cleaning product, such as gloves, safety goggles and respirators 
• How to obtain and use hazard information, including an explanation of labels and SDSs
  

Other considerations in developing a safety plan for appropriate reprocessing practices include: 

• Potential for patient toxicity/allergy 
• Residual effects including antibacterial residual and patient toxicity/allergy 
• Ease of use 
• Stability of products, including concentration, potency, efficacy of use, and effects of organic material 
• Odor 
• Cost 
• Monitoring requirements and regulations 
• Specific labeling requirements for reprocessing single-use devices (specific information may be obtained at https://www.fda.gov/media/71405/download) 

Element VI

Prevention and control of infections and communicable diseases in healthcare workers.

Element VI Objectives

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

• Recognize the role of occupational health strategies in protecting healthcare workers and patients 
• Recognize non-specific disease findings that should prompt evaluation of healthcare workers 
• Identify occupational health strategies for preventing transmission of blood-borne pathogens and other communicable diseases in healthcare workers 
• Identify resources for evaluation of healthcare workers infected with HIV, HBV, and/or HCV 

Definitions

Infectious Disease: A clinically manifest disease of humans or animals resulting from an infection. 

Communicable Disease: An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent from an infected person, animal, or inanimate source to a susceptible host. 

Occupational Health Strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare workers.   

Pre-Placement and Periodic Health Assessments

Occupational health strategies are aimed at ensuring that employees are healthy and stay healthy. Upon hiring, employees should undergo an initial health screening that reviews immunization records. The CDC suggests that healthcare workers are screened when newly hired and on a periodic basis to (all from 1): 

• Ensure sufficient immunity to vaccine-preventable diseases such as measles, mumps, rubella, varicella, hepatitis B, annual influenza and any other recommended or mandated requirements 
• Assess for and manage underlying conditions and illness that may affect workplace safety 
• Prevent, assess, and treat any potential infectious exposures or illness that may be acquired or transmitted within the healthcare setting 
• Initiate and continue personalized health counseling 
• Thorough history and physical   

A tuberculosis screening should be completed prior to new employees providing patient care and upon possible exposure for an existing employee.  A thorough assessment should include an evaluation of the following symptoms: 

• Fever 
• Cough 
• Chest pain, or pain with breathing or coughing 
• Night sweats 
• Chills 

A Mantoux tuberculin skin testing (TST) must also be completed. The test is performed by injecting a small amount of tuberculin to the epidermis of the forearm. The test is then evaluated for a reaction in 48 to 72 hours. If there is no reaction, the test result is negative. If reactive, a scale is used to interpret the measurement of induration and to direct further testing or treatment (2). 

When working in healthcare, nursing staff must be healthy to provide optimal care. This is especially true with vulnerable patients that have weakened immune symptoms. The following symptoms require immediate evaluation by a licensed medical professional: 

• Fever 
• Cough 
• Rash 
• Vesicular lesions 
• Draining wounds 
• Vomiting 
• Diarrhea 

Upon evaluation, there may be restriction from patient care activities and work clearance must be completed prior to a return.   

Management Strategies for Potentially Communicable Conditions

Management and the Infection Prevention department should collaborate and strategize to ensure that employees that have had an exposure or possible exposure are protected and have support in seeking treatment without fear of retaliation or job loss (3). Managerial support should prioritize: 

• Appropriate evaluation and treatment 
• Limiting contact with susceptible patients and staff  
• Placement in a non-clinical setting 
• Depending on severity of symptoms or potential transmission, a furlough until noninfectious may be necessary 

Specific Occupational Health Strategies for Prevention and Control of Blood-borne Pathogen Transmission 

Robust training and educational programs are essential for the prevention of healthcare worker exposure and transmission. Prevention strategies should include education, training, and availability of the following: 

• Information on potential agents such as HBV, HCV, and HIV 
• HBV vaccination (including safety, efficacy, components, and recommendations for use) 
• Hand hygiene 
• Appropriate PPE and barrier precautions (see Element II) 
• Sharps safety (see Element III) 
• Standard and Universal Precautions 
• Education on the availability of confidential and anonymous testing for blood borne pathogens (4)   

Post-Exposure Evaluation and Management

Each facility must make a plan for post-exposure evaluation and management in the case that any employee or patient experiences a potential or actual blood borne exposure. The plan should incorporate the following: 

1. Prompt evaluation by licensed medical professional 
2. Risk assessment in occupational exposures 
3. Recommendations for approaching source patient and healthcare worker evaluations 
4. Recommendations for post-exposure prophylaxis emphasizing the most current CDC guidelines 
5. Post-exposure management of patients or other healthcare workers when the exposure source is a healthcare worker requires that the patient be informed of the type of exposure, whether it is healthcare worker’s blood or other potentially infectious material. 

Airborne or droplet pathogens require several special considerations. The below guidelines should be applied appropriately.  

• Risk of exposure or illness 
• Testing 
• Options for and risks and benefits of post-exposure prophylaxis or treatment 
• Need for specialty care 
• Follow-up testing and treatment 
• Work restrictions, if indicated 
• Risk of transmitting infections to others and methods to prevent transmission, and 
• Signs and symptoms of illness to report after an exposure, including side effect of prophylaxis.   

Evaluation of Healthcare Workers Infected with HIV, HBV, HCV and/or other Blood-borne Pathogens

The CDC provides the following recommendations based on scientific evidence-based practice in relation policies to prevent infected health care personnel-related blood-borne pathogen transmission (3). 

• Strict adherence to Standard Precautions 
• Voluntary testing without fear of disclosure or discrimination 
• There is not mandatory screening of healthcare workers for blood-borne pathogens in every state. Such a program would cost millions of dollars and would not produce any appreciable gain in public safety. Negative antibody tests for HIV, HBV, and HCV do not rule out the presence of infection since it can take some time for measurable antibodies to appear.  

Criteria must be followed when evaluating infected health care workers for risk of transmission in order to adhere to laws protecting workers from discrimination. The following outlines a general assessment to determine the risks posed: 

1. Nature and scope of professional practice 
2. Techniques used in performance of procedures that may pose a transmission risk to patients 
3. Assessed compliance with infection control standards 
4. Presence of weeping dermatitis, draining or open skin wounds 
5. Overall health:  

• Physical health – ability to carry out duties with Cognitive status 

Element VII

Sepsis Awareness and Education

Element VII Objectives

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

• Describe the scope of the sepsis problem  
• Describe persons at increased risk of developing sepsis 
• Identify common sources of infection that may lead to sepsis 
• Describe early signs and symptoms that may be associated with sepsis in adults and children and infants 
• Understand the need for immediate medical evaluation and management if sepsis is suspected 
• Educate patients and families on methods for preventing infections and illnesses that can lead to sepsis and on identifying the signs and symptoms of severe infections and when to seek medical care   

Definitions

Sepsis: a life-threatening condition caused by a host’s extreme response to infection. The Surviving Sepsis Campaign 2016 International Guidelines define sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. Earlier definitions defined sepsis as an inflammatory response to infection, while sepsis associated with organ dysfunction was identified as severe sepsis.

Septic shock: a subset of sepsis that manifests with circulatory and cellular/metabolic dysfunction; it is associated with a higher mortality risk.   

Sepsis – Scope of the Problem

Over 1.7 million Americans are diagnosed with sepsis each year, with the incidence rising by approximately 8% annually. Sepsis is a life-threatening medical emergency that requires early recognition and intervention. Sepsis occurs when the body overcompensates in response to an infection, resulting in multiple organ dysfunction and damage. Most sepsis cases are community-acquired. Early recognition and treatment are the most effective ways to combat sepsis. 

In 2013, New York State became the first in the U.S. to develop a state mandate that requires all hospitals to develop and adopt sepsis protocols. The mandate is dubbed “Rory’s Regulations,” after Rory Staunton, a 12-year-old boy whose death was attributed to lack of sepsis recognition. These protocols were required to adopt the following practices (all from 2): 

1. A process for the screening and early recognition of patients with sepsis, severe sepsis, and septic shock 
2. A process to identify and document individuals appropriate for treatment through severe sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care 
3. Guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and time frame goals 
4. For infants and children, guidelines for fluid resuscitation with explicit time frames for vascular access and fluid delivery consistent with current evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children 
5. A procedure for identification of infection source and delivery of early antibiotics with time frame goals 
6. Criteria for use, where appropriate, of an invasive protocol and for use of vasoactive agents