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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

Introduction 

In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women's liberation movement. In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This course will focus on the problem in rural areas in the state of Texas and how nurses working in these facilities can best assist patients who have been sexually assaulted. 

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 

The Basics: Sexual Assault 

What is Sexual Assault? 

Sexual assault, also termed sexual violence, is described as “any type of unwanted sexual contact, including words and actions of a sexual nature against a person’s will and without their consent; a person may use force, threats, manipulation, or coercion to commit sexual violence” (3). Sexual assault is often defined separate from rape. Rape consists of penetration, whether vaginally, anally, or orally. Sexual assault is any type of unwanted sexual content and is not limited to rape.  Sexual abuse, as described by the American Psychological Association (APA) "is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent" (3). Assault can be the product of domestic abuse, gang violence, date rape, and incest. Assault can be inflicted on any age or gender and often occurs by someone who is related to or knows the victim.  

What is SANE? 

In many parts of the United States, Sexual Assault Nurse Examiners (SANE), nurses who are expertly trained in performing forensic examinations and collection of evidence, are utilized (5). SANEs are nurses who specialize in forensic nursing. In forensic nursing, the health and legal system intersect (10). SANE programs began as early as the 1970s. At that time, nurses noticed that victims of sexual assault were not provided high quality care like other patients were in the emergency department. Nurses also noticed that the victims were very concerned about STDs and pregnancy and needed special treatment.  Over the next 20 years, the forensic specialty grew, and the First SANE programs were started in Tennesse, Minnesota, and Texas. Today, Texas registered nurses working in the emergency departments must learn the SANE process to perform the forensics exams and evidence collection by completing a 2-hour educational program.  

Nursing's Role 

Sexual assault is an extremely traumatic experience. Those affected can have a wide range of issues, emotionally, spiritually, physically, and psychologically. Nurses working in the emergency department are often first responders. Compassion, empathy, and privacy are a hallmark of excellent practice when caring for patients who have been sexually assaulted.  

Many patients will experience shock and disbelief. "Why me? Will I be okay?" or "It's no big deal, I'm fine" (6). There may be "fear of responses from friends, family, the public, and criminal justice providers" (7). Victims of rape may also have concerns about pregnancy, STIs, and HIV/AIDS. These patients may feel their world has turned upside down. They may be scorned, told it was deserved, and fear their names could be made public (7).  

In order to provide excellent care, all gender identities must be taken into consideration, as well as age and sexual orientation. No bias or judgment should be displayed to the patient. Customs, beliefs, religious, and spiritual needs should also be considered during the visit 

Team Collaboration 

Working with all personnel in the emergency department is essential. From paramedics, law enforcement officers, family, or anyone accompanying the patient to physicians, social workers, and forensic medical examiners, each professional has a specific skill set and role in the patient's care. Teamwork among these groups of individuals will provide the best possible outcomes for the patient. Team members involved in a victim’s care may include (8): 

• “Community-based advocates 
• Law enforcement officers 
• SANEs, physicians or nurses trained in sexual assault medical forensic evidence collection 
• Law enforcement victim service advocates 
• District Attorney’s Office personnel, legal victim advocates and attorneys” 

Interview 

The interviewing nurse should actively listen, believe what the patient discloses, validate the patient’s feelings, maintain confidentiality, and honor the patient’s decisions on what to do about the assault. When caring for patients who have sexually assaulted, treating the whole person rather than the "problem" alone is vital. Repeating information back to the patient can help to elicit more precise information. Repeating information can also help to validate what the patient is saying, creating an atmosphere of trust. Consider that patients may not want to talk about the assault, as reliving it could bring out unwanted emotions. 

If the patient arrives alone, the nurse should inquire if the patient wants a companion or an advocate to be present. An advocate could be a family member, friend, member of the clergy, or social worker. The patient can choose if they want someone present. Care must be taken to ensure the patient feels comfortable, as the presence of someone emotionally involved (or even the assaulter themselves) may deter the patient from being open and honest. An interpreter should also be arranged if needed, with the patient's consent.  

If the patient has not alerted the local police, the nurse should inquire if they wish to report the assault and if so, the police should then be called. If available, a sexual assault response team (SART) should be immediately contacted. It is of the utmost importance to remember that the patient always makes the primary decision of what to do surrounding the case. Also, the patient must give consent first before any decisions are made. Admitting the patient to a private room in a quiet area of the emergency department lessens interruptions from outside sources.  

Assessment 

After obtaining consent to perform the assessment, the patient should be advised of every step before each part of the exam. The patient should be informed they have total control of what is happening. It is important for the nurse to help the patient understand they always have the right to refuse any and all steps in the examination.  

When performing the initial assessment and gathering information, documentation must include a very detailed and complete history, including any physical trauma to the patient’s body. The history should include any bruises, lacerations, or other visual injuries and how and when they occurred. The nurse should perform the interview slowly, giving the patient time to process and answer each question. The patient may or may not want to identify the person who assaulted them and should not be coerced into doing so. 

A complete medical, surgical, and gynecologic history, in the case of a female patient, and any new symptoms occurring after the assault should be asked. Drug allergies, medications, and any alcohol or illegal drugs used at the time of the event are also documented. A compassionate and empathic tone should always be used to allow the patient to feel safe. The patient should not feel any judgment from any emergency department personnel. Patients should be given the opportunity and encouraged to grieve and react during this time. They should feel comfortable enough to ask and answer questions throughout the interview.  

According to Texas law, nurses must obtain written consent from the patient. During the complete physical exam, the nurse will be charged with ensuring physical evidence of the assault from clothing or body fluids is not disturbed. Also, during this time, suicidality and emotional support should be assessed. Providing expert treatment for patients who have been sexually assaulted is of utmost importance. When available, a SANE nurse will perform the forensic examination. This examination is vital to collect and preserve physical evidence from the patient while also assessing life and limb injuries. If a SANE nurse is unavailable, as may be the case in Texas's rural areas, a "medical forensic examiner" will perform the examination. 

Documentation 

When documenting the case, the nurse should use open-ended questions to elicit the patient's best and clearest responses. Documentation must be complete and exact, including every stage of the assault with times, dates, and descriptions, with consideration for the patient's emotional state and ability to recall. Using motivational interviewing can be helpful as well. Documenting in the patient’s own words is best practice. Nurses should try their best to document all of the following about the case (8): 

• “All those present during the patient’s history and examination 
• Time, date, and location of assault(s) 
• Contact and/or penetrative acts by suspect(s) 
• Was the suspect injured in any way, if known? 
• Use of lubricant, including saliva 
• Patient’s actions between the sexual assault and arrival at the facility (brushing teeth, using mouthwash, smoking, vaping, changing clothes, vomiting, swimming, showering, or bathing) 
• Was a condom used? 
• Did ejaculation occur? Where?  
• Any weapon use or physical force, or threat of weapon use or physical force? 
• Description of condition of clothing (and was clothing torn or stained prior to assault?)”  

In the case of a minor, a parent will give consent, and if no parent is available or is the assaulter, the child will be turned over to the appropriate child and family services in the state. If the assaulted patient has dementia or is an elder with cognitive issues and is therefore unable to consent, adult protective services should be contacted (8). There are also rules governing military sexual offenses. Remember when documenting these cases, whether using handwritten or electronic medical records, any and all information is subject to HIPAA.  

Texas Forensic Law 

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 collected evidence in areas where a SANE nurse is not available. In these cases, a medical forensic examiner may perform the exam and evidence collection.  

A medical forensic examiner is described as any practitioner Medical Doctor, 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.  

Texas Forensic Law: Statute of Limitations 

The statute of limitations for sexual assault cases can be defined as a deadline in which a person can report a sexual assault. The statute of limitations vary per state and the length of time for reporting can depend on whether the case is criminal or civil. Criminal cases are committed against the state and prosecuted by the state; civil cases occur between individuals/groups and are prosecuted by a civil court (i.e. family court or personal injury cases) (12). In Texas, the statute of limitations varies by age and whether the case is criminal or civil. The following are general statute of limitations regarding sexual assault in Texas (13)(14). The legal age of sexual consent in Texas is 17. 

For adults, the statute of limitation is 10 years from the victim’s 18th birthday. As of 2019, victims of sexual assault can file a personal injury claim for injuries arising from childhood sexual abuse up to 30 years from the incident. 

There is no statute of limitations if: 

• During the investigation of the offense, biological matter (evidence) is collected, and the matter has not yet been subjected to forensic DNA testing 
• Forensic DNA 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  
• Continuous sexual abuse of young child or disabled individual occurs 
• Indecency with a child occurs 

Texas Forensic Law: Evidence 

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 (11): 

• Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off 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 
• Sampling materials and swabs 

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

As described by RAINN, prior to the forensic 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. If they have already showered or bathed and have not arrived at the emergency room yet, emergency personnel need 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. Collecting 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 cases (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). 

Texas Law: 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). 

Collection of Evidence and Packing 

• “Collect evidence so that it will be admissible as evidence in legal proceedings later. Therefore, chain of custody must be maintained and documented throughout the entire patient assessment and evidence collection processes.
• Chain of custody documents the dates and times of everyone who handles every piece of evidence, from the time it is collected through to legal proceedings."  
• Evidence should be labeled with patient’s name, date of birth, unique identifier number, examiner’s initials, date, and time. 
• If adult patient chooses non-reporting method, the external SAEK is labeled only with the unique identifier number (often the medical record number or the Track-Kit barcode). The Track-Kit identifier can be utilized. 
• Consider also labeling additional evidence not included in the kit (i.e., clothing collected when patient is reporting to law enforcement) with Track-Kit labels without the barcode. 
• Evidence inside the SAEK is labeled according to standard facility procedure. Follow facility protocols on non-reporting evidence collection. 
• Consider providing a card with the unique identifier for the patient if the Track-Kit identifier is not utilized.” 

Chain of Custody Documentation 

Documentation must include:  

• Receipt of evidence 
• Storage of the evidence  
• Transfer of the evidence 
• Date and time of each transfer 
• The printed name and signature of each person in possession of or transferring the evidence  
• Signatures of all persons transferring or receiving the evidence 

Conclusion 

Sexual assault has become a major 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 emergency department nurses not served by SANE personnel.  

It is imperative that emergency department nurses become educated on the use of SAEK kits for evidence collection and chain of custody protocols. The utilization of the SANE method allows for standardized care that is safe, and protective of the patient and their rights. 

Texas Human Trafficking

Introduction   

Often likened to modern-day slavery, human trafficking is a heinous global crime that is getting more and more attention in recent times. Healthcare practitioners should be up to date on the topic as much as possible, considering they are very frequently a point of contact for individuals being trafficked.

It is imperative to recognize the signs of trafficking, as well as resources available to those involved. Furthermore, it is crucial that the practitioner develops trust with the victims he or she encounters, providing patient-centered, trauma-informed care.

• Identification: Potential indicators of trafficking; barriers to survivor disclosure; strategies for building trust with victims; challenges and opportunities faced by practitioners; appropriate language and documentation. 
• Health Impact: Acute and chronic physical health problems experienced by trafficking victims; quality of life and independence issues; mental health concerns.
• Response and Follow-up: The practitioner’s role in intervention; mandated reporter obligations; resources on state and federal levels; the importance of survivor-centered, multidisciplinary organizational protocols

Human Trafficking 

A 2018 report confirms that between 50-88% of human trafficking survivors accessed healthcare services, yet only six percent of healthcare workers report treating a survivor during their career (27).  

While human trafficking remains an often-hidden crime, there are still many signs that everyone should be able to recognize. There are myriad resources available for victims of trafficking, including the National Human Trafficking Hotline Number (888-373-7888) and its text line, BeFree (233733). These options are available to call or text 24 hours a day, 7 days a week, 365 days a year. Other local and statewide resources are available and will be discussed throughout this course.  

Case Study: Mahad 

Just after midnight, a 23-year-old man named Mahad presents to the ED where you work. The triage notes state that he has been coming in for generalized fatigue, muscle aches, and nausea for the past three days. He is accompanied by an older man who states he is Mahad’s uncle and has translated for Mahad thus far.  

Upon exam, Mahad appears significantly malnourished with a firm, distended abdomen. He is noted to have jaundiced sclera, dark circles under his eyes, and several wounds of varying age on his bilateral lower extremities. The uncle states that Mahad works in a metal stamping plant and occasionally gets injured on the job.  

Mahad is reluctant to talk to you and does not make eye contact. He defers to his uncle to do the talking and translation, flinching whenever the uncle moves. Both Mahad and the uncle seem wary of the law enforcement officer walking on the floor. You feel this encounter is concerning for human trafficking, so excuse yourself to go talk with some of your colleagues about this situation.

What Is Human Trafficking?  

Human trafficking is a crime and a human rights abuse. It includes at least one of the three components of force, fraud, or coercion to obtain labor and/or a commercial sex act (3,4). It can also be defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, solicitation, patronage or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery.” (2).  

This can happen to anyone at any time; a person of any race, age, gender, religion, or nationality can be a victim of trafficking (3). Healthcare practitioners should be aware that boys, men, and people over the age of 18, and those of any racial or socioeconomic group may be victims.  

Human trafficking is an enormously egregious yet profitable industry, comprising some $150-$600 billion of the global economy each year and affecting roughly 25-50 million people worldwide (11, 17). In Texas alone, this crime has already affected some 313,000 people (17). The majority of trafficking happens in the form of forced private sector labor, despite sexual exploitation being what initially comes to mind for many people (11).  

Unfortunately, the general public and even people being trafficked are not always aware of what is happening, for a myriad of reasons. This may be due in part to a lack of recognition of what exactly is involved in human trafficking.  

In the year 2000, the United States Congress passed the Trafficking Victims Protection Act of 2000, also known as TVPA (1). This legislation helps to define human trafficking and protect those involved.  

What Is Not Considered Trafficking 

Despite many media portrayals, human trafficking is not synonymous with smuggling or sex work.  

• Smuggling involves illegally crossing state or international borders (5). Human trafficking deals solely with the exploitation of people; human smuggling is a crime against a country and involves transportation, whereas human trafficking is a crime against a person (6, 7).  
• Consensual commercial sex (i.e., sex work) is not trafficking, provided that the person is over the age of 18. Anyone under the age of 18 who provides commercial sex, regardless of circumstances, is considered to be trafficked (3). This is because a minor, in the United States, is legally unable to provide consent for commercial sex (4, 6, 7). 

Types of Human Trafficking  

While many people think of human trafficking only involving sex exploitation, it can also include labor trafficking, child soldiering, and more (6).  

• Forced Labor – occurs when force, fraud, or coercion are used to exploit the services or labor of another person (6, 9, 19), and often involve physical or verbal violence, forced overtime, limited freedom of movement or communication, and lack of freedom to resign (8). Forced labor can include the following industries or elements: 
  • Domestic Servitude involves work in a private residence, where victims’ food, housing, and transportation are often controlled by their exploiter. 
  • Forced Child Labor still occurs in the United States, despite labor laws, and in this situation, children are forced or compelled to work. 
  • Agriculture  
  • Construction/Landscaping 
  • Illicit Activities 
  • Health and Beauty 
  • Traveling Sales Crews 
  • Retail/Small Businesses 
  • Restaurant/Food Service, Hospitality
• Sex Trafficking requires the components of acts, means, and purpose to establish a sex trafficking crime for those age 18 and over (anyone under the age of 18 who engages in commercial sex, regardless of circumstances, is a victim of child sex trafficking) (6).  
• Child soldiering is a type of human trafficking that involves unlawfully recruiting children – through force, fraud, or coercion- to act as combatants or other workers for government armed forces, paramilitary organizations, or rebel groups (10, 18). Children can also be used in sexual slavery, where they are forced or coerced to “marry” or be raped by commanders or combatants (6, 18). 

All types of human trafficking include actions, means, and purpose (7).  

• Actions are met when a trafficker does any of the following: 

• • Recruits by targeting a vulnerable person and/or using grooming behaviors 
  • Harbors by isolating, confining, and monitoring 
  • Transports by arranging travel for or moving the victim 
  • Provides something to the victim (like food or housing) 
  • Patronize the person by giving them financial support 
  • Obtains by forcibly taking or exchanging something for the ability to control the victim 
  • In cases of sex trafficking, the trafficker may also solicit or receive something of value in exchange for sexual acts by the victim 
  • They may solicit forced labor or other acts of servitude from a person in exchange for something of value. 

• Means include force, fraud, or coercion used by the trafficker. Examples of these include threats to others, debt manipulation, psychological harm, or threats of serious physical harm.  
• Purpose is the commercial sex act itself, or forced labor, and can occur in many places: in private homes, online, in hotels, brothels, massage parlors, and more.

The Trafficking Victims Protection Act of 2000 (TVPA) 

Although human trafficking has been around for centuries, no real legislation had existed in the United States or internationally to address it. There were also no good working definitions of human trafficking, as it often shares overlapping characteristics with sexual assault, smuggling, and the commercial sex trade. Since the inception of the United States, not until this century has there been any significant progress on making laws related to human trafficking. 

In November of 2000, the Palermo Protocol was adopted by the United Nations in order to prevent, suppress, and prosecute human trafficking on a global level (24). This was the year that United States followed suit by passing the TVPA (23). This legislation has also had reauthorization acts that updated measures and refined the language in 2003, 2005, 2008, 2013, 2017, and 2018 (25).  

The TVPA has three goals, also called the three Ps: to protect victims, prosecute offenders, and prevent future human trafficking occurrences (23, 25).  

Protection of victims includes efforts such as issuing a T-visa to victims of trafficking if they meet eligibility requirements and cooperate in the investigation and prosecution of traffickers. The T-visa grants non-immigrant status and allows victims to remain legally in the United States for up to four years.  

After three years or the closing of the related criminal case, they can apply for permanent residency (22). Furthermore, those who were previously ineligible for government assistance may be able to obtain it under the TVPA (25).  

Prosecution of perpetrators involves creating a series of new federal crimes that now define human trafficking and make it prosecutable in every state (25).  

Prevention of human trafficking includes both foreign and domestic efforts to increase awareness and establish laws related to this crime (25).  

The TVPA, established and amended as 22 USC §7102, recognizes that human trafficking includes three specific means, not all of which need be used, defining them as follows (1,2, 7):  

• Coercion: “Threats of serious harm to or physical restraint against any person,” a plan that would lead someone to believe that not performing a certain act would lead to serious harm, as well as “abuse or threatened abuse of the legal process”  
• Force: Can include physical harm or restraint, sexual assault, and beatings. During the early stages, the trafficker might monitor and confine victims to control them and break down resistance. 
• Fraud: False promises in regard to wages, working conditions, employment, a better life, marriage, or love. The victim may experience unexpected changes in the nature of a relationship or working conditions.  

Case Study: Mahad 

Upon consulting with the attending physician at your ED, you both agree Mahad is a potential victim of human trafficking. Since you are both new to the facility, you work with others on your team to locate appropriate resources to address Mahad’s situation. One of the nurses tells you that you should use the official translation service available in the ED and ask Mahad’s uncle to step outside of the room.  

 
When you come back to see Mahad, you bring the translation device with you and ask Mahad’s uncle to step out, which he does after a few quick phrases to Mahad. Another nurse escorts Mahad’s uncle to the waiting room, and you prepare to interview and assess Mahad more fully.

Who Is Trafficked?  

Anyone can be trafficked at any time, provided the right circumstances. While many people tend to think of girls and young women as the main trafficked persons, many boys and men are also trafficked (4, 6).  

For sex trafficking in the United States, victims are more likely to be Black (40%) or white (26%) versus other races; those being trafficked for labor are more likely to be Latino (63%) or Asian (17%) (22).  

Many victims of trafficking have certain vulnerabilities and situations that make them more likely to be trafficked (4, 12). These include, but are not limited to:  

• Experiencing poverty or economic hardship
• Being victims of violence
• Having physical or cognitive disabilities
• Presence of childhood abuse, neglect, or trauma
• Working as migrant laborers
• Being of a racial or ethnic minority
• Identifying as lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals
• Being children in foster care and/or juvenile justice systems
• Having run away as a youth or not having adequate housing
• Experiencing housing insecurity or being homeless as adults
• Having a history of substance abuse
• Surviving a natural disaster, political instability, or armed conflict

Who Are the Traffickers?  

Just as anyone can be trafficked, anyone can be a trafficker as well; there is no universal trafficking profile. Many times, the traffickers themselves are close to or are family of those whom they traffic in (13, 14). These can include parents, intimate partners, gang members or networks, restaurant and other business owners, government representatives, corporate executives, and many more (15).  

Some traffickers experience the same types of financial or social oppression as their victims, while others use positions of power and privilege as a means of control (15.) Many traffickers target people whose needs are not being met, like young adults who seem to lack confidence, or whose emotional, financial, or material needs aren’t being met (13).  

Regardless of who the traffickers are, they are illegally participating in the exploitation of others for personal gain.  

What Are Some Common Trafficking Methods or Techniques?  

While there is a constellation of ways by which a trafficker may entrap, coerce, or defraud their victim, there are some common characteristics (14, 16). Approximately two-thirds of traffickers are men, though women are often prosecuted at a far higher rate (18).  

Many times, traffickers offer jobs or opportunities that seem too good to be true, such as a modeling contract or promise of high salary for a factory position. They may give promises of love and a place to live or shower the victim with expensive gifts. Sometimes, particularly in the case of debt bondage, the trafficker forces the victim’s children or other family members to help pay off debts (18).  

For labor trafficking, traffickers may force their victims to: 

• Live at the business, sometimes in crowded conditions with others. 
• Sign a contract in a language they cannot read. 
• Work long shifts or unusual hours, often in isolation. 
• Engage in debt bondage, where the trafficked person owes a large debt that is never paid off and continually increases. 
• Give up control of their identification documents and finances. 
• Produce goods or services that are priced below general market rates. 

For sex trafficking, traffickers may employ the following tactics: 

• Brand the people they traffic with tattoos.  
• Prohibit the victim from coming or going as they please, especially if they live in a “massage” business. 
• Hold identification documents so that the victim cannot access them.  
• Prohibit any outside communication with others that is not monitored.  
• Control their finances. 

 In addition to the methods above, there are other potential red flags that someone might be a victim of trafficking. These include, but are not limited to, the individual (34):  

• Making little, if any money, or only being paid in tips. 
• Trying to pass themself off as older, particularly if involved in commercial sex acts.
• Exhibiting a flat effect and/or avoiding eye contact.
• Acting unusually anxious, restless, fearful, tense, submissive, or nervous; particularly when there is any mention of law enforcement.
• Appearing malnourished.
• Showing signs of physical abuse, torture, restraint, and/or confinement.
• Exhibiting prolonged, untreated illness or disease and/or unexplained injuries.
• Being unable to produce any form of identification, money, or other personal possessions.
• Not being allowed to speak for themselves when in the presence of someone else who escorted them in.
• Demonstrating a lack of knowledge of the city / geographic location they are in.
• Exhibiting a sense of loss of time.
• Having several inconsistencies in their story.
• Being brought in by police for medical clearance; they may have been part of an illegal activity.

(19) 

Why Don’t We Have Better Data?  

Getting accurate data on human trafficking is an imprecise science. Due in part to the stigma associated with trafficking, as well as victims themselves are not aware of their situation. When these factors are coupled with the many types of trafficking that exist, it is difficult to get precise figures on the matter (17).  

Victims may be coached on what to say by their traffickers, or these cases may be reported under the heading of child abuse or neglect instead of being identified also as a case of human trafficking (26). Healthcare providers may lack a trauma-informed approach, leading them to miss the signs of trafficking or for the victim to lack enough trust to confide in the provider (26). As discussed above, only in the past few decades has a definition of human trafficking even been formalized, so many laypeople and healthcare practitioners may be unaware that they have even encountered a victim of trafficking.  

Human trafficking is also often a hidden crime, hard to identify, and embedded in everything from housekeeping to nail salons to agriculture. While men make up as much as 20% of trafficking victims in the United States, they are often criminalized or deported at a much higher rate than females, making their numbers virtually impossible to track (20).  

Finally, since human trafficking takes place on a global level, it is difficult to aggregate data from each country, particularly when there is no good way to reliably report known cases.  

The Health Impact of Human Trafficking  

Human trafficking can cause or exacerbate myriad physical and mental health problems among its victims and survivors. Healthcare providers should be fully versed in all the ways these can present when victims are seen in clinical settings. In a 2017 study, nearly 88% of sex trafficking victims sought treatment in the United States healthcare system but were often left unidentified or not offered adequate resources by the clinical treatment team (21).  

Acute Injuries  

When those being trafficked seek healthcare, they may present to any of the following or more: dental offices, emergency departments, walk-in clinics, OB/GYN offices, mental health care facilities, substance use disorder treatment centers, and primary care providers. Upon presentation, certain acute injuries may be present. These include, but are not limited to (20, 22):  

• Amputation  
• Anxiety and/or depression 
• Back or neck pain 
• Burns 
• Contusions  
• Dental complaints 
• Fractures 
• Headaches
• Head and neck trauma
• Infectious diseases from worksite, including parasites, hepatitis, and tuberculosis
• Musculoskeletal pain or trauma
• Pelvic pain and/or pelvic inflammatory disease
• Respiratory problems from occupational hazards
• Sexually transmitted infections
• Skin conditions: scabies, lice, suspicious tattoos
• Substance abuse
• Suicidal ideation
• Unplanned pregnancy or abortion complications  

Almost 60% of human trafficking survivors report physical injuries, with up to 95% of those enduring physical and/or sexual violence (20). There is a degree of overlap between domestic violence signs and those found in human trafficking; healthcare providers should note wounds or injuries of varying ages, injuries around the head or genital areas, burns or contusions, and any wound that appears self-inflicted (20).  

Other acute injuries to be aware of are dehydration and/or malnutrition, visual complaints, somatization, injuries, or illness due to exposure to unsafe water or hazardous chemicals, poor dental care, and impacted tampons in vagina (19).  

Chronic Injuries  

Due to the nature of trafficking occurring primarily within the labor and sex markets, there are some chronic injuries the healthcare provider might anticipate. Some of these include (20, 22):  

• Addiction disorders 
• Back pain 
• Cancer 
• Chronic generalized or localized pain
• Headaches
• Hearing loss from working conditions
• Hepatitis
• Human Immunodeficiency Virus (HIV)
• Pelvic inflammatory disease 

Many chronic conditions may stem from repetitive work, such as those involved in factories or through repeated sexual trauma. These can also include reproductive and mental health issues as well.  

Mental Health Issues  

Since force, fraud, and/or coercion are necessary parts of human trafficking, a plethora of mental health problems can be experienced by its victims. While many survivors report having a preexisting mental health condition before being trafficked, these conditions can also be created or exacerbated by the condition of trafficking (20, 21, 22).  

Human traffickers often use methods like sleep or food deprivation to increase compliance of their victims (20). They may also employ tactics such as forced social isolation, close monitoring of behavior, control over identification documents and finances, abuse, and neglect (20).  

Mental health issues often experienced by victims and survivors include, but are not limited to:  

• Anxiety disorder 
• Autonomic arousal 
• Cognitive or developmental delays, learning disabilities in the younger population
• Depression
• Dissociation, which can lead to memory loss or impairment
• Insomnia, sleep disturbances, nightmares
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Self-harm or mutilation
• Suicidal ideation
• Trauma bonding (i.e., Stockholm Syndrome)  

 Also, due to its horrific impact on body and mind, human trafficking can cause other mental health problems, such as: anger, irritability, hopelessness, isolating behavior, fear of being alone, denial, exhaustion, aggression, recurrent or intrusive memories of abuse, guilt/ shame/ self-blame, increased crying, numbness, distrust or fear of strangers, difficulty concentrating, and more (22).  

Furthermore, many victims may be retraumatized if faced with other instances of violence or having to face their trafficker(s) again, perhaps in a courtroom setting (22).  

Healthcare providers should be aware of the impact their own demeanor can have on people who are trafficked; if particularly curt or rushed with a patient, that can cause the victim even further traumatization and more reluctance to disclose their situation.

Other Health Impacts  

While human trafficking undoubtedly causes or exacerbates countless physical and mental health conditions, it has other overlapping impacts as well.

Substance Abuse  

Substance abuse is a very common comorbidity within the human trafficking realm, and for many reasons. Some victims already had a history of substance abuse, others use(d) it as a coping mechanism for their situation, and others yet were forced or coerced to use substances of abuse (22). Since traffickers understand that those who are addicted are more easily manipulated and controlled, this remains a popular tactic used (22). A victim of human trafficking who is abusing a substance may also be afraid to seek out help from law enforcement, as they might fear prosecution (20).

Reproductive and Sexual Health Concerns  

While mentioned above in both acute and chronic conditions, sexual health concerns can leave a lasting impact on a trafficked person’s life. Since those being trafficked for sex often encounter a large number of sexual partners, STIs and unwanted pregnancies occur at high rates (20, 21, 22). Some victims have absorbent items like sponges placed in their vaginal vaults during menstruation so that they may still “work;” this can lead to chronic pelvic infections and vaginal pain (20). Repeated pregnancies and abortions can also take their toll on a victim’s body, leading to chronic pain, infections, and fertility problems (20, 22). Finally, since up to 80% of sex trafficking victims in the US are female, healthcare practitioners who provide women’s services should be aware of how to identify, treat, and provide resources to victims (20).

Quality of Life, Autonomy, and Independence  

During the time a person is trafficked, much of their life is often not under their control. They frequently have their whereabouts monitored, social interactions limited, and do not have a great deal of physical or mental autonomy and independence. As discussed above, many victims of human trafficking experience physical and psychological abuse, leading to innumerable problems. Psychological issues and substance abuse often go hand-in-hand, severely limiting the victim’s quality of life (22). The repeated trauma, potential for trauma bonding, and lack of basic needs being met can severely interfere with long-term healing and establishment of independence for survivors.  

Case Study: Mahad 

Now that you know Mahad is willing to meet with you away from his uncle, you, and another nurse plan how to best approach the situation. Since neither of you has much experience with people who have potentially been trafficked, you decide on some basic care parameters for this encounter.

Trauma-Informed Care 

Providers involved in the care of any vulnerable population should be cognizant of trauma-informed care. This paradigm acknowledges that traumatic experiences can pervade all aspects of an individual’s life and behavior, including their self-perception and their relationships with others (44).  

Trauma-informed care prioritizes the emotional, psychological, and physical safety for everyone involved, including staff members. Further, this type of care emphasizes the goals of treating, educating, and empowering the patient, not for the disclosure of victimization (37).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines individual trauma as a circumstance or event that results in mental, physical, and/or life-threatening harm (31). Furthermore, SAMHSA goes on to describe the “three Es” of trauma (32):  

• Event: A circumstance or set of events that occurred to an individual, which may include natural disasters, violence, warfare, and so on 
• Experience: How the person experiences the event defines it as traumatic to them or not; for it to be traumatic, it needs to be physically or psychologically harmful.  
• Effects: These can be acute or chronic, and adversely impact the person’s physical, social, emotional, mental, and/or spiritual well-being.  

 As victims of human trafficking are very often traumatized, it is essential that the practitioner provide care specifically geared toward this population. SAMHSA has developed some goals of such care, called the trauma-informed approach, that is ideal for interactions with survivors of human trafficking (32).

The main goals of trauma-informed care are:  

• Safety: Patients and the staff around them feel safe, physically, and psychologically 
• Trustworthiness and Transparency: The goal of building trust is developed through making decisions in a transparent manner 
• Peer Support: Others with a similar experience are involved in care, and are used by the treating organization as an integral part of the services provided 
• Collaboration: Whenever possible, shared decision-making is utilized among patient, clinician, and other staff 
• Empowerment: Strengths of both patient and provider are recognized and built upon, fostering the ability to heal from trauma in a resilient way 
• Humility and Responsiveness: Any biases and stereotypes are recognized and addressed, as is historical trauma  

What can practitioners do? SAMHSA offers “four Rs” to using the trauma-informed approach (32):  

• Realizing the prevalence and immense impact of trauma 
• Recognizing the clinical and signs and symptoms of trauma in patients and other staff members 
• Responding to the situation by utilizing the appropriate resources in the institution and within the wider community 
• Resisting re-traumatization of the people being served by not making the situation worse with language or action 

Patient-Centered Approach 

When providing high-quality care to potential victims of human trafficking, it is essential to use a trauma-informed, patient-centered approach. This means providing for the person’s safety, well-being, and dignity first and foremost.  

The following are some elements of this type of care (33):  

• Safety: Ensure that the patient is alone, having escorted other guests to a waiting area while any screenings or assessments are being conducted. The person should feel comfortable with the provider and any other staff members or professional interpreters present. If possible, give the patient the option of where to sit in the room, perhaps with the door in sight. 
• Physical needs: Since victims of human trafficking are often sleep- or food-deprived, it is reasonable to offer them food or water if appropriate. This may not be feasible for those who need a SANE evaluation, but for others, it may make it easier for them to respond. Offer bathroom breaks and check to see if the patient is as physically comfortable as possible. Soft lighting may also help, if available.  
• Use non-threatening, open body language: Try not to cross arms across the chest and sit or squat near the patient. Establish eye contact frequently, and respect personal space. Do not touch the patient unless necessary for the exam, and always inform them beforehand.  
• Engage the patient: Use calm, slow, nonjudgmental speech. Try to keep facial expressions neutral and avoid generalizing about the person’s experience. Make sure to give adequate time for listening.  
• Resist probing too many details: Since the goal is to ensure the patient’s safety and adequate care, only obtain information necessary for their care at this time. Avoid criticizing the trafficker, since this can cause the trafficked person to become distressed or defensive.  
• Use respectful, empathetic language: Say things such as: 

• “This seems difficult for you to talk about. Please, take your time and let me know if you need anything, including a break. I will try to make this as brief and comfortable as possible for you.” 
• “Please answer the following questions as ‘yes,’ ‘no,’ or ‘I don’t know.’ You do not have to answer a question if it makes you too uncomfortable.”  
• “I want you to feel safe here. Please let me know if I can do anything else to help.” 

• Be prepared to help coach the patient through a trauma reaction. Talking about such difficult experiences can re-traumatize the patient, potentially resulting in a trauma reaction. In this case, the person may experience a flashback or anxiety/panic attack. These techniques can help:  

• 4-7-8 breathing: Have the person put their tongue on the roof of their mouth, behind their teeth. They should then exhale through their mouth loudly, close their mouth, and inhale through their nose for 4 counts. Have them hold their breath for 7 seconds. Finally, have them exhale again through their mouth with the tongue still on the roof of their mouth. This 4-7-8 cycle can help immensely and can be done in the future.  
• 5-4-3-2-1 technique: Have the person think of 5 things they can see in the room, 4 things they can feel, 3 they can hear, 2 they can smell, and 1 they can touch. This can help ground the person in the present moment, instead of getting lost in traumatic memories.  

Identification and Assessment  

While a healthcare provider may suspect a patient is potentially being trafficked, certain considerations need to be made when assessing this population. A person being trafficked may be present for care at any time, in any situation. They may want to be seen for an injury related to their trafficking, or for something else, like mental health services, dental care, evaluation of pre-existing conditions, addiction treatment, or a general check-up (19).  

In a 2014 study, nearly 88% of human trafficking victims sought healthcare while in their situation, 68% of which were emergency services (19). Perhaps more concerningly, more than half of the survivors surveyed in another study stated that they were not asked any questions about trafficking or abuse during their healthcare visit (27).  

Challenges and Opportunities When Interfacing with Trafficked Persons  

While there are many reasons human trafficking goes undertreated and underreported, the practitioner must keep in mind that disclosure is not necessarily the ultimate goal when encountering these victims.  

First and foremost, the person’s safety is paramount, then their medical care, and finally, if appropriate and with available resources, disclosure of the potential crimes.  

Though not exhaustive, the following are some challenges healthcare professionals may face when they encounter potential victims of human trafficking, and ways they may be addressed: 

1. Guilt or shame: Victims may often feel guilty for what has happened to them or feel ashamed of their situation. The practitioner should do their best to provide calm, non-judgmental care. This can be conveyed through open body language, cultural awareness, eye contact as appropriate, and a non-rushed manner of talking and assessing.  

What to say:  

“I’m here for you to listen to what you have to say. It is not my job to judge you”.  

“This situation is not your fault.”  

What NOT to say:  

“How come you let yourself get into this situation?”  

“Does your mother know what you do for a living?” 

1. Lack of trust: Due to the nature of the crime, traffickers have likely conditioned their victims to distrust healthcare providers, law enforcement professionals, and others. Though more time consuming, building as much trust as possible is in the best interest of human trafficking victims.  

Ways to establish oneself as trustworthy are to first establish a private setting to interview and assess the patient. Follow through on promises, give the person time to speak, exude a calm demeanor, and reiterate to the person that they are in a safe place.  

What to say:  

“I care about your safety and your health.”  

“I will help you to the best of my ability.”  

What NOT to say:  

“What do you think I can do for you today?”  

“We’ll send you home soon and make a follow-up appointment”  

1. Language barrier: English may not be a language the victim speaks well or at all. Be wary of anyone accompanying the patient who wishes to act as sole interpreter. It is absolutely critical to use a formal interpreter provided by the practitioner’s facility.  

As much as possible, ensure that the interpreter has no relation to the potential victim or their situation, and has training in translating in situations such as these.  

What to say:  

“We will get you a professional interpreter.”  

“Please let me know if you don’t feel comfortable talking about this.”  

What NOT to do:  

Do NOT use the person who accompanied the patient as the interpreter.  

Do NOT use your phone’s translation app or other informal web-based program.  

1. Psychological disturbances: Whether from prior history, acute trauma, substance abuse, or a combination of these factors, many people who are trafficked may not be able to fully discuss their situation upon initial assessment. It may take time for the victim to be more coherent, particularly if the disturbances are drug-induced.  

What to say:  

“I’m here for you if you would like to talk.” 

“I can wait until you feel a little better.”  

What NOT to say:  

“Why did you use drugs if you knew you were going to come in here?” 

“Focus and talk to me.” 

Case Study: Mahad 

After getting Mahad in the room alone, you secure the services of your facility’s formal interpretation service. Through the interpreter, you ask Mahad if his cell phone is off. After a minute, he reluctantly turns it off. Next, you ask Mahad if he would like a male interviewer instead, or a male chaperone, since some cultures prefer to speak with the same gender for these types of encounters. Mahad declines, and you are able to begin your formal history and physical.  

Throughout the process, you discover that Mahad came to this country from Somalia on a student visa three years ago, and his visa is now expired. The man accompanying him is not his uncle, but rather one of the people he works for at the metal stamping plant. The man, who just goes by the letter J, found Mahad when his student visa was expiring, and promised him a lucrative factory job and a place to stay. After a month of working without a paycheck, Mahad asked J where his money was. J told Mahad that he owed him the cost of the room at the factory, as well as a referral bonus for getting him the job in the first place. That was now six months ago, and Mahad has yet to see any money.  

When Mahad tried to leave the factory to return home to Somalia, he found the factory perimeter locked and a guard who prevented him from leaving. J confronted Mahad and told him if he left, he would face arrest and deportation. At that time, J took Mahad back to his room and severely beat him. Mahad states that he has been working for 14 to 16 hours a day with hardly any breaks. At night, he and the other workers drink whiskey until they fall asleep, since J provides one meal a day and allows the workers to bond over drinking alcohol the company provides. Mahad states there are seven other men living with him in cramped quarters, all of them from Somalia. The other men tell Mahad that they have been there for years and have been threatened with death or deportation if they leave the factory grounds.  

Mahad states that this is his third visit to the emergency department. He had come before due to a concussion sustained from a work-related injury, as well as alcohol poisoning before that. He said no one had ever asked him much about his situation, assuming he was a lazy alcoholic.  

Upon examination, Mahad is cooperative but with a flat affect. He states things matter-of-factly, without much emotion. His skin assessment reveals bruises on all extremities, his back, and his abdomen. His sclera appears jaundiced, and he endorses right upper quadrant pain accompanied by intermittent nausea. He states he has had no appetite for the past few days and was only allowed to come to the emergency department because of his inability to work. J stated that he was to get seen, get put on medications to help, then get back to work immediately.  

Barriers to Disclosure  

As stated before, the healthcare provider’s main goal with a potential victim of human trafficking should be to maintain safety and focus on their well-being. There may be myriad, insurmountable reasons a person may not want to disclose their situation. These include, but are not limited to (22):  

• Fear of arrest: Due to the illegal nature of human trafficking and some of the illicit industries it encompasses, the victim may worry about being arrested and incarcerated.  
• Fear of retaliation: Traffickers may have threatened the victim’s family or friends if disclosure occurs.  
• Fear of deportation: If the victim is not a US citizen, they may worry that they will be sent back to their country of origin, where the situation may be even worse for them.  
• Fear of stigmatization: It may be humiliating or embarrassing for a person to disclose all that has happened, exacerbated by the extra layer of social stigma.  
• Lack of trust of the healthcare workers: Even if the trafficker has not predisposed their victim to mistrust of the healthcare system, the particular individuals the victim encounters may not develop sufficient trust for the victim to feel comfortable disclosing their situation.  

Provider Challenges to Identification and Response  

In addition to the barriers related to a victim’s self-disclosure of their trafficking, there are more challenges to identifying potential human trafficking victims. Generally, these fall into two categories: provider-related and individual-related (29). To prevent individual-related barriers, the practitioner should be aware of them and be prepared to resolve them.

Provider-Related Barriers 

While there is increasing awareness of healthcare providers to identify and treat human trafficking victims, some roadblocks still remain. Common reasons providers may not be able to properly recognize or assist victims may include:  

• Lack of understanding of human trafficking and related laws 
• Bias of how a person who has been trafficked may present 
• Feeling the case may be too complex for their level of practice 
• Uncertainty of available resources or referral options 
• Not having adequate training on trauma-informed care; may exhibit victim-blaming and/or culture stereotyping 
• Misidentifies the case, often as abuse or neglect without further context 
• Lack of access to neutral and appropriate translators 
• Feeling that it is not their role to get too involved in the case 
• Frustration with questioning patient: may feel their story is rehearsed, or that the patient is hostile or uncooperative 
• Concern over fears of violating HIPAA (Health Insurance Portability and Accountability Act)  

Individual-Related Barriers 

Since human trafficking is a complex matter with no cookie-cutter case, the victims themselves may also have difficulty identifying themselves as such. Other possible obstacles of people who have been trafficked include:  

• Language barriers and/or limited literacy that hinder communication 
• Lack of identification 
• Legal worries: not understanding their rights in this case, or feeling complicit in an illegal activity  
• Concern that the traffickers will cause harm to the patient or their loved ones 
• Fear of deportation, arrest, being sent back to an abusive place, or going into foster care 
• Presence of trauma bonding (also called Stockholm Syndrome) with the trafficker and/or other victims 
• Feelings of shame, fear, guilt, hopelessness, and helplessness 
• Lack of trust toward the provider and/or other authority figures 

How to Combat Barriers to Identification  

First and foremost, it is crucial to establish trust with the potential victim of trafficking. The healthcare provider must have the person’s well-being and safety as their primary goals. Trust can be developed by slowly talking to the patient, keeping body language open and non-judgmental, and giving plenty of time to speak. Personal space and eye contact are to be dictated by the patient’s perceived comfort, as well as their culture.  

The provider should reiterate to the person that the clinical environment is always a safe one, and that their information will be kept as confidential as possible, within the limits of the law. If possible, it may be helpful to enlist the help of others in the facility: a social worker, sexual assault nurse examiner (SANE) nurse if required, legal counsel, patient advocate, and others. If the patient fears retaliation on their family members or other loved ones, they should know they can get help in this matter and can return to the healthcare facility any time as needed.  

Providers need to be aware of their own implicit biases. Human trafficking victims are a diverse population; there is no single gender or racial or ethnic makeup that comprises this group of people. Men, especially those working in manual labor jobs and the hospitality industry, can also be trafficked, regardless of age, race, or religion. Furthermore, the provider should be aware that in cases of sexual assault or abuse, a further investigation needs to be done to determine if the situation involves trafficking. Simply treating a sexually transmitted disease and discharging the patient after being seen by a SANE nurse is not sufficient care if trafficking is suspected.  

The Importance of a Professional, Unbiased Interpreter 

In the United States, it is estimated that over 350 languages are spoken (30). It is thus likely that in any given shift, a healthcare provider will need at least some degree of translation services for their patients. When working with potential human trafficking victims, it is of the utmost importance that an unrelated, unbiased, professional translator be used. This interpreter should have familiarity with medical language and be free from judgment when translating for the patient. Some things to keep in mind when using an interpreter service for potential victims are (30):  

• If possible, talk to the interpreter alone before talking with the patient to briefly explain the situation. The interpreter should be calm and free of prejudice, ideally having had experience with this type of situation before. Both the provider and interpreter should use a trauma-informed, patent-centered approach.  
• Ensure the patient’s comfort with the particular interpreter; the patient may wish to specify a certain gender, race, or dialect to best meet their needs.  
• An in-person translator is always preferrable, though not always feasible.  

Maintaining a Safe Environment for Staff and Patients  

Without proper safety measures, an encounter with a person who is potentially being trafficked, especially if they are present with their trafficker, can become dangerous very quickly. Providers should remember that human traffickers are criminals and may be armed or violent (35).  

The healthcare practitioner must take steps to ensure that everyone remains safe, including other staff members and patients. When meeting with a potential victim of human trafficking, here are some ways to best maintain a safe environment (35, 37):  

• Privacy: Have a plan to get the patient alone to conduct the interview and assessment. This may be difficult to enforce, so it is critical to have a protocol in place to ensure private conversations with those suspected of being trafficked. There should be a plan to physically separate the patient from their escort and may require the services of security personnel. Some strategies may include: 

• • Assess the power dynamics between the patient and accompanying person(s), and if the patient seems to be comfortable talking about their situation 
  • Decide who is to do the separating  
  • Give reasons such as the patient needs to go for a diagnostic test in another area; cite clinic or hospital policy to interview the patient alone; ask the accompanying party to step out to help complete paperwork or a phone call for scheduling an appointment 
  • Always maintain safety in the environment, noting that involving law enforcement at this point might not always be in the best interest of the patient, particularly terms of future safety 

• Safety Screening: Ask questions pertaining to the person’s physical safety at the time of the interview. This might include asking:  

• • Do you feel safe talking here?  
  • Is there anything that would make you feel safer here as we talk?
  • Can you bring information or phone numbers back with you?
  • Is it safe to contact you another day? If so, which phone number is best? How should I introduce myself when I call? How can we get back in touch if we get disconnected?  

• Conclusion of Visit: If the patient is discharged, how can it be done safely? If the patient is admitted for further care, what will be done with the person escorting them? Does law enforcement need to be involved? If so, how will that be handled? There should be a protocol in place to address these and other immediate safety concerns.  

The Healthcare Provider’s Role  

If the healthcare practitioner suspects a patient is being trafficked, these are the steps that should be taken (47):  

1. Provide safety and privacy for the person.  
2. Assess and treat the medical conditions.  
3. Follow mandatory state reporting laws, as described in the Mandated Reporting section below. 
4. Follow institutional policies for law enforcement involvement if patient is in immediate, life-threatening danger. As much as possible, work with the patient to determine whether or not to involve law enforcement. 
5. Offer the patient resources for reporting and additional services, as described below.  
6. During discharge planning, address safety concerns and future plans. 
7. Ensure proper documentation of assessment and treatment, as described below.  

Survivor-Centered, Multidisciplinary Referrals 

For a situation as sensitive as human trafficking, it is crucial to provide survivor-centered, multidisciplinary referrals to all victims. The referrals should be both within the healthcare organization where the survivors are seen, as well as with community partners. Having survivor engagement enables organizations to better serve this population, as well as create better programs and opportunities within the healthcare system and the larger community.  

Since each survivor is unique, he or she will require a specific mix of resources. These can include any and all of the following: public health professionals, survivor networks, healthcare, legal aid, law enforcement, social services, and behavioral health. Depending on the person’s situation, emergency resources might be needed for housing, food, medical and mental healthcare, substance abuse treatment, legal assistance, and overall safety (48). Ongoing needs may also include transportation to service appointments, therapeutic counseling, and emotional support.  

Appropriate Documentation  

As with all other aspects of nursing, documentation is key. In cases of human trafficking, however, this proves challenging for several reasons. First and foremost, the healthcare practitioner’s role with the patient is to diagnose and treat, while providing for safety. There may be legal ramifications for any information included in the medical record, and legal counsel should be available in cases such as these (37).  

Some aspects to consider include (37): 

• Limit the amount of initial questioning if a SANE nurse evaluation will be done; the SANE nurse will collect evidence with patient consent, and keeping the rehashing of the situation to a minimum will reduce the likelihood of retraumatizing the patient even further.  
• If the case goes to trial, some information entered into the medical chart can harm the victim (e.g., if the patient was involved in illicit activity, they may be prosecuted for this). It is best for the practitioner to clarify with law enforcement and prosecutors how the information may be used and released.  
• In cases of sexual assault or injury, using direct quotations from the patient can be helpful, but might be detrimental if any of the details of the story change later on.  
• Any photographs taken during the medical assessment may be shared with a defense attorney and potentially the traffickers themselves; this can retraumatize the victim, particularly if these photographs are displayed during their trial.  
• Developing an institutional system for flagging potential victims of human trafficking is beneficial; documentation of resources provided (e.g., “Gave patient number for National HT Hotline” or “Referred patient to community agency…”) can both protect the patient and show the clinician’s suspicion of the situation.

Mandated Reporting  

The healthcare provider is in a unique position when it comes to human trafficking cases. While the primary goals are to provide patient safety and give high-quality medical care, there are also legal obligations in certain cases.  

If a minor, elderly person, or person with a mental or physical disability is suspected of being a victim of human trafficking, they are classified as being abused under Texas law, and thus fall under the mandated reporting category for healthcare professionals (41).  

In Texas, mandated reporting obligations pertain to suspected abuse, neglect, or exploitation of the following populations (38):  

• Children under the age of 18 
• Elderly persons aged 65 or older
• People with disabilities

Suspected abuse or neglect of children must be reported within 48 hours. For suspected abuse or neglect of those 65 or older or adults with disabilities, a report must be made to the Department of Family and Protective Services (DFPS) and/or law enforcement immediately. This task may not be delegated to anyone else; the provider who suspects the abuse is responsible for making the report (40, 41).  

The following information for must be included in cases involving the elderly or people with disabilities: The name, age, and address of the suspected victim; the name and address of the caretaker or person involved; the nature and extent of the abuse, neglect, or exploitation; the basis of the reporter’s knowledge; any other relevant information. Failure to report suspected cases can result in a Class A misdemeanor. Further, as long as the report was made in good faith, the reporting party is immune from civil or criminal liability in Texas (38).  

All suspicions described above should be reported to the Texas Department of Family and Protective Services (DFPS) at 1-800-252-5400, particularly if they are urgent and need to be investigated within 24 hours (40).  

As always, in a life-threatening situation outside of a hospital or correction facility, it’s best to call 9-1-1. For matters that can wait more than 48 hours, an online report may be made to DFPS here: https://www.txabusehotline.org/Login/Default.aspx .  

As of September 1, 2023, all reports of children suspected of being abused, neglected, or exploited can no longer be made anonymously to DFPS. Reporters must give their first and last name and a phone number where they may be reached. Though not anonymous, this information is kept confidential by law. If the reporter wishes to make an anonymous report, they may do so with local and state law enforcement agencies instead (40).  

A healthcare provider is not to report the abuse of adults younger than 65 and with no disability without the trafficked person’s consent. Still, the provider can submit a report to the National Human Trafficking Hotline (888-373-7888), without the trafficked person’s identifying information (46). It should be reiterated to the patient that they are welcome to return to the facility any time, that they are safe there, and that they can decide to report at any time.  

Implications of Law Enforcement  

As discussed in this course, victims of human trafficking may be understandably fearful or apprehensive of law enforcement. Depending on the concurrent crimes involved during the period of trafficking, the survivor may face legal repercussions. Luckily, law enforcement officials can provide some resources to healthcare providers, including (42):  

• Local victim service providers 
• A network of resources available through a human trafficking task force, where available 
• Assistance with applying for immigration relief  

It is best for the provider to limit disclosures to law enforcement related to the individual if the potential victim of trafficking wishes to speak to law enforcement, or if the provider suspects imminent danger to the staff and/or individual (42).  

Contacting Community, Local, and/or State Resources  

Fortunately, there are a wide variety of resources available for people who are trafficked and the clinicians who take care of them.  

The National Human Trafficking Hotline, or NHTH (888-373-7888), is available 24/7, toll-free.  

The NHTH is also available by texting BeFree, or 233733.  

This hotline helps maintain a federal database of anti-trafficking agencies and resources and is a response to protecting trafficked persons. The NHTH also has an online directory of anti-trafficking services and groups: https://humantraffickinghotline.org/en/find-local-services.  

In Texas, there is a wide array of online resources that can aid practitioners and potential victims of human trafficking or other forms of abuse:  

• Texas Association against Sexual Assault (TAASA): https://taasa.org/
• The TAASA Service Directory: http://taasa.org/wp-content/uploads/2018/10/TAASA_Service-Directory-102318.pdf
• Texas Department of Family and Protective Services (DFPS) and/or local law enforcement: Reporting Abuse, Neglect, or Exploitation: https://www.dfps.texas.gov/Contact_Us/report_abuse.asp
• Texas Health and Human Services (HHS) Provider Guidebook: Services for Victims of Human Trafficking in Texas: https://www.hhs.texas.gov/sites/default/files/documents/services/safety/human-trafficking/provider-guidebook-services-victims-human-trafficking-texas.pdf
• Office of the Texas Governor’s Child Sex Trafficking Team: https://gov.texas.gov/organization/cjd/childsextrafficking 

(3) 

Organizational Protocols 

With such a multifaceted issue as human trafficking, it is essential that every healthcare organization have clear policies, guidelines, and protocols for responding to this situation. While awareness of the issue is on the rise, many facilities are lacking adequate resources and training to combat human trafficking. 

The benefits of organizational protocols include some of the following (37): 

• Optimizing patients’ interaction with healthcare staff 
• Improving staff’s ability to recognize and appropriately treat patients at risk for trafficking  
• Maximizing staff and patient safety 
• Assuring adequate support for trafficked patients who are not ready or able to disclose their situation or accept assistance  

To develop a functional and helpful protocol within a healthcare setting, these are some of the first steps (37): 

1. Identify community multidisciplinary responders 
2. Engage non-medical community entities  
3. Utilize medical stakeholders within the community 
4. Understand local and national indicators of health and human trafficking  
5. Create and convene an interdisciplinary protocol committee 
6. Develop a multidisciplinary treatment and referral plan

(49)

Building a Trusted Local Network of Resources  

Since each community has its own unique population, various resources may be needed to appropriately address the needs of the individuals involved. It would behoove the practitioner and their institution to establish or build upon a list of resources available for human trafficking. In addition to the list above, there may be other services available in each community. Establishing a good working relationship with local social workers, lawyers, and law enforcement officers is crucial for any healthcare establishment.  

Conclusion

Human trafficking is a heinous crime that affects individuals from every walk of life. In the United States, most of those who are trafficked will seek some form of healthcare during the time they are trafficked. It is up to healthcare professionals to collaborate with relevant community resources to provide safe, adequate, compassionate care to this vulnerable population.  

It is essential that healthcare providers be aware of the people and organizations available to help their patients, and to have an institutional protocol in place to appropriately address the issue of human trafficking.  

By providing patient-centered, trauma-informed care, the healthcare professional will be able to best assist survivors of human trafficking. This means adopting a nonjudgmental approach to all patients, and to realize why disclosure is not necessarily a goal of each encounter. Local law enforcement and social services may be needed, and accurate documentation is crucial in all these cases.  

Finally, the practitioner should be aware of mandated reporting laws, as well as how to best provide adequate safety and confidentiality for their patients. It is with all these concepts in mind that the healthcare field may help more fully address the challenges inherent in human trafficking.  

Quality Improvement for Nurses

Introduction   

Welcome to the world of Quality Improvement (QI) in healthcare, a dedicated field committed to continually enhancing patient care and outcomes. Quality Improvement involves a systematic approach to identify, analyze, and address areas for improvement within healthcare processes, ultimately resulting in improved patient safety, satisfaction, and overall healthcare excellence (13). In this course, we will embark on a journey to explore the fundamental principles and practical applications of QI, explicitly tailored for nurses who aspire to make a positive impact in their healthcare settings.

As a nurse, you know the significance of providing high-quality patient care. However, you may wonder how you can actively contribute to improving the systems and processes in your workplace.

Imagine this scenario: You observe a recurring issue with medication administration, where doses are occasionally missed due to workflow inefficiencies. Through this course, you will acquire the knowledge and skills to apply QI methodologies like Plan-Do-Study-Act (PDSA) cycles to investigate such issues, implement changes, and monitor the impact of your interventions. By understanding QI principles and tools, you will be better equipped to collaborate with your colleagues, drive meaningful improvements, and ensure that your patients receive the best care possible.

What is Quality Improvement?

Quality Improvement (QI) in healthcare represents an ongoing, systematic effort to elevate the quality of patient care and healthcare services that involves identifying areas needing improvement, implementing changes, and evaluating the effects of those changes to ensure better patient outcomes (12).

Let’s envision a scenario where a hospital's surgical department grapples with a higher-than-average rate of post-operative infections. Through a QI initiative, the healthcare team can meticulously scrutinize the surgical processes, pinpoint potential sources of infection, and introduce evidence-based practices such as enhanced sterilization techniques or more rigorous antibiotic prophylaxis protocols. Over time, they can gauge the effectiveness of these changes by monitoring infection rates for a reduction.

Commonly used QI methodologies in healthcare include the DMAIC (Define, Measure, Analyze, Improve, Control) process and the Plan-Do-Study-Act (PDSA) cycle. These approaches provide structured frameworks for healthcare professionals to tackle issues systematically and iteratively. For example, imagine a bustling primary care clinic with extended patient wait times.

Here, the PDSA cycle can come into play using the systematic iterative steps below:

1. The team defines the problem (lengthy wait times)
2. The team proceeds to test a change (for example, adjusting appointment scheduling)
3. The team then scrutinizes the results and acts accordingly to refine the process.

History and Background of Quality Improvement 

The history and background of Quality Improvement (QI) in healthcare have a rich and evolving timeline, dating back to the early 20th Century, with significant developments occurring over the years. One pivotal moment in this journey was the introduction of statistical quality control by Dr. Walter A. Shewhart in the 1920s (24). Dr. Shewhart's pioneering work laid the foundation for using statistical methods to monitor and enhance processes, a concept that would become integral to QI initiatives (24). 

In the mid-20th Century, the contributions of Dr. W. Edwards Deming further propelled QI principles forward (7). Dr. Deming emphasized the significance of continuous improvement, active employee engagement, and process variability reduction. His ideas found fertile ground in post-World War II Japan, playing a crucial role in the nation's economic recovery and the emergence of renowned companies like Toyota, famous for its Toyota Production System (TPS), incorporating QI concepts (7). 

Until today, QI has become indispensable to healthcare systems worldwide (16). To illustrate, envision a scenario where a hospital grapples with a high readmission rate among heart failure patients. By scrutinizing historical data and implementing evidence-based protocols for post-discharge care, hospitals can effectively lower readmissions, enhance patient outcomes, and potentially evade financial penalties under value-based reimbursement models (16). 

Models 

At the heart of ongoing transformations in healthcare lies various Quality Improvement (QI) models. These models provide structured frameworks for identifying and addressing areas of improvement within healthcare systems (14). These models offer healthcare professionals a systematic approach to instigate meaningful process changes, ultimately resulting in elevated care quality. See some models below. 

Model for Improvement 

The Model for Improvement is a widely recognized and highly effective framework for Quality Improvement (QI) in healthcare. This is because it empowers healthcare professionals to systematically test and fine-tune their ideas for process improvement, ensuring that changes are grounded in evidence and proven effective (17).  

The Model for Improvement offers a structured and systematic approach to identifying, testing, and implementing changes to enhance healthcare processes and ultimately elevate patient outcomes.  

Developed by Associates in Process Improvement (API), this model revolves around the iterative "Plan-Do-Study-Act" (PDSA) cycle, which forms the foundational structure of QI initiatives (17). The Plan-Do-Study-Act (PDSA) cycle is a systematic approach that guides healthcare teams through quality improvement, and it comprises the four key phases below, each contributing to developing and implementing meaningful changes in healthcare practices (12). 

• Plan: In this initial phase, healthcare teams define the specific problem they aim to address, set clear and measurable goals, and craft a comprehensive plan for implementing the proposed change. For instance, if a hospital seeks to reduce patient wait times in the emergency department, the plan may involve adjustments to triage protocols or streamlining documentation processes. 
• Do: Once the plan is established, the proposed change is implemented, typically on a small scale or within a controlled or pilot environment. This enables healthcare professionals to assess the feasibility and potential impact of the change without making widespread adjustments. 
• Study: The study phase involves rigorous data collection and analysis to evaluate the effects of the change. In our example, the hospital would measure the impact of the new triage protocols on wait times, closely examining whether they have decreased as expected. 
• Act: Based on the findings from the study phase, the healthcare team makes informed decisions about the change. They may adopt the change if it has successfully reduced wait times, adapt it further for enhanced effectiveness, or, if necessary, abandon it.

The PDSA cycle's iterative nature means adjustments can be made, and the cycle repeats until the desired improvement is achieved (12).

Lean Model 

The Lean model, initially conceived in the manufacturing sector, has found considerable success and applicability in healthcare as a potent tool for process enhancement and waste reduction (22). At its core, Lean thinking revolves around the principles of efficiency and value optimization because it focuses on refining processes to eliminate wasteful elements while simultaneously delivering care of the highest quality (22).  

Healthcare organizations have adopted Lean methodologies to tackle many challenges, from reducing patient wait times to improving inventory management and elevating overall patient satisfaction (22). For instance, when a hospital is challenged with prolonged wait times in its outpatient clinic, it can apply Lean principles to systematically analyze the patient flow, pinpoint bottlenecks, and streamline processes.  

This might involve reconfiguring furniture to enhance flow, adjusting appointment scheduling, or implementing standardized work procedures. The ultimate objective is to cultivate a patient-centric, efficient environment that ensures timely access to care while meticulously conserving time and resources. 

Another integral aspect of Lean thinking is the unwavering commitment to continuous improvement and the pursuit of perfection through the systematic identification and eradication of various forms of waste (19). The forms of waste are often categorized into seven types: overproduction, waiting, unnecessary transportation, overprocessing, excess inventory, motion, and defects (19). By keenly identifying and addressing these forms of waste, healthcare organizations not only enhance the utilization of resources but also curtail costs and elevate the overall quality of care delivery. 

Six Sigma model  

The Six Sigma model is a robust and widely adopted healthcare method for improving processes and reducing mistakes (9). It was first used in manufacturing but is now used in healthcare to make processes more consistent and improved by finding and fixing mistakes and inefficiencies (9).  

An example is when a hospital is concerned about the accuracy of medication dosing for pediatric patients, a Six Sigma team might include: indicating the problem, gathering data on mistakes regarding dosing, and finding out why the mistakes happened. The strategy may encompass the implementation of standardized dosing protocols, refining staff training programs, and closely monitoring the medication administration process to ensure that mistakes are eliminated. 

Six Sigma uses a framework called DMAIC (Define, Measure, Analyze, Improve, Control) to make improvements. This framework utilizes data-driven tools to discern problems, quantify their origins, develop practical solutions, and institute control mechanisms to sustain improvements (11). Through this systematic journey, healthcare organizations position themselves to deliver care of elevated quality, curtail costs, and bolster patient safety.  

TeamSTEPPS model 

TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety, is a teamwork and communication model designed explicitly for healthcare settings (4). Developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS focuses on improving patient safety by enhancing team collaboration, communication, and decision-making among healthcare professionals (4). 

One key element of TeamSTEPPS is using structured communication techniques to prevent errors and misunderstandings. For instance, during patient handoffs from one healthcare provider to another, TeamSTEPPS emphasizes using a structured tool like SBAR (Situation, Background, Assessment, Recommendation) to convey critical information succinctly and accurately. This ensures that essential patient details are noticed, reducing the risk of adverse events (18). 

In a surgical team scenario, TeamSTEPPS principles can be applied to improve teamwork and communication among surgeons, nurses, and anesthesiologists. The model encourages briefings before procedures to set clear objectives, huddles during surgery to address emerging issues, and debriefings afterward to reflect on the process and identify areas for improvement. By fostering a culture of open communication and mutual respect, TeamSTEPPS contributes to safer, more efficient healthcare delivery (4). 

IOM Six Domains of Patient Care 

The Institute of Medicine (IOM), now known as the National Academy of Medicine, introduced the Six Domains of Quality in Healthcare as a framework to assess and improve the quality of patient care (14). These domains, introduced in 2001, encompass various aspects of care delivery and patient experience, helping healthcare organizations and providers identify areas for improvement (14). The domains serve as pillars for assessing the different dimensions of care delivery, ensuring that healthcare organizations and providers address the holistic needs of patients (14).  

Definitions  

The Six Domains of Patient Care are essential for providing high-quality healthcare. See definitions of each of the IOM's six domains of patient care below. 

• Safe: Safety is the foundational domain, emphasizing the importance of reducing the risk of patient harm. This includes preventing medical errors, preventing infections, and ensuring the safe administration of medications. Healthcare organizations implement safety protocols and engage in continuous monitoring to minimize risks (14). 
• Effective: Effective care ensures that patients receive evidence-based treatments and interventions that result in the desired outcomes. It involves using the best available scientific knowledge to make informed decisions about patient care avoiding unnecessary or ineffective treatments (14). 
• Patient-Centered: Patient-centered care focuses on individualizing healthcare to meet each patient's unique needs and preferences. It involves respecting patients' values and preferences, engaging them in shared decision-making, and delivering care with empathy and compassion (14). 
• Timely: Timely care emphasizes reducing delays in healthcare delivery. It includes providing care promptly and avoiding unnecessary waiting times for appointments, tests, and treatments. Timely care is especially critical in emergencies (14). 
• Efficient: Efficiency in healthcare means maximizing resource utilization and minimizing waste while providing high-quality care. This domain emphasizes streamlining processes, reducing unnecessary costs, and optimizing healthcare resources (14). 
• Equitable: Equitable care underscores the importance of providing healthcare that is fair and just, regardless of a patient's background, socioeconomic status, or other factors. It aims to eliminate healthcare access and outcomes disparities among different patient populations (14). 

Measures 

Measures in the context of the Institute of Medicine (IOM) six domains of patient care refer to the metrics and indicators used to assess and evaluate the quality of care provided in each domain. According to (14), the measures below are essential for monitoring and improving healthcare services. See details below. 

• The "Safe" domain measures focus on tracking and reducing adverse events and medical errors. Key indicators include rates of medication errors, hospital-acquired infections, falls, and complications from procedures. Safety measures also assess the implementation of safety protocols, such as hand hygiene compliance and patient identification bracelets. 
• Measures in the "Effective" domain assess how evidence-based practices and treatments are utilized. These measures include adherence to clinical guidelines, appropriate use of medications, and the success rates of medical interventions. Additionally, outcomes such as patient recovery, remission, or improvement are indicators of the effectiveness of care. 
• The "Patient-Centered" domain focuses on assessing the patient’s experience and satisfaction with care. Patient surveys and feedback are standard measures, evaluating aspects like communication with healthcare providers, involvement in decision-making, and overall satisfaction with the care received. Healthcare organizations also measure shared decision-making and respect for patient preferences. 
• Measures related to the "Timely" domain evaluate the efficiency of healthcare delivery. Key metrics include waiting times for appointments, diagnostic tests, and procedures. Additionally, measures track the timely delivery of urgent care and the avoidance of unnecessary delays in treatment. 
• Efficiency measures aim to quantify resource utilization and the reduction of waste in healthcare. Metrics may include the cost of care per patient, length of hospital stays, and resource allocation efficiency. Improvement in resource utilization and cost-effectiveness are vital indicators of efficiency. 
• Measures within the "Equitable" domain assess disparities in healthcare access and outcomes among different patient populations. Healthcare utilization and outcomes data are stratified by demographics, socioeconomic status, race, and ethnicity to identify and address inequities. Key indicators include access to preventive care, healthcare utilization rates, and health outcomes across various demographic groups. 

Nursing Quality Indicators 

According to (5), nursing quality indicators are essential metrics used to evaluate and improve the quality of nursing care in healthcare settings. These indicators provide valuable insights into nursing practice and patient outcomes, helping healthcare organizations and nursing staff deliver safe, effective, patient-centered care. Let's delve into some key nursing quality indicators and their significance below. 

Patient Falls 

Patient falls are a critical quality indicator in nursing care since they can result in severe injuries and complications for patients (5). As a result, healthcare organizations measure and monitor the rate of patient falls to identify trends and implement preventive measures.  

For example, when a hospital notices an increase in the rate of falls among elderly patients in a particular unit, they may introduce interventions such as nonslip flooring, improved lighting, and patient education as fall prevention strategies to reduce the incidence of falls. 

Medication Administration Errors 

Ensuring accurate medication administration is crucial in nursing practice because medication errors can lead to adverse events, including patient harm or death (5). Nursing quality indicators related to medication administration errors include the rate of medication errors and adherence to medication reconciliation processes (5). For instance, nurses are encouraged to verify patient allergies and cross-check medication orders to prevent errors. If there is an increase in medication errors in a healthcare facility, it may prompt a review of medication administration protocols and additional staff training.

Pressure Ulcers (Bedsores) 

Pressure ulcers are a quality indicator of patient skin integrity since they develop when patients remain immobile for extended periods (5). As a result, healthcare organizations measure the incidence and prevalence of pressure ulcers as an indicator of the quality of nursing care (5).  

Patient Satisfaction 

Patient satisfaction is a patient-centered nursing quality indicator since it reflects the overall patient experience and perception of care (5). Surveys and feedback mechanisms are used to measure patient satisfaction. For example, a scenario might involve patients receiving post-discharge surveys that assess various aspects of their hospital experience, including nurse responsiveness, communication, and pain management. Healthcare organizations can use this feedback to identify areas for improvement and enhance patient-centered care. 

In summary, nursing quality indicators encompass a range of metrics that evaluate nursing care quality, patient safety, and patient experiences. By monitoring and responding to these indicators, healthcare organizations and nursing staff can continuously improve their quality of care, leading to better outcomes and increased patient satisfaction (5). 

Data Collection 

Quality improvement data collection is a critical component of healthcare quality initiatives, providing the necessary information to assess the current state of care, identify areas for improvement, and monitor progress over time (2). Accurate and meaningful data collection enables healthcare organizations to make informed decisions, implement evidence-based interventions, and ultimately enhance patient outcomes. Let's explore the methods of data collection below. 

• Clinical Outcome Collection: Clinical outcome data collection is essential for assessing the effectiveness of healthcare interventions (2). For example, consider a scenario where a hospital is implementing a quality improvement project to reduce surgical site infections (SSIs) following orthopedic surgeries. Data collection would involve tracking the number of SSIs occurring over a specific period and collecting information on patient characteristics, surgical techniques, and post-operative care protocols. By analyzing this data, the healthcare team can identify trends, risk factors, and areas for improvement, ultimately leading to targeted interventions to reduce SSIs. 
• Patient Satisfaction Survey Data Collection: Patient satisfaction surveys are valuable tools for collecting data on patient experience (2). A primary care clinic that aims to improve patient satisfaction may administer surveys to patients after each visit, asking about aspects of care such as communication with healthcare providers, wait times, and overall experience. The collected data can reveal areas of strength and areas requiring improvement. For instance, if survey results consistently indicate longer-than-desired wait times, the clinic can adjust scheduling practices or implement strategies to reduce wait times and enhance patient satisfaction. 
• Process Measures Data Collection: Process measure data collection focuses on evaluating the efficiency and effectiveness of healthcare processes (2). For instance, in a medication reconciliation scenario, a healthcare organization might collect data on the accuracy and completeness of medication lists during care transitions. By tracking the frequency of medication reconciliation discrepancies, they can identify process inefficiencies and implement standardized protocols for reconciliation, leading to safer care transitions and reduced medication errors. 
• Adverse Event Reporting Data Collection: Adverse event reporting is a crucial mechanism for collecting data on incidents that result in patient harm or near misses (2). For example, consider a scenario where a nurse administers the wrong medication dose to a patient but catches the error before any harm occurs. Reporting this near-miss event allows the healthcare organization to investigate the root causes, implement preventive measures, and share lessons learned with the care team to prevent similar incidents in the future. 

Types of Data 

Data types play a crucial role in understanding the current state of care, identifying areas for improvement, and implementing evidence-based interventions (2). Let’s explore the different types of data used in quality improvement below. 

• Quantitative Data: Quantitative data involves numerical measurements and is particularly useful for assessing the frequency and extent of specific events or outcomes (2). For instance, in a hospital's quality improvement project focused on reducing hospital-acquired infections, the team collects quantitative data on the number of infections over time, allowing them to track trends and measure the impact of interventions, such as hand hygiene protocols or disinfection practices. 
• Qualitative Data: Qualitative data provides insights into the "why" and "how" behind healthcare processes and patient experiences (2). This data type is collected through interviews, focus groups, and open-ended surveys. For example, in a primary care setting aiming to improve patient satisfaction, qualitative data may be collected through patient interviews to gather in-depth information about their perceptions of care. Qualitative data can uncover nuances and provide valuable context to complement quantitative findings (2). 
• Patient-Reported Data: Patient-reported data includes information directly provided by patients about their health, symptoms, experiences, and preferences. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are standard data collection tools. In a scenario involving chronic disease management, patients with diabetes may be asked to complete a PROM assessing their quality of life and symptom management. This data helps healthcare providers tailor care plans to individual patient needs and preferences (2). 
• Process Data: Process data track the steps and activities involved in healthcare delivery to help assess the efficiency and effectiveness of care processes. For example, in a surgical quality improvement initiative, process data may include the time from patient admission to surgery, surgical team checklist completion, and adherence to anesthesia protocols. By collecting and analyzing process data, healthcare organizations can identify bottlenecks and areas for improvement in care delivery processes. 

In summary, quality improvement data collection relies on various data types, including quantitative, qualitative, patient-reported, and processed data. Each data type contributes to a comprehensive understanding of healthcare quality and supports evidence-based decision-making to enhance patient care and outcomes. 

Identification Stage  

The identification stage for quality improvement data collection is a critical initial phase where healthcare organizations and teams define what data to collect, why it is relevant, and how it aligns with their quality improvement goals (23). This stage is essential for ensuring meaningful data collection efforts will lead to actionable insights. Let's explore the identification stage in more detail. 

• Defining Objectives and Goals: During this stage, healthcare organizations must clearly define the objectives and goals of their quality improvement initiative (23). For instance, a hospital aiming to reduce readmission rates for heart failure patients may set a specific goal of reducing readmissions by 20% within the following year.  
• Selecting Relevant Metrics: Identifying the right metrics and data points is crucial, and organizations should choose metrics that directly relate to their quality improvement goals (23). Continuing with the example of reducing heart failure readmissions, relevant metrics might include the number of heart failure patients readmitted within 30 days, the reasons for readmission, and patient characteristics. By selecting these metrics, the organization ensures that data collection efforts are aligned with their specific improvement goal. 

• Determining Data Sources: Healthcare organizations must identify where the necessary data will be sourced (23). This may involve looking at electronic health records, claims data, patient surveys, or other sources. For instance, to collect data on heart failure readmissions, the hospital may extract relevant information from electronic health records, including admission and discharge dates, diagnosis codes, and patient demographics. 
• Creating Data Collection Protocols: Establishing clear data collection protocols is essential for consistency and reliability (23). Healthcare teams should define how data will be collected, who will be responsible for data collection, and the frequency of data collection. For example, in a hospital project aiming to improve hand hygiene compliance, data collection protocols might specify that trained observers will monitor hand hygiene practices at random intervals and record their findings on standardized forms. 

By carefully navigating the identification stage, healthcare organizations ensure that their quality improvement data collection efforts are purposeful and aligned with their goals. This sets the stage for collecting meaningful data to drive evidence-based decisions and interventions to enhance healthcare quality. 

Gathering Stage  

The gathering stage of quality improvement data collection is crucial for healthcare organizations to collect the identified data based on their quality improvement objectives and goals (23). This stage involves systematically collecting data from various sources and often requires careful planning and coordination to ensure data accuracy and completeness. Let's delve into the gathering stage in detail below. 

• Data Collection Methods: To gather data, healthcare organizations must determine the most suitable methods for collecting the identified data, which may involve a combination of electronic health records, patient surveys, direct observations, and administrative databases (23). For example, in a quality improvement project aimed at reducing hospital readmissions, data may be collected by reviewing electronic health records to track patient outcomes, conducting patient surveys to gather feedback on discharge instructions, and analyzing administrative data to identify trends in readmission rates. 
• Ensuring Data Accuracy and Consistency: Data accuracy is critical in the gathering stage, and organizations must implement procedures to collect data consistently and without errors (23). For instance, if a healthcare facility is collecting data on medication administration, nurses may use standardized protocols to accurately record medication administration times and doses. Regular training and quality checks may also be implemented to maintain data accuracy. 
• Timely Data Collection: Timeliness is another important aspect of the gathering stage, and data should be collected promptly to ensure it is current and relevant for analysis and decision-making (23). In a scenario involving tracking patient outcomes, healthcare teams may set specific intervals for data collection, such as collecting post-surgical complication data daily or weekly, depending on the project's requirements. 
• Data Security and Privacy: Protecting patient data is a paramount concern in healthcare. As a result, healthcare organizations must adhere to strict privacy and security protocols during the gathering stage to ensure that patient information is handled confidentially and complies with applicable laws and regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) (23). For example, when collecting patient-reported data, organizations may anonymize responses to protect patient identities and comply with privacy regulations. 

By effectively managing the gathering stage, healthcare organizations can ensure that they collect accurate, timely, and secure data that will serve as the foundation for subsequent analysis and quality improvement efforts. 

Analysis stage  

The analysis stage for quality improvement data collection is a critical phase where collected data is processed, examined, and transformed into actionable insights. This stage involves various analytical techniques and tools to identify patterns, trends, and areas for improvement (2). Let's explore the analysis stage in detail below. 

• Descriptive Analysis: Descriptive analysis is the initial step in data analysis, focusing on summarizing and presenting data meaningfully (2). For example, in a quality improvement project aimed at reducing patient wait times in an emergency department, an analysis may involve calculating and displaying key statistics, such as average wait times, 95th percentile wait times, and the distribution of wait times (2). These descriptive statistics provide an overview of the current situation and help identify areas that need attention. 
• Root Cause Analysis (RCA): Root cause analysis is a critical aspect of the analysis stage, as it helps pinpoint the underlying causes of issues or problems (2). In our scenario, if the analysis reveals prolonged wait times in the emergency department, RCA may involve a thorough investigation into the factors contributing to the delays. Potential root causes include staffing shortages, inefficient triage processes, or bottlenecks in diagnostic testing. Identifying these root causes is essential for developing effective interventions. 
• Statistical Analysis: Statistical analysis plays a vital role in quality improvement by examining the relationships between variables and testing hypotheses (2). In reducing hospital readmissions, statistical analysis may be used to identify factors associated with readmission risk. For example, healthcare teams can use logistic regression to analyze patient data to determine which variables, such as comorbidities or medication adherence, are statistically significant predictors of readmission risk. This information can guide the development of targeted interventions for at-risk patients. 
• Benchmarking: Benchmarking involves comparing an organization's performance data with industry standards or best practices to identify performance gaps (2). When a hospital is looking to improve patient satisfaction, benchmarking may involve comparing its patient satisfaction scores to those of similar hospitals or national averages. Identifying areas where the hospital falls behind benchmarks can inform strategies for improvement, such as implementing best practices from higher-performing institutions. 

The analysis stage is critical for transforming raw data into actionable insights and understanding healthcare quality factors (2). Through descriptive analysis, root cause analysis, statistical techniques, and benchmarking, healthcare organizations can gain valuable insights that drive evidence-based decisions and interventions to improve care quality (6). 

Benchmarking 

The benchmarking stage in quality improvement data collection is a crucial phase where healthcare organizations compare their performance against established benchmarks or best practices (1). This gives healthcare organizations a clear understanding of their position relative to recognized standards and allows them to effectively identify areas for improvement, prioritize, and focus their improvement efforts (5). Let's delve into the benchmarking stage in detail below. 

• Defining Benchmarks: In the benchmarking stage, healthcare organizations must define the benchmarks or standards against which they will measure their performance. These benchmarks can be internal (comparing current performance to historical data) or external (comparing to industry standards, best practices, or similar organizations) (1). For example, a primary care clinic seeking to improve appointment scheduling efficiency may choose to benchmark its appointment wait times against industry benchmarks for acceptable wait times. 
• Collecting Comparative Data: Gathering data that allows for a meaningful comparison is critical in benchmarking, so healthcare organizations must collect data from relevant sources to measure their performance against the chosen benchmarks (1). Continuing with the appointment scheduling example, the clinic may collect data on the time it takes to schedule an appointment, the number of scheduling errors, and patient feedback. This data is then compared to industry benchmarks or best practices. 
• Identifying Performance Gaps: The benchmarking process reveals gaps or disparities between an organization's performance and the benchmarks to highlight improvement areas (1). For instance, if the clinic discovers that its appointment wait times are significantly longer than industry benchmarks, this identifies a performance gap that needs to be addressed to enhance patient access and satisfaction. 
• Developing Improvement Strategies: Healthcare organizations can develop targeted improvement strategies once performance gaps are identified. These strategies are based on evidence from the benchmarking process and aim to align performance with or exceed established benchmarks (1). In our scenario, the clinic may implement strategies such as optimizing appointment scheduling processes, enhancing staff training, or using technology to improve scheduling efficiency. 

Change Models in Healthcare 

Change models are essential frameworks used in healthcare, including nursing, to guide and manage the effective implementation of quality improvement initiatives (15). These models offer structured approaches to initiate, plan, execute, and sustain changes in healthcare practice (15). Let’s discuss some prominent change models used in nursing quality improvement below. 

• Kotter's 8-Step Change Model: Developed by Dr. John Kotter, this model emphasizes the importance of creating a sense of urgency, building a guiding coalition, and sustaining the change (15). For instance, in a nursing scenario focused on reducing hospital-acquired infections, the 8-step model would involve creating urgency by highlighting the impact of infections on patient safety, assembling a coalition of nurses and infection control specialists, and sustaining change by monitoring infection rates over time and continually reinforcing hygiene protocols. 
• Lewin's Change Management Model: Lewin's model consists of three stages: unfreezing, changing, and refreezing (15). Let's consider implementing a new electronic health record (EHR) system in nursing. Nurses first "unfreeze" by acknowledging the need for a new system and undergoing training. Then, they "change" by adopting the EHR and adjusting workflows. Finally, they "refreeze" by becoming proficient and maintaining the new system's use as a standard practice. 
• PDSA Cycle (Plan-Do-Study-Act): This model emphasizes iterative cycles of planning, implementing, observing, and adjusting (15). For instance, if a nursing unit aims to improve patient handoffs, they might "plan" by identifying handoff best practices, "do" by implementing changes, "study" by assessing the impact on patient outcomes, and "act" by making further refinements based on their findings. This continuous cycle allows for gradual, data-driven improvements. 
• ADKAR Model: The ADKAR model focuses on individual change management, and this could apply to a scenario where nurses are adopting new pain management protocols (15). Nurses would first need awareness of the change (A), followed by desire (D) to participate, knowledge (K) of how to implement the new protocols, ability (A) to do so, and reinforcement (R) to sustain the change over time. 

In summary, change models provide structured approaches to drive quality improvement initiatives in nursing, and by applying these models, nurses and healthcare organizations can systematically plan, implement, and evaluate changes to enhance patient care, safety, and outcomes (15).

Implementing Change 

Implementing changes for quality improvement in nursing is a multifaceted process that requires careful planning, effective communication, and the engagement of healthcare professionals at all levels. According to (15), successful implementation ensures that desired changes are integrated into daily nursing practice, improving patient outcomes. Let’s explore key strategies and considerations for implementing changes in nursing quality improvement below. 

• Engage Interdisciplinary Teams: According to (15), collaborative engagement is crucial when implementing changes in nursing practice, and healthcare organizations should assemble interdisciplinary teams that include nurses, physicians, administrators, and other stakeholders. For example, in a scenario involving the adoption of a new pain management protocol, nurses can collaborate with physicians to ensure the consistent application of evidence-based pain management practices. This team approach facilitates a shared understanding of the change and fosters buy-in from all parties. 
• Effective Communication: Clear and consistent communication is essential during the implementation phase, so nurses should communicate the rationale behind the change, its expected benefits, and the specific steps involved (15). For example, suppose a hospital is transitioning to a new electronic health record system. In that case, nurses can attend training sessions to understand its features and communicate effectively with patients about how it will enhance their care. This ensures that all stakeholders are informed and can adapt to the change seamlessly. 
• Training and Education: Providing adequate training and education is critical to equip nursing staff with the knowledge and skills to implement the change effectively (15). In the case of introducing a new wound care protocol, nurses would require training on the updated practices, wound assessment techniques, and the use of new wound care products. In addition to initial training, ongoing education would ensure that nursing staff stay current with best practices to provide quality care confidently. 
• Continuous Monitoring and Feedback: According to (15), implementing change is an ongoing process that requires constant monitoring and feedback since feedback mechanisms allow for adjustments and refinements to the change process. As a result, nursing quality improvement initiatives benefit from the regular collection and analysis of data to assess the impact of the change. For example, suppose a hospital introduces a sepsis screening tool. In that case, nurses can track the number of patients screened, identify missed cases, and evaluate whether early interventions have reduced sepsis-related mortality rates. By engaging interdisciplinary teams, fostering effective communication, providing training and education, and implementing continuous monitoring and feedback mechanisms, nurses can successfully implement changes that improve the quality of patient care and enhance overall healthcare outcomes (8). 

Evaluating Change 

Evaluating change for quality improvement in nursing is a critical phase that involves assessing the impact and effectiveness of implemented changes on patient care outcomes, safety, and the overall quality of healthcare services. According to (15), rigorous evaluation ensures that improvements are sustained, and necessary adjustments are made. Let’s explore key strategies and considerations for evaluating changes in nursing quality improvement below. 

• Establishing Clear Evaluation Metrics: To evaluate change effectively, it is essential to define clear and measurable evaluation metrics, and according to (15), these metrics should align with the specific objectives of the change initiative. For example, suppose a nursing unit has introduced a new hand hygiene protocol to reduce hospital-acquired infections. In that case, evaluation metrics may include the number of infections before and after the change, adherence to hand hygiene guidelines, and patient satisfaction scores related to cleanliness and infection prevention. 
• Data Collection and Analysis: Data collection is a fundamental component of the evaluation process, and nursing teams should collect relevant data using standardized methods and tools (15). In our scenario, data on infection rates can be collected regularly, and statistical analysis can be performed to determine whether the change has had a statistically significant impact. Nurses can then use run charts or control charts to visualize trends in infection rates over time, allowing for early detection of any potential issues. 
• Patient and Staff Feedback: Patient and nursing staff feedback is invaluable in evaluating change since patients' perspectives on the quality of care and their experiences following the change can provide insights into the initiative's effectiveness (15). Additionally, nursing staff can provide feedback on the practicality and feasibility of the new practices. For instance, nursing staff may suggest further improvements in infection control procedures. 
• Sustainability and Continuous Improvement: Evaluating change is not solely about assessing immediate outcomes but also ensuring sustainability and continuous improvement. According to (15), nursing teams should determine whether the positive effects of the change are maintained over time and whether there is room for further refinement. For example, when a nursing unit has reduced infection rates, regular audits and monitoring should continue to ensure sustained compliance with hygiene protocols. 

• Enhancing Medication Safety: Medication errors can have severe consequences for patients (6). A quality improvement project may target medication safety by introducing barcode scanning systems for medication administration, implementing double-check procedures for high-risk medications, and providing ongoing training to nursing staff. The project's effectiveness can be assessed by monitoring the number of medication errors reported and verifying that the new safety measures reduce the occurrence of such errors. For example, a nursing team could reduce the incidence of wrong-patient medication administration by implementing barcode scanning during medication administration. 

• Improving Nurse-to-Patient Ratios: Adequate nurse staffing levels are crucial for patient safety and quality of care (6). A quality improvement project may involve adjusting nurse-to-patient ratios based on patient acuity levels, introducing workload management tools, and conducting regular staffing needs assessments. In this case, the project's success can be measured by tracking patient outcomes, nurse workload, and patient satisfaction scores. For example, a nursing unit could reduce nurse burnout and improve patient care by optimizing staffing ratios during peak hours. 

• Enhancing Discharge Planning and Care Transitions: Effective care transitions from the hospital to home or other healthcare settings are essential to preventing readmissions and ensuring continuity of care (6). A quality improvement project may focus on improving the discharge planning process, including patient education, medication reconciliation, and post-discharge follow-up. Success can be assessed by monitoring readmission rates and patient-reported experiences. For example, a nursing team could work on reducing hospital readmissions by ensuring that patients receive thorough discharge instructions and have access to follow-up care. 

The above examples illustrate the diverse range of quality improvement projects in nursing, each addressing specific challenges to enhance patient safety and care quality.

Conclusion

In conclusion, this course provides essential knowledge and skills valuable for nurses aiming to deliver high-quality, safe, patient-centered care. Quality improvement in nursing is not merely a theoretical concept but a practical approach that can be applied to various aspects of healthcare, and one critical aspect to remember is the importance of interdisciplinary collaboration. As frontline caregivers, nurses must collaborate with physicians, administrators, pharmacists, and other healthcare professionals to drive improvements in healthcare delivery.  

As nurses continue to play a pivotal role in healthcare delivery, the knowledge and skills gained from this course will empower them to lead and actively participate in quality improvement initiatives. By applying quality improvement principles, nurses can contribute to better patient experiences, patient outcomes, and overall healthcare quality. 

Final Reflection Questions 

1. What have you learned from this course? 
2. Why is interdisciplinary collaboration essential for nurses to effectively implement quality improvement initiatives in healthcare settings, and how can nurses foster collaboration among healthcare professionals? 
3. How does the concept of continuous learning and adaptation align with the dynamic nature of healthcare, and what strategies can nurses employ to stay current with evolving best practices and guidelines? 
4. In what ways does Quality Improvement benefit both healthcare providers and patients?  
5. What are the potential challenges in implementing QI initiatives in a healthcare organization? 
6. In what ways has QI in healthcare become intertwined with the broader goals of healthcare reform, such as improving patient outcomes and reducing healthcare costs? 
7. What role does leadership play in the effective implementation of QI models? 
8. How can leaders promote a culture of continuous improvement within healthcare organizations? 
9. How do QI models facilitate interdisciplinary collaboration among healthcare professionals to drive improvements in patient care? 
10. What challenges might healthcare organizations face when attempting to adopt and sustain QI models, and how can these challenges be overcome? 
11. How does the "testing and learning" concept in the PDSA cycle align with the principles of evidence-based practice in healthcare? 
12. In what ways do QI models promote patient-centered care and patient safety, and can you provide examples of tangible improvements in these areas achieved through QI initiatives? 
13. How can the Six Sigma model contribute to the reliability and consistency of healthcare processes? 
14. Safe: What steps can healthcare organizations take to minimize the risk of medical errors and adverse events? 
15. Practical: How do healthcare providers ensure that evidence-based treatments and interventions lead to positive patient outcomes? 
16. Patient-centered: Why is it important to involve patients in their care decisions, and how can healthcare professionals effectively engage patients in the decision-making process? 
17. Timely: What are some key factors contributing to delays in healthcare delivery, and how can these delays be reduced to improve timeliness? 
18. Efficient: How can healthcare processes and workflows be streamlined to enhance efficiency and reduce waste? 
19. Equitable: What are some barriers to achieving healthcare equity, and how can healthcare organizations address these disparities? 
20. How can nurses actively involve patients in data collection to enhance patient-centered care? 
21. What tools or technologies are available to streamline data collection processes in nursing practice? 
22. How can nurses effectively collaborate with interdisciplinary teams to gather comprehensive data for quality improvement initiatives? 
23. What strategies can nurses employ to maintain patient privacy and confidentiality while collecting sensitive healthcare data? 
24. What methods can nurse use to analyze and interpret the data they collect to identify areas for improvement? 
25. Why must nurses regularly review and assess the data they collect to drive continuous quality improvement in healthcare settings? 
26. Regarding patient falls, what strategies can healthcare organizations implement to reduce the incidence of patient falls, and how can nursing staff actively contribute to fall prevention efforts? 
27. How can nurses ensure the accurate and safe administration of medications, and what measures can be taken to minimize medication errors? 
28. What are the key nursing practices and interventions that can prevent the development of pressure ulcers in hospitalized patients, and how can nursing staff collaborate to achieve this goal? 
29. Why is patient satisfaction an important nursing quality indicator, and what actions can nurses take to enhance the overall patient experience? 
30. What impact do nurse-to-patient staffing ratios have on the quality of nursing care, and how can healthcare organizations ensure safe nurse staffing levels? 
31. How can nurses enhance patient education to promote better understanding and self-management of their health conditions? 
32. How can you ensure that the data collected is reliable and valid? 
33. What role does standardization play in data collection for quality improvement? 
34. How can you establish baseline data for comparison in your quality improvement project? 
35. What challenges or obstacles might you encounter when collecting data for quality improvement? 
36. How frequently should data be collected to monitor progress in a quality improvement project? 
37. How can you involve frontline staff in the data collection to ensure accuracy? 
38. What measures can be taken to protect patient privacy and confidentiality during data collection? 
39. How can you analyze the data collected to identify trends or patterns? 
40. What actions should be taken if the data collected indicates a problem or deviation from the desired outcome? 
41. What strategies can ensure that data collection remains an ongoing and sustainable practice in healthcare quality improvement efforts? 
42. What are the potential challenges or resistance nurses might encounter when implementing changes using these models? 
43. How can a guiding coalition or interdisciplinary team be effectively assembled to support nursing quality improvement efforts? 
44. What strategies can nurses employ to sustain changes and prevent reverting to previous practices once implemented? 
45. How can nursing leaders ensure that staff have the necessary knowledge and skills to embrace the changes outlined in these models? 
46. How can nurses use these change models to promote a culture of continuous improvement in healthcare settings? 
47. How can nurses ensure their implementation changes align with evidence-based best practices and clinical guidelines? 
48. What potential challenges or barriers might nurse teams encounter when trying to implement changes for quality improvement? 
49. What strategies can address resistance to change among nursing staff and promote their active participation in the implementation process? 
50. How can nursing leaders effectively communicate the expected outcomes and benefits of the change to gain support and commitment from their teams? 
51. What are the advantages of using data and performance metrics to monitor the progress and impact of change implementation in nursing practice? 
52. How can nursing staff ensure that changes are sustained and become integral to their daily practice rather than temporary modifications? 
53. Why is it crucial to consider the sustainability of change when evaluating its long-term impact on nursing quality improvement? 
54. What challenges or obstacles might nurse teams encounter when collecting and analyzing data for change evaluation, and how can these challenges be addressed? 
55. How can nursing leaders encourage a culture of continuous improvement among their teams as part of the change evaluation process? 
56. What strategies can be employed to ensure that the feedback and insights gathered during the evaluation phase are actively used to refine and optimize nursing practices? 
57. What are the potential consequences of not conducting thorough and systematic evaluations of changes in nursing practice for quality improvement? 
58. How can nursing staff and healthcare organizations ensure that the lessons learned from change evaluations are applied to future improvement initiatives to enhance patient care outcomes? 

Workplace Violence Against Nurses

Introduction   

The role of the registered nurse, while fundamentally dedicated to the care and wellbeing of patients, has long been fraught with challenges that extend beyond the complexities of medical care. One such pressing concern is workplace violence, an issue that nurses confront with alarming frequency. Recent statistics show that healthcare workers, particularly nurses, are at a higher risk for workplace violence compared to other professions.  

Given the vital role nurses play in patient care and the broader healthcare system, it is imperative to understand the scope, sources, and solutions to this pressing issue. This continuing education course is dedicated to arming nurses with the knowledge, tools, and strategies to recognize, respond to, and prevent incidents of workplace violence, thereby ensuring their safety and the uninterrupted provision of quality care. 

Workplace Violence  

Definitions 

The Occupational and Safety Health Administration (OSHA) (3) defines workplace violence (WPV for the purpose of this course) as any act or threat of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the work site.  This can also include verbal, written, or acts of sabotage against an individual while they are at work. 

Workplace violence crosses all demographic barriers and is indiscriminate in who it can and does affect. Even seeing workplace violence influences morale, attendance, and the overall well-being of employees and their co-workers.  

Types of Violence  

Currently, there are four categories of workplace violence according to the American Nurses Association (5).  

1: Criminal Intent - normally involves theft from the business or employees. 

Example: Carol is working on documentation and notices a person lingering in the hallway. Carol doesn’t really think anything of it, assuming they are family members of one of the patients. Several minutes later, the person exits quickly from the supply room and down the stairs. Carol calls security to let them know, but they can’t locate the individual. After looking through the supply room, they find that several containers of wound dressing supplies are missing.  

2: Customer/client/patient - the individual becomes violent with employees while receiving services. 

Example: David was updating a family on their father’s critical condition. David could tell the family was upset, but the patient’s son seemed more frustrated than the others. During David’s explanation, the son grabbed David’s clipboard and yelled, “You’re not doing anything! You’re just letting him die!” The son then threw the clipboard at David’s head. David blocked the clipboard with his arm, receiving a rather deep cut as a result. Security became involved, and David had to go to the ER for treatment.  

3: Worker on worker - an employee bullies, attacks, or threatens another employee. 

Example: Emily was rounding when Dr. G. came onto the floor. This doctor was well known for being difficult to work with, and he always required the nurses to stand behind him in the room while he talked with his patients. Emily had one of Dr. G.’s patients today and was in the room, he asked her if the patient had ambulated. Emily told him they had not, but they planned to before and after lunch. The doctor made an audible sigh and while shaking his head at the patient said, “See…this is what I deal with every day. These nurses can’t get anything right. They’re all useless.” 

4: Personal relationship - involves a person who has an interpersonal relationship with the nurse, but no association with the nurse’s employer or the business. 

Example: Rebecca was walking to her car after work. Halfway to her car, she noticed an individual leaning against the trunk of her vehicle. Rebecca recognized this person as the someone her friend was currently dating. This person approached Rebecca aggressively and began yelling about gossiping and trying to break their relationship. Rebecca started back toward the building, hoping security was nearby, and was pursued by the female. Eventually, Rebecca made it to the building and got inside. Luckily, the door only opened with an employee badge, and Rebecca was safe. She went ahead to security.  

Currently, the customer/client type of workplace violence is the most prominent, especially in healthcare and toward nurses. The American Nurses Association (ANA) reports that OSHA does not require employers to implement workplace violence prevention programs, but it supplies voluntary guidelines and may cite employers for not supplying a workplace free from recognized serious hazards.  

Some states have legislated that employers develop a program while most states have advanced laws that amend existing statute for assaults of first responders by adding health care providers / nurses and/or increasing the penalty associated with such behavior. (3) 

It is worth noting that since there are, in most cases, no actual requirements for employers to provide safe work environments for nurses, preventing and dealing with WPV proves problematic. It falls on nurses to understand what constitutes WPV, how to manage it, how to cope with it, how to report it, and how to ensure action is taken and a resolution is reached when WPV occurs.  

Epidemiology 

Workplace violence can take many forms, and the possible varieties and scenarios are endless. Regardless of how it manifests, the effects of workplace violence are clear and widespread. It can affect productivity of employees, morale, attendance, turnover rates, quality of work, patient outcomes, and much more.  

Workplace violence can affect and involve workers, clients, customers, and visitors. WPV ranges from threats and verbal abuse to physical assaults and even homicide. In 2010, the Bureau of Labor Statistics (BLS) data reported healthcare and social aid workers were the victims of approximately 11,370 assaults by persons; a greater than 13% increase over the number of such assaults reported in 2009 (10). Almost 19% of these assaults occurred in nursing and residential care facilities alone. Unfortunately, many more incidents probably go unreported (5). 

Impact on Nurses Well-Being 

Workplace violence can take a heavy toll on nurses. These tolls can be emotional, mental, and physical as well as short-term or long-term. The seriousness of these injuries can vary widely ranging from minor upset to permanent injury and in worst cases, even death. (13) 

This harm doesn’t stop with the nurse. The effects of workplace violence may also include effects spanning the unit the nurse works on or even the entire facility. Low morale, reduced productivity, lack of trust in employers, and fear of going to work can be results of violent events occurring to even a single co-worker.  

Workplace violence can also have a financial effect on nurses and their employers related to lost time at work from injury or callouts, costs of care for treatment related to the incident (physical and/or psychological), or even legal fees. (13) 

Given that incidents of workplace violence are rapidly increasing, these impacts are expected to increase as well. It is easy to see how this harm is widespread and can potentially ripple outward into the nurse’s professional and personal life. The stress and harm do not stay at work, and can spread to the nurse’s family, social interactions, and more. 

Barriers to Reporting 

One way to combat workplace violence is knowledge of its existence, its nature, and its frequency. Unfortunately, there are many factors that either prevent or discourage nurses from coming forward with reports when they are the victims of WPV.  

A study presented in a Chinese nursing journal surveyed 325 nurses. Of these nurses, 266 were spread across 165 hospitals, and these hospitals were in 72 cities.   

A total of 172 nurses (64.7%) experienced violent incidents during the past year. Of these incidents, 45.5% were reported; and the reporting rate of physical assaults (69.0%) was higher than those of verbal abuse (36.9%), threatening behavior (51.7%), and sexual harassment (60.0%). Formal reporting accounted for 25.4% (15.4% in written form and 10.0% through a computer-assisted reporting system. 

 Almost half of the nurses (49.6%) said that the hospital had no reporting system, or they were uncertain about the reporting system. For reasons of not reporting, 51.9% of the nurses were unaware of how and what types of violence to report, and 50.6% of the nurses believed that the hospital paid greater attention to patients rather than staff. (7) 

Interestingly, almost fifty percent of the nurses surveyed had limited knowledge, if any, of a reporting system available to them, while fifty percent felt the hospital favored the patients over their own employees. Combined with an actual or perceived lack of supervisory support, this encourages an environment where nurses feel powerless to protect themselves or to take proper action when threatened or harmed. 

The Minnesota Nurses Association, in August of 2022, published a press release with the results of a nursing survey on the topic of workplace violence. In this survey, ninety-seven percent of the nurses surveyed observed WPV or harassment over the previous two years.  

The top reasons cited by nurses who did not report workplace violence were lack of time due to overwork and under-staffing, cited by fifty-eight percent of respondents, and lack of action by hospital management, cited by fifty-three percent of nurses in the survey. (4) 

It would appear from these studies that many nurses feel it is futile to report incidents of workplace violence they encounter, and even if they realized an incident was reportable, they may not be aware of a way to report it or have time to do it. This perceived powerlessness and sense of futility in the face of abuse and violence will only continue to worsen unless action is taken to remove barriers to reporting and for nurses to have access to aid and support for supervisory staff. 

Culture of Safety 

A commonly used phrase is “Culture of Safety”, but is there a standardized definition of what it is or could be? Many resources point to the safety of patients about medical errors, patient rights, and protecting the patient’s information, but few address the issue facing caregivers and especially nurses. However, there is no agreed-upon or standard definition of what exactly a “culture of safety” is or what it should look like.  

The American Nurses Association approaches the concept by saying, “Establishing a culture of safety in health care is essential to the security and well-being of your patients, staff, and organization. Effective nurse leaders embrace safety protocols that ensure their organization delivers a secure, protective environment that prioritizes patients and caregivers.” (12)  

Currently, there is only a single federal legislation in place about the issue. 

The only federal regulation currently in place is the General Duty Clause of the Occupational Safety and Health Act of 1970. This clause requires employers to supply a work environment free from recognized hazards that are causing or likely to cause death or serious physical harm. However, the general duty clause offers no specific recommendations about management of workplace violence.  

The Occupational Safety and Health Administration (OSHA) issued guidelines for workplace violence prevention for health care and social service workers. First issued in 1996 and later updated, the guidelines are only advisory. (1) 

It is paramount that nurses and other direct care providers accept the responsibility of creating policies and procedures within their organizations to define and enforce a work environment where violence is not tolerated and dealt with accordingly. 

There is currently a small body of research and work of the effects workplace violence has on nurses as human beings. Most of the evidence focuses on how workplace violence increases the risk nurses present to patients in the form of medical errors, staffing issues due to missed work, poor documentation, etc. 

The main body of evidence discussing how workplace violence affects nurses is noted in research around nurse burnout. A 2020 study published by the National Health Institute (10) states, “Workplace aggression is a source of extreme socio-emotional stress, which may lead to the experience of psychological strain.  

A large body of research shows that exposure to workplace aggression and violence may severely impair healthcare workers’ mental health, including symptoms of post-traumatic stress disorder, depression, and burnout.” 

This study also shows an important association with workplace aggression and violence targeting nurses and drastically increased levels of emotional exhaustion, depersonalization, and deep feelings of poor personal accomplishment. Over time, these feelings lead to complete burnout, and even worse, possibly psychological and/or physical conditions in the nurse affected.   

Even with this preliminary information and research, we still have a long way to go to show the full and far-reaching effects of workplace violence on nurses. Again, by being proactive and acting now, we as nurses can foster this research and bring to light the issues so they can be addressed. 

ANA Zero Tolerance Policy 

In 2019 the American Nurses Association (ANA) (2) release a brief titled “Reporting Incidents of Workplace Violence”. In it, they discussed several issues surrounding workplace violence, barriers to its reporting, and made recommendations to healthcare organizations on strategies relating to the issues of workplace violence.  

They also set forth a “Zero Tolerance Policy on Workplace Violence”, which provided some definitions and several recommendations on how to deal with WPV. 

The introduction to the “Culture of Safety” part of this brief is as follows:  

By prioritizing, developing, and sustaining an organizational culture focused on safety, we can drive the future of healthcare to a place where patients and those who care for them are free from harm. It is not only one of many priorities but is the overriding ethical imperatives for all leaders. (9) 

The ANA also suggested a three-level prevention strategy, each with a part for the employer and the employee. Essentially, the role of the employer is gathering data, providing a “safe” work environment, non-punitive reporting, and development of programs to provide a safe work environment for nurses. The employee’s role is to take part in the implementation and evaluation of said programs.  

Unfortunately, these are only suggestions and employers do not have to implement any programs or services to protect employees against workplace violence. Also, healthcare employers do not have to report any incidents to JCAHO who consider events of workplace violence to be “sentinel events”.  

In the end, it falls on the nurses and employees directly affected by WPV to assume the charge against workplace violence, hold employers accountable, communicate with local and state legislators, and effect change to protect themselves. 

Strategies to Prevent Workplace Violence 

To end nurse abuse for good, Boston-Leary says it takes every nurse speaking up and reporting abuse within an organizational culture that has an established process for allowing nurses to report abuse without fear of recrimination and then follows up with a resolution. (8) 

There are some suggested actions to help prevent and combat workplace violence in your practice setting. These actions include: 

Know the definition of abuse.  

The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.” 

Agreeing on this definition is an important first step to achieving widespread acknowledgement of the distinct types of nurse abuse, particularly non-physical abuse, Boston-Leary explains. (8) 

Report Abuse 

Ask about how your workplace manages abuse reporting, whether it is in your current workplace or when you are applying for a position, Boston-Leary suggests. “Ask about how reporting abuse happens during any shift because there should be a reporting mechanism in place for everyone, even if it’s on a weekend or evening shift with no manager easily accessible to report to.” 
 
If (when) you do experience abuse, it’s essential that you speak up immediately and note any witnesses who could corroborate your description of the incident, she says. 
 
Even after you experience abuse and even if you didn’t report it, it’s important to share your past abuse with others to empower them to report abuse they experience. (8) 

Change Your Culture 

Join or meet a committee to build or strengthen zero-tolerance abuse policies. Based on ANA’s Zero Tolerance Policy on Workplace Violence, Boston-Leary suggests these crucial elements of a zero-tolerance abuse program: 

Stop violence before it starts through education to find risks and reduce vulnerabilities for workplace violence. 

Create an effective response to violence immediately after it occurs, including emergency care. 

Establish long-term responses that reduce the long-term negative effects of workplace abuse. (8)  

Communicate with your Legislator! 

Congress was considering legislation to #End Nurse Abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R 1195). If approved, this law would have required health care and social service industry employers to develop and implement a comprehensive workplace violence prevention plan that protects nurses and other healthcare professionals from on-the-job abuse. 
 
Boston-Leary believes legislators are very attuned to the trusted voice of nurses to share about what is happening in health care today (8). 

Nurse-led Strategies 

You can join these committees or work with your employer to create them. Collaborating with your supervisory staff and HR, you can create workflows, policies, reporting methods, and provide education on prevention of workplace violence and make a difference in your overall work environment.   

Regarding Your Legislators 

As mentioned before, 2021 Congress was considering federal legislation to end nurse abuse by passing The Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195). The bill was passed by the House on April 16, 2021, but was never passed by the Senate.  

You can find your local and state legislator contact information very easily on the internet. A simple search for “how to find state legislator contact information” is a wonderful place to start. As a voting citizen, you have every right to contact them, and demand laws be created to protect you while you work.  

Below are some links to help you find elected officials: 

• https://www.usa.gov/elected-officials 
• https://www.usa.gov/state-governor 
• https://www.senate.gov/senators/senators-contact.htm 
• https://www.house.gov/representatives/find-your-representative 

Advocate for your own safety the same way you would for your patients!  

As nurses we aren’t afraid of stepping up to bat for our patients when they need something, but we are notorious for taking a hit and letting it slide, sometimes even to our own detriment.  

We owe it to ourselves to offer that same level of advocacy to ourselves and our co-workers.  

Resources 

The Joint Commission supplies resources available to report and learn about how to report workplace violence. The links included are for federal, state, professional, and other resources. The direct link to this page is: 

The Joint Commission: Workplace Violence Prevention Resources 

Local law enforcement  

As a private citizen, you are protected by laws about assault, battery, and other attacks on your person. You are within your rights to call the police on events of workplace violence, especially if your life or health are threatened, or you are physically attacked. It is likely your employer will not support you in this situation due to legal implications. It is best to ask your HR department and supervisory staff how these situations should be managed if they occur. 

Legal Counsel 

Consult with a lawyer about your legal rights in situations on workplace violence and how to best manage them. Be sure to bring scenarios, information on how your employer suggests dealing with these situations, and examples of violence you have seen or have experienced.  

Educate and Train Yourself 

Learn as much as you can about recognizing and managing workplace violence. Your employer may supply these courses, and if they don’t, it may be prudent to request them. Also, you can seek outside education and training on these topics including self-defense classes and crisis management courses. 

Practice Self-Awareness 

We all have inherent beliefs, perspectives, and feelings that can prevent us from acting in certain situations. Knowing yourself and understanding possible nuances within yourself that could be a detriment to you appropriately handling a situation of workplace violence could mean the difference between prevention and becoming a victim.   

Conclusion

Being an agent of change can be intimidating, terrifying, and even force us to deal with feelings and beliefs we didn’t even realize were in our way. Incidents of WPV have been rising sharply over the past several years, and there is no sign of slowing. It’s up to us as front-line workers, nurses, and co-workers to take responsibility for our own safety and work environment.  

Through cooperation and consistency, we can create and bring solutions to the workplace and hopefully one day, aid in the creation of laws that make our jobs safer for us to supply the care and support our patients need. We owe it to ourselves to take the necessary steps to show our employers it’s time to address this issue. “Be the change you wish to see in the world.” ~Mahatma Gandhi – 

Telemetry Basics - Rhythm Recognition

Introduction   

To truly understand telemetry, nurses must have knowledge about the anatomy of the heart and how electricity passes through it, how the electrocardiograph (EKG) works to receive and record the electrical activity, and how this information is transmitted via telemetry to the appropriate receiving device.

Defined as the transmission of instrumental readings by various methods such as radio waves or wires, telemetry gathers and transmits EKG readings to a central or remote monitor for interpretation and storage (71). The ability to read EKG rhythms from a variety of monitors consists of more than looking at a rhythm strip and identifying the rhythm. It consists of knowing the anatomy of the heart, how electricity travels through it and translates into the EKG we know, and what changes can happen based on injury, electrolytes, or other causes.

Heart Anatomy 101

As we know, the heart consists of four chambers, two atria—right atria (RA) and left atria (LA)—and two ventricles—right ventricle (RV) and left ventricle (LV)—working in a cycle to ensure adequate blood flow occurs. The heart receives blood from the inferior and superior vena cava (IVC and SVC) and enters the RA, moves to the RV, passes through the pulmonary artery (PA) and lungs, returns to the LA, enters the LV, and exits the heart through the aorta.

Heart cells, known as myocytes, are negatively charged, or “polarized” at rest. When these muscle cells contract, they become “depolarized” or positively charged. But how do the myocytes know when to contract? Less than 1% of the cells in the heart have a special role and name. These are known as the pacemaker cells and their role is to ensure that the heart beats. This is done through the action potential that is spontaneously created by the pacemaker cells. Some of these pacemaker cells have different speeds in depolarization, meaning that the fastest pacemaker cells are the ones controlling the speed. This will make more sense later when discussing specific cardiac rhythms (69).

Starting in the right atria, the sinoatrial node (SA node) is the primary group of pacemaker cells that determines the heart rhythm. The SA node, as well as the other pacemaker cells within the heart, progress through a rapid depolarization and repolarization process (2).

Pacemaker cells do not have a true resting potential, this means they are always in an “unstable” state to create spontaneous action potential. The action potential is the brief reversal of polarity in the cell; polarity consists of potassium (K⁺) in the cell with a negative charge, while sodium (Na⁺) and calcium (Ca⁺⁺) are outside of the cell with a positive charge (2).

Starting at the beginning of the cardiac cycle the pacemaker cells always have a membrane potential or voltage—the voltage of the cellular membrane as a result of permeability and concentrations of ions inside and outside the cell—of -60 microvolts (mV). From -60mV to -50mV the channels within the cells open, leading to a slow influx of Na⁺ inside the cell and a slow depolarization of the cell. Once the membrane voltage has reached the minimum threshold of -50mV the Ca⁺⁺ channels open, causing Ca⁺⁺ to move into the cell. This is known as the rising depolarization phase. The membrane voltage reaches the peak and the next thing that happens is the falling repolarization phase. This is where the K⁺ channels open to return the cell to a repolarized state (2).

(20)

Once these steps have occurred, the energy is transferred to surrounding cells, and the cardiac cycle continues. However, the action potential in the other myocytes is slightly different. Myocytes have a resting potential, which is different from the pacemaker cells. The resting potential is around -90mV and these cells only start the depolarization process when stimulated by an external force. During the end of the pacemaker cell’s action potential phase, additional Ca⁺⁺ is passed into the neighboring myocytes through gap junctions. The introduction of Ca⁺⁺ into the cell causes a sharp rise in the membrane voltage that approaches the threshold which is -70mVs. Once that threshold has been reached, the NA⁺ fast channels open and a rapid depolarization occurs since Na⁺ is brought into the cell. The Ca⁺⁺ slow channels open at -40mVs, further causing depolarization with Ca⁺⁺ entering the cell (2).

At the peak of cellular depolarization, the Na+ channels close, leading to a slight repolarization through some K⁺ entering the cell. This is minor as the Ca⁺⁺ channel is still open and continues to move K⁺ out of the cell. A plateau is created because of this and allows for the cell to go through two important phases. The first phase starts when the membrane voltage increases from the resting potential and continues until the plateau phase ends. This is known as the absolute refractory period and is where the myocytes relax before they can respond to additional stimuli. It prevents summation and tetanus which could lead to the heart not beating. The second phase is where additional Ca⁺⁺ is pulled out of the sarcoplasmic reticulum (SR) to further push K⁺ out of the cell (2).

The phase ends when the Ca⁺⁺ channel closes, extra Ca⁺⁺ is sent back to the SR, and K⁺ is allowed back into the cell. The sodium/potassium pump allows Na⁺ to exit the cell, returning the cell to its resting potential. This rapid process occurs in every myocyte for the life of the cell. Pacemaker cells are the only cells that can generate a heartbeat. Impulses from the nervous system can increase or decrease the heart rate, but they are influencing the pacemaker cell to generate more beats, not creating them (2).

It is important to note that there are several sets of pacemaker cells within the heart. The SA node starts the process, but there are a few others spaced out along the electricity’s path to ensure that the atria and ventricles of the heart have time to fill and properly contract. The second set of pacemaker cells is the atrioventricular node (AV node) where a slight delay of 0.01-0.05 meters per second (m/s) happens to make sure that the ventricles fill up adequately. The bundle of His takes the electric impulse to the left and right bundle branches and from there, the Purkinje Fibers are triggered. These fibers have a speed of 2-4 m/s to provide enough force to eject the blood from the ventricles (69).

Correlating all of this back to telemetry, scientific development within the medical profession has allowed us to visualize this electrical activity and translate it into an effective method of diagnosing cardiac conditions such as abnormal heart rates or cell death.

Types of Telemetry

EKG

There are many ways to view cardiac rhythms now, however, the oldest method is the EKG. During the late 1700s, the Italian physician Luigi Galvani was experimenting with electricity and animal tissue. His experiments spanned at least three decades and inspired other physicians during and after his time. Using legs removed from the bodies of frogs, Galvani theorized that “animal electric fluid” enabled the muscles within the legs to move when touched by metals; according to him, this was “natural” fluid and not created as static electricity or friction is. He went on to theorize that the brain is an essential part of creating the “electric fluid” with nerves as the conductors (6).

Jumping forward to 1842, Doctor Carlo Matteucci made a significant contribution to EKGs. During his time researching electrical detection in animals, he discovered the electrical currents within the heart that accompany each heartbeat. Thirty-five years after Matteucci, Augustus Waller was able to use a capillary electrometer and electrodes to perform the first human EKG. These electrodes were placed on the chest and back of the participant and were vital in demonstrating there was electrical activity that preceded the contraction of the ventricles. William Bayliss and Edward Starling improved upon Waller’s research by using improved capillary electrometers to demonstrate triphasic cardiac electrical activity (1).

The Dutch physician most noted for creating the EKG known today was Doctor Willem Einthoven. He was inspired by Waller and those before him to improve the capillary electrometer, successfully identifying five deflections that were initially named ABCDE. Having to factor for inertia, Einthoven implemented mathematic correlation, resulting in the traditional EKG rhythm strips we use today with the letters PQRST depicted in the image below. Einthoven is also responsible for coining the word electrocardiogram or electrokardiogram in Dutch. This is where providers get the “k” in EKG from (1).

While Waller’s EKG utilized ten electrodes, Einthoven was able to condense that number to three, eliminating the right leg and the mouth electrodes. These three leads created Einthoven’s triangle; an important concept still used today and that will be discussed later. All of Einthoven's work resulted in him being awarded the Nobel Prize in Physiology and Medicine in 1924 (1).

Bedside Monitor

Emergency departments (ED), intensive care units (ICU), and other specialized areas that require continuous monitoring of a patient’s EKG and vital signs utilize various bedside monitors to ensure they are receiving accurate, real-time information on the patient. Cords are used to connect the patient to the monitor. The electrodes to display and document cardiac rhythm and heart rate are applied to patients in the standard 5 lead placement displayed in the below image. The vitals displayed on the monitor can also be displayed outside the room on a screen with multiple patients. Nurses, paramedics, or trained telemetry monitor technicians can watch many of these monitors at a time.

(14)

The placement of the five leads consists of the following:

• RA: 2^nd intercostal space, anterior axillary on the right – some providers may put this lead higher on the chest or on the right arm
• LA: 2^nd intercostal space, anterior axillary on the left – some providers may put this lead higher on the chest or on the left arm
• RL: 8^th intercostal space, anterior axillary on the right – some providers may put this lead lower on the abdomen
• LL: 8^th intercostal space, anterior axillary on the left – some providers may put this lead lower on the abdomen
• V: 4^th intercostal space, right margin of the sternum

Note: Always follow the manufacturer’s instructions for specific lead placement.

Helpful Tip: Many healthcare providers quickly remember lead placement based on color is smoke (black) over fire (red) and snow (white) over grass (green). This leaves brown (chocolate) in the middle.

These bedside monitors can monitor pulse oximetry, respiratory rate, temperature, capnography, blood pressure, and arterial pressure. Some devices may have other unique monitoring features. These monitors may be portable or have a way to transfer the cords to a transport monitor. They come with alarms that can be adjusted based on the patient’s unique vital signs or hospital policy.

First responders have similar devices they use when transporting patients with the added benefit of having a defibrillator and a real-time feedback device built in (91).

Remote Monitoring

Remote cardiac monitoring is similar to bedside monitoring; however, the EKG rhythm, heart rate, and pulse oximetry are not displayed at the bedside. Instead, they are displayed in a different location, sometimes a monitor room, where a trained professional is watching many patients. When they recognize an abnormal rhythm, they will contact the appropriate staff to assess the patient. They may call for the leads to be removed, a change in rhythm, or a low battery.

The EKG leads are placed the same way as the bedside monitor leads are placed (always be sure to consult the manufacturer’s instructions). The information is transmitted wirelessly via wireless medical telemetry service (WMTS) from the “tele box,” but the leads must be wired to the box. WMTS does not use Wi-Fi and protects transmissions from Wi-Fi interference (48).

Mobile Cardiac Monitor and Event Monitor

A mobile cardiac or event monitor is a device attached to the skin that can perform continuous or event-specific monitoring. This device is attached to the patient’s chest near the heart and records when activated. This device is smaller than other portable cardiac monitoring devices like the Holter Monitor which will be discussed later. Information can be transmitted to the monitoring center to be reviewed by trained staff and/or artificial intelligence. Abnormalities like tachycardia, bradycardia, atrial fibrillation, or cardiac pauses are reported to a physician. The patient may or may not know about the rhythm abnormalities occurring as some patients are asymptomatic (18).

Event monitoring consists of the following methods (23):

• Patch monitor: depending on the manufacturer, the device is stuck to the chest and left on for a designated period of time.
• Loop memory monitor: the sensors always stay on the patient and the patient activates the devices to begin recording when symptoms occur in addition to a few minutes before the event starts and after it ends. There is an implanted option as well.
• Symptom event monitor: Patients place the monitor on them and activate it like a patch monitor, but only when symptoms start.

Insertable Monitor

Insertable or implantable cardiac monitors are just like mobile and event monitors, but they are surgically inserted into the patient. They perform the same actions, but there is an added benefit to these devices. If the patient has worn an external device in the past and has known cardiac arrhythmias, they may have an implanted cardioverter-defibrillator (ICD) inserted to detect and treat the abnormal rhythm. These devices are connected to the heart via wires (they may be placed in the right atria, the right ventricle, or both) and are operated by batteries that do need to be changed per manufacture direction. Patients and providers should be aware of magnets, or electrical signals from other devices that can interfere with the insertable device (61).

Healthcare providers can “interrogate” ICDs or pacemakers with a device created by the monitor’s manufacturer. When interrogated, the device’s information is transmitted to a monitor center who calls the provider to give them a verbal report of what the device has recorded; a paper copy is often faxed to the provider as well. Some newer interrogation devices may display the information of the device on the screen.

Holter Monitor

As mentioned with mobile cardiac monitors, the Holter monitor is another wearable device that can be used to monitor and diagnose cardiac arrhythmias outside of the hospital setting. This device consists of five electrodes and a monitor that the patient can wear or carry on them. It is similar to the remote telemetry devices used in the inpatient hospital setting as shown in the next image. Patients wear this device for a short time, and information is not transmitted to a monitor technician. Instead, information collected is sent to a monitoring center where it is interpreted and sent to the physician (58).

As covered in this section, there are many options for cardiac telemetry monitoring, and providers may encounter many types of them. It is important to know these devices and how they operate.

Lead Placement

Now that we have discussed the types of telemetry monitoring devices that are available, it is time to discuss how to properly place the EKG leads on a 12 lead, 15 lead, right-sided EKG, and where to place the V₄R lead.

12 Lead EKG

For the 12 lead EKG, providers should start with the four limb leads (14):

• RA: On the upper or lower right arm
• LA: On the upper or lower left arm
• RL: on the upper or lower right leg
• LL: on the upper or lower left leg

From there, the six pericardial leads are placed strategically around the chest to create a partial circle around the heart (14):

• V1: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V2: 4^th intercostal space, left margin of the sternum
• V3: sits midway between leads V2 and V4 on the left
• V4: 5^th intercostal space, mid-clavicular line on the left
• V5: 5^th intercostal space, anterior axillary line on the left (aligned horizontally with V4, between V4 and V6) on the left
• V6: 5^th intercostal space, mid-axillary line on the left (aligned horizontally with V4)

15 Lead EKG

The 15 lead EKG uses the same leads as the 12 lead EKG, but it adds V7, V8, and V9, known as the posterior leads, to encompass the posterior angles of the heart (14):

• V7: left posterior axillary line (aligned horizontally with V6, across from V5)
• V8: tip of the left scapula (aligned horizontally with V6, across from V4)
• V9: left of the spinal column (aligned horizontally with V6, across from V3)

Right Sided EKG

The right-sided EKG is important to rule out the diagnosis of a right-sided myocardial infarction (MI) or ischemia in or out while treating a patient. Lead placement is the same for the four limb leads, but the 6 precordial leads are flipped (14):

• V1: 4^th intercostal space, left margin of the sternum
• V2: 4^th intercostal space, right margin of the sternum (this is lead V on the 5 lead EKG)
• V3: sits midway between leads V2 and V4
• V4: 5^th intercostal space, mid-clavicular line on the right
• V5: 5^th intercostal space, anterior axillary line on the right (aligned horizontally with V4, between V4 and V6)
• V6: 5^th intercostal space, mid-axillary line on the right (aligned horizontally with V4)

V4R Lead Placement

A full right-sided EKG is not always needed. Lead V4 on the right side of the heart is the most important lead when it comes to determining an MI on the right side of the heart (14):

• V1, V2, V3, V5, V6: same placement as the 12 and 15 lead EKGs.
  • V4 is removed and placed on the right side of the chest
• V₄R: 5^th intercostal space, mid-clavicular line on the right (Where it is located on a complete right sided EKG)
  • The “R” stands for right to ensure that those reading the EKG are aware that lead is on the right while the rest are located on the left side of the chest.

Limb Leads

Now that lead placement has been covered, we can now discuss how lead placement shows different parts of the heart.

Leads I, II, III, AVR, AVL, and AVF are considered limb leads when reading the EKG. It is important to note that the right leg lead is the grounding electrode and does not affect the EKG (83). Leads I, II, and III leads form a triangle over the chest known as Einthoven’s Triangle as reflected in the below image. Lead I always has negative polarity while lead III always has positive polarity. Lead II’s polarity depends on what side of the triangle is being discussed. If we are looking at lead I on the EKG, then lead II is positive, but if we are looking at lead III, then lead II is negative (82).

The importance of what leads are negative and positive comes from how electricity travels through the heart. It starts on the right side and moves to the left, so it would make sense for lead I to have negative polarity while leads II and III are positively charged (82). This is also why the height of a PQRST complex changes based on what lead is being looked at on an EKG as reflected below.

Augmented or unipolar leads AVR, AVL, and AVF have the heart as the negative electrode and the limb leads are the positive electrodes. AVR goes from the heart to the right arm lead, AVL goes from the heart to the left arm lead, and AVF goes from the heart to the left leg lead. Just as discussed with leads I, II, and III, the path of the electricity in the heart determines how the PQRST complex appears on the rhythm strip (82). Lead II is the preferred strip to read by providers due to the best view of the rhythm due to the way electricity travels through the heart and how lead II follows that path by starting at the right shoulder and going to the left leg.

The chest leads, V1 – V9, create a circle around the heart on a horizontal plane. These leads are unipolar as well, with the heart being the negative electrode. Multiple views of the heart are captured because of the many leads placed along the patient’s body. This can give providers valuable knowledge on what areas of the heart may be affected. The next image gives a visual depiction of how the leads display their view of the heart.

Reading EKGs: EKG Components

To be able to interpret EKGs successfully, nurses must first have knowledge about the EKG components displayed on the EKG strips and how each part correlates to a part of a single heartbeat.

P wave

The P wave is the first deflection from the isoelectric line or baseline. Correlating this to the heart, this is where the atria depolarize or contract. The contraction of the right atria starts at the beginning of the P wave while the contraction of the left atria begins in the middle and end of it. Normal P waves are apparent between 120 and 200 milliseconds (msec) before the upward deflection of the QRS complex (44)

PR Interval

The next part of the PQRST complex is the PR interval. The interval symbolized the time between the depolarization of the atria and the depolarization of the ventricle. The normal speed is 120 to 200 msec (44).

PR Segment

Next is the PR segment. This is similar to the PR interval but starts at the end of the P wave and ends at the start of the Q wave. This line is important because if there is a deviation from the isoelectric line, it could indicate a cardiac rhythm abnormality like Wolff-Parkinson-White syndrome which will be discussed later. The EKG may have a “slurred” upstroke from the P to R points on the EKG, making the Q wave appear to be on the isoelectric line. This is because the ventricles were stimulated or excited early, leading to a shortened PR interval. The “slurred” area is known as a delta wave (13).

QRS Complex

The QRS complex is where the ventricles depolarize and contract. The first downward deflection of the beat is the Q wave that lasts for < 0.05 seconds. It is present in all leads save for V1 and V3 due to the angle of the vector. The R wave is the upward deflection of the complex. R waves do not have a set height, but severely elevated R waves can be an indicator of ventricular hypertrophy. The second downward deflection is the S wave. Overall, the QRS complex is 0.07 to 0.10 seconds long and variations to this time can be an indicator of abnormal heart rhythms (17).

ST Segment

The ST segment starts when the S wave ends by returning to the isoelectric line and ends when the T wave begins. This period represented the completion of ventricular depolarization (17). The ST segment lasts 0.08 seconds to 0.12 seconds (51).

T Wave

The final wave in the standard EKG components is the T wave. This wave symbolizes the ventricles repolarizing. Inverted T waves can be an indication of past or current infections. A peaked T wave—as opposed to the normal curved T wave—can be caused by hypocalcemia, hyperkalemia, and left ventricular hypertrophy (17). The T wave runs from 0.01 seconds to 0.25 seconds (51).

The image below depicts the components of an EKG with labels to assist with understanding how the waves appear.

(4)

Reading EKGs: EKG Paper

The EKG paper has sets of squares, 25 little squares within one larger square. The smaller squares symbolize 0.04 seconds making the larger square 0.20 seconds. A single small square is 1mm while the large square is 5mm, this is because the larger square is five small squares tall.

(15)

Some EKG strips are presented in a six second format. To determine if the strip is a six-second, you must count the larger boxes. 30 larger boxes are required for the strip to be six seconds. Some may even have second markers that symbolize one second of time passed.

The 12 lead EKG can be more challenging to read and is often used to make an overall observation about the patient’s heart rate and rhythm. It can provide more information to providers than a single lead strip can. 

As discussed previously, the leads are placed along the path of the heart, and providers can determine what part of the heart may be affected by knowing what leads are placed where.

(51)

Now that we have discussed leads, lead placement, the PQRST complex, and EKG paper, it is time to cover different cardiac rhythms that you may encounter.

Rhythm Recognition

Normal Sinus (41):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic (curves above and then dips below the isoelectric line) in V1
  • Duration:
    • Less than 0.12 seconds
  • Rhythm Strip:

(29)

Sinus Bradycardia (87):

• Rate: less than 60bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    

(87)

• Signs and Symptoms:
  • None – depending on the patient
  • Cyanosis
  • Peripheral edema
  • Shortness of breath
  • Dizziness
  • Fatigue
  • Syncope or near syncope
  • Lightheadedness
• Causes (not limited to):
  • Normal physiology in an athlete
  • Medications like beta-blockers
  • Ischemia
  • Heart diseases
  • Sick sinus syndrome
  • Hypothermia
  • Hypothyroidism
  • Neuro-mediated bradycardia as caused by a vasovagal reaction
  • Pericarditis
  • Hypoxia

• Electrolyte imbalances

• Treatment:
  • None if asymptomatic, admission for observation may be indicated
  • Medications:
    • Atropine 0.5mg every 3 to 5 minutes for a maximum dose of 3mg
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker
  • Return patient to a normothermic state if hypothermic

Sinus Tachycardia (55):

• Rate: greater than 100bpm but less than 150bpm
• Conduction:
  • PR interval 120-200ms
  • QRS width 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(42)

• Signs and Symptoms:
  • Shortness of breath
  • Chest pain
  • Dizziness
  • Syncope or near syncope
  • Lightheadedness
  • Palpitations
• Causes:
  • Infection or sepsis
  • Medications
  • Withdrawal
  • Electrolyte imbalances
  • Blood loss or anemia
  • Dehydration
  • Hypoglycemia
  • Pulmonary embolism
  • Trauma
  • Cardiac tamponade
  • Myocarditis
  • Pregnancy
• Treatment:
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Insulin
    • Electrolyte replacement
    • Fluids
    • Heparin or other anticoagulant medications
  • Blood replacement
  • Surgery

1st Degree AV Block (68):

• Rate: 60-100 beats per minute (bpm)
• Conduction:
  • PR interval greater than 0.20 seconds
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • A QRS complex always follows the P wave
• Duration:
  • Less than 0.12 seconds
• Rhythm Strip:

(32)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones in young patients
  • Fibrotic changes in the elderly
  • Cardiac disease
  • Inflammation
  • Medications
  • Electrolyte abnormalities
• Treatment:
  • None if asymptomatic
  • Medications
    • Antibiotics
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type I AV Block (Mobitz Type 1 or Wenckebach) (60):

• Rate: varies
• Conduction:
  • PR interval increases with each beat, eventually “dropping off” and another P wave appears
  • “Longer, longer, drop, that’s a Wenckebach.”
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(27)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
• Causes:
  • Increased vagal tones
  • Cardiomyopathy
  • Myocardial infarction
  • Cardiac surgery
  • Electrolyte abnormalities
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine if bradycardic
    • Antidotes or reversal agents
    • Electrolyte replacement

2nd Degree Type II AV Block (Mobitz II) (60):

• Rate: varies
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
    • QRS does not follow all P waves
  • P wave morphology:
    • The maximum height of the P wave is:
      • Lead II and III: 2.5 mm
    • The P wave is:
      • Positive or above the isoelectric line in II and AVF
      • Biphasic in V1
    • Rhythm Strip:

(40)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Cardiac arrest
• Causes:
  • Structural heart disease
  • Amyloidosis
  • lymphoma
  • Cardiac tumors
  • Transcatheter placement of valves
  • Myocardial infarction
  • Genetics
• Treatment:
  • None if asymptomatic
  • Medications
    • Atropine does not work on these patients
    • Antidotes or reversal agents
  • Transcutaneous cardiac pacing or pacemaker since this rhythm can progress to a complete heart block or cardiac arrest

3rd Degree AV Block (78):

• Rate: varies, but usually bradycardic
• Conduction:
  • PR interval varies
  • QRS width 60-100ms when present
  • P wave and QRS complex do not communicate (called AV disassociation)
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:

(33)

• Signs and Symptoms:
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Lightheadedness
  • Hemodynamic instability
  • Cardiac murmurs
  • Cardiac arrest
• Causes:
  • Cardiac surgery
  • Cardiac disease
  • Medications
  • Electrolyte imbalances
  • Lyme disease
  • Transcatheter aortic valve replacement
  • Myocardial infarction
  • Systemic lupus erythematosus
  • Sarcoidosis
• Treatment:
  • Medications
    • Atropine usually does not work, but can be administered
    • Epinephrine
    • Dopamine
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Transcutaneous cardiac pacing or pacemaker

Premature Ventricular Contraction (PVC) (88):

• Rate: varies, underlying rhythm is usually normal sinus
  • The impulse to beat comes from the ventricles, not from the SA node
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
  • PVC QRS width is at least 120ms but usually 160-200ms
  • Regular QRS width is 60-100ms
  • PR interval after a PVC is longer due to the PVC and the retrograde concealed conduction goes back into the AV node junction.
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave is:
    • Positive or above the isoelectric line in II and AVF
    • Biphasic in V1
  • Rhythm Strip:
    • Monomorphic: All PVCs are shaped the same

(38)

• Biomorphic: PVCs are shaped differently

(64)

• Bigeminy: Every PVC is separated by one sinus beat.

(35)

• Trigeminy: Every PVC is separated by two sinus beats.

(9)

• Ventricular Couplet: Two PVC beats in a row.

(9)

• Ventricular Triplet: Three PVC beats in a row.

(9)

• Signs and Symptoms:
  • None
  • Fatigue
  • Shortness of breath
  • Syncope or near syncope
  • Chest pain
  • Palpitations
  • Lightheadedness
  • Abnormal neck pulsation
  • Hemodynamic instability with frequent PVCs
  • Cardiac arrest
• Causes:
  • Hypoxia
  • Illicit drug use
    • Amphetamines
    • Alcohol
    • Cocaine
  • Electrolyte imbalances
  • Myocarditis
  • Mitral valve prolapse
  • Hypercarbia
  • Cardiomyopathies
  • Myocardial infarction
  • Medications
• Treatment:
  • None if asymptomatic
  • Medications
    • Beta-blockers
    • Calcium channel blockers
    • Amiodarone is for those with preexisting coronary artery diseases, but used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Electrolyte replacement
  • Cardiac ablation
  • Defibrillation if cardiac arrest occurs

Premature Atrial Contractions (PAC) (54):

• Rate: varies, underlying rhythm is usually normal sinus
• Conduction:
  • PR interval varies, but in a regular PQRST complex PR interval is 120-200ms
  • PAC
  • Regular QRS width is 60-100ms
• P wave morphology:
  • The maximum height of the P wave is:
    • Lead II and III: 2.5 mm
  • The P wave:
    • Can be inverted
    • May be hidden in the T wave creating a hump or peaked T wave
  • These rhythms can come in the same variations as PVCs:
    • Bigeminy
    • Trigeminy
    • Couplet
    • Triplet
  • Rhythm Strip:

(37)

• Signs and Symptoms:
  • None
  • Palpitations
  • Shortness of breath
  • Anxiety
  • Signs and symptoms of heart failure
  • Early or additional heart sounds
  • Pauses in rhythm
• Causes:
  • Coronary artery disease
  • Left ventricular hypertrophy
  • Septal defects
  • Congenital heart deformities
  • Medications
    • Beta-blockers
    • Chemotherapeutic agents
  • Congestive heart failure
  • Diabetes mellitus
  • Hypertension
  • Chronic obstructive pulmonary disorder
  • Anxiety
• Treatment:
  • None if asymptomatic
  • Avoiding triggers
  • Medications
    • Beta-adrenergic blockers
    • Antiarrhythmic agents are used with caution and close observation and monitoring
    • Antidotes or reversal agents
    • Cardiac ablation

Ventricular Tachycardia (V Tach) (45):

• Rate: greater than 100bpm
• Conduction:
  • PR interval none
  • QRS width greater than 140ms
• P wave morphology:
  • Not present
• Non-sustained V-Tach: three or more ventricular beats over a maximum of 30 seconds.
• Sustained V-Tach: a run of V Tach for more than 30 seconds or less is treated by cardioversion
• Monomorphic V-Tach: all ventricular beats look the same
• Polymorphic V-Tach: the ventricular beats look different.
• Biphasic V Teach: where the QRS complexes alternate with each beat.
  • Digoxin intoxication
  • Long QT syndrome
• Rhythm Strip:
  • Monomorphic V-Tach

(11)

• Signs and Symptoms:
  • Palpitations
  • Shortness of breath
  • Chest pain
  • Syncope or near syncope
  • Signs of heart failure
  • Hemodynamic instability
  • ICD shocks if the patient has one
  • Cardiac arrest
    • Also known as pulseless V-Tach
  • Causes:
    • Ischemic heart disease
    • Acute coronary artery disease
    • Myocardial scar-related reentry
    • Congenital heart deformities
    • Cardiomyopathy
    • Illicit drugs
      • Cocaine
      • Digitalis toxicity
      • Methamphetamine
    • Medications
      • Beta-blockers
      • Chemotherapeutic agents
    • Electrolyte imbalances
    • Sepsis
    • Metabolic acidosis
    • Inherited cardiac channelopathies
  • Treatment:
    • Cardiopulmonary resuscitation (CPR) and defibrillation if no pulse present
    • Cardioversion if hemodynamically unstable and has a pulse
    • Treatment for myocardial infarction
    • Medications
      • Amiodarone, procainamide, sotalol
      • Antidotes or reversal agents
    • ICD
    • Cardiac ablation

Torsades de Pointes (V Fib) (25):

• Rate: none
• Conduction:
  • Polymorphic V-Tach with a prolonged QR interval
• P wave morphology:
  • Not present
• Rhythm Strip:

(12)

• Signs and Symptoms:
  • None
  • Syncope or near syncope
  • Dizziness
  • Lightheadedness
  • Hypotension
  • Rapid pulse
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Medications
      • Zofran causes a long QT interval (19)
    • Congenital prolonged QT:
      • Jervell and Lange-Nielsen
      • Romano-Ward syndrome
    • Bradycardia
    • Diuretic use
    • Female gender
    • Age
  • Treatment:
    • Electrolyte replacement
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
    • Cardioversion
    • Treatment of the underlying cause

Supraventricular Tachycardia (SVT) (72):

• Rate: Greater than 160bpm
• Conduction:
  • PR interval not present
  • QRS width less than 120 milliseconds = narrow complex, regular SVT
  • QRS width greater than 120 milliseconds = wide complex, regular SVT
• P wave morphology:
  • Not present
• Rhythm Strip:
  • Narrow complex, regular SVT

(30)

• Wide complex, regular SVT

(79)

• Signs and Symptoms:
  • None
  • Hypotension
  • Shortness of breath
  • Lightheadedness
  • Signs and symptoms of heart failure
  • Shock
• Causes:
  • Narrow complex, regular SVT - Orthodromic reentry phenomenon (56):
    • Accessory pathway that connects the atria and ventricles without passing through the AV node
    • A pulse goes through the AV node, down into the ventricles via the Bundle of His, up through the accessory pathway, and back into the AV node
  • Wide complex, regular SVT - Atrioventricular reentry phenomenon (57):
    • Signals from the SA node travel through the accessory pathway down the ventricles via the Bundle of His and up to the AV node, creating a backward cycle.
    • This is slower than the orthodromic SVT because it is traveling against the regular path of conduction, leaving to a wide QRS complex
  • Medications
  • Caffeine
  • Smoking
  • Stress
  • Alcohol
• Treatment:
  • None if asymptomatic
  • Vagal maneuvers
    • Bearing down
    • Blowing into a straw
  • Medications
    • Adenosine: 1^st dose 6mg, 2^nd dose 12mg
      • Ensure rapid saline flush after pushing medication as it has an extremely short half-life
    • Cardizem
    • Antidotes or reversal agents
  • Cardioversion
  • Cardiac ablation

 Ventricular Fibrillation (V-Fib) (3):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • Not present
• Rhythm Strip:

(39)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Sudden blow to the chest right over the heart
    • Medications
    • Anemia
    • Cardiomyopathy
    • Electrocution
    • Thoracic trauma
    • Heart surgery
  • Treatment:
    • CPR and defibrillation
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Asystole (59):

• Rate: none
• Conduction:
  • PR interval not present
  • QRS width not present
• P wave morphology:
  • May or may not be present
• Rhythm Strip:

(21)

• Signs and Symptoms:
  • Cardiac arrest
    • No pulse
    • Not breathing or only gasping for air
    • Loss of consciousness
  • Causes:
    • Electrolyte imbalances
    • Myocardial infarction
    • Congenital heart defects
    • Medications or illicit drugs
    • Blood loss
    • Cardiomyopathy
    • Electrocution
    • Trauma
  • Treatment:
    • CPR
      • Since there is no electrical activity with this rhythm, defibrillation cannot be used
    • Medications
      • Epinephrine
      • Atropine
      • Electrolytes
    • Surgery
    • Coronary perfusion
    • Treatment of the underlying cause

Pulseless Electrical Activity (PEA) (22):

• Rate: varies
  • There is no pulse with this rhythm despite the fact that it may appear as an organized rhythm
• Conduction:
  • PR interval none
  • QRS width greater than 110ms
• P wave morphology:
  • Not present
• The P wave is:
  • Not present
• Rhythm Strip: