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Communication For Nursing Professionals Today’s Objectives Increase awareness of the risks surrounding poor communication, specifically targeting exposure to negligence and malpractice claims Enhance the quality and effectiveness of communication by expanding awareness in order to provide quality patient care and avoid malpractice incidents To address specific communication methods and recommendations to protect your patient from harm and minimize your liability exposure Agenda Introduction to Communication Section I: Communication with Patients Section 2: Communication with Other Healthcare Providers Section 3: External Communication Case Study What is Communication? The exchange of information, ideas, or opinions Interactive or one-way Often complex and affected by a variety of elements, which can affect patient safety and quality of care provided Importance of Communication The Joint Commission, which accredits the majority of hospitals in this country and some nursing homes and other facilities, analyzes the root causes of sentinel, or critical, events. Miscommunication is the most common cause of patient injury or death. Importance of Communication Breakdowns in communication can cause: – Medical errors – Patient injury or death – Malpractice lawsuits – Delays in treatment – HIPAA violations – A culture of intimidation – And more… Four C’s of Communication Clear Concise Correct Complete Communication Channels Patient & Patient’s Family Internal Nurse Physicians Colleagues Technicians Supervisors Office Staff Patient External Legal team Social Media HIPAA Section I Communication with Patients The Human Connection Phone and E-mail Communication Informed Consent and Duty to Disclose Workplace Violence The Human Connection: Nonverbal Communication to the Patient Nonverbal dynamics have great impact on: – Rapport – Trust – Mutual respect Remember: – People pick up on your nonverbal messages – Respond to the patients’ negative nonverbal signals with empathy – Be culturally sensitive to nonverbal communication differences Nonverbal communication has an enormous impact! Your posture, tone, pace, and face all give away your real meaning. The Human Connection: Nonverbal Communication from the Patient Pay attention to your patients’ nonverbal signs Nonverbal behavior may not always support what is said – Posture – Tone of voice – Facial expression – Nodding and smiling – Eye contact Resist responding to the content of what patients are saying, when the nonverbal behaviors communicate a different message The Human Connection: Communicating with Patients and Families Nurses may deal with difficult situations involving language barriers, disagreements, or complaints about delivery of care. Remember to: Deal with the situation honestly and treat all participants with respect Utilize appropriate therapeutic and listening skills Establish rapport Avoid medical jargon Provide a private neutral place Use interpreter services Phone and E-mail Communication While telephone and e-mail facilitate contact with patients, they also may jeopardize privacy. It is important to follow written policies addressing appropriate and secure use to safeguard patients’ protected health information (PHI). Phone and E-mail Communication: Parameters of Use Most suitable for brief exchanges of minimally sensitive information Consent form at initial patient visit should outline the expectations, risks and limitations Phone and E-mail Communication: Security Guidelines Two key risk management principles: Ensure security of transmitted information Ensure privacy of content Phone and E-mail Communication: Security Guidelines E-mail Risk Reduction Tips: Avoid patient identifiers in the subject heading Include a privacy notice with all e-mails Limit unsecured messaging to notification of services Never send blind copies or group e-mails where other names are visible to recipients Rely on a centralized patient e-mail database Retain the original e-mail message Transmit through an approved and secure serve Phone and E-mail Communication: Security Guidelines Telephone Risk Reduction Tips: Designate a separate telephone conversation area Use landlines when possible Never leave sensitive information on an answering machine, in a voicemail message or with an answering service. Update patient telephone numbers on a regular basis Phone and E-mail Communication: Advice Protocols Safeguards to help limit liability: Advise callers to seek emergency medical attention if symptoms worsen or fail to improve Establish protocols for which telephone calls must be immediately referred to a physician, nurse practitioner, physician assistant or other licensed independent practitioner Establish telephone advice protocol parameters for specific symptoms Make a physician/practitioner available for nurse staff consultation during any form of telephone or electronic assessment Require physicians/practitioners to sign off on all telephone advice protocols Review telephone advice protocols annually and maintain discontinued ones in a secure location Securely fax or e-mail patients an approved health information sheet following any protocol-based telephone advice discussion Use a checklist format for telephone advice protocols Phone and E-mail Communication: Documentation Same documentation and retention requirements as other forms of documentation Attach e-mails to electronic medical records Telephone messages must be written down - use preprinted telephone logs Phone and E-mail Communication: Special Situations Prescription requests Laboratory results Urgent and non-urgent requests Out-of-office communication Informed Consent Informed Consent: the voluntary permission that a patient or patient’s legal representative gives to the physician or authorized healthcare provider to do something to or for that patient after having been apprised of the risks, benefits and alternatives to the proposed test, medication or treatment. Patient Autonomy: process of giving the power of choice to patients by respecting their decisions about their own health care. The Law of Informed Consent: varies from state to state. Refer to the specific statues of your state. Informed Consent - Documentation Regarding strictly nursing procedures, the nurse SHALL verify that the patient’s informed consent was obtained, and SHALL document the information given. Regarding medical informed consent, if the patient/legal representative is unclear or has questions regarding their consent, the nurse should contact the involved practitioner to personally meet with the patient or their legal representative to be certain they understand the risks, benefits and alternatives to the treatment, medication or procedure proposed. Informed Consent The nurse should be knowledgeable as to the protocol for obtaining informed consent, from the patient…as established in organizational policies and procedures.* When organizational policies fail to ensure informed consent, discuss additional strategies with your risk manager and/or legal counsel. *Ibid. Capacity to Consent Decision-making capacity is based on the patient’s ability to: Understand his or her condition Use relevant information presented Communicate his or her preference Types of Consent: Expressed Consent The practitioner obtaining the informed consent is responsible for documenting the consent. Documenting written and oral consent includes: High quality documentation Date and time of the discussion Nature of the discussion Statement that patient gave consent Types of Consent: Implied Consent Applies in an emergency situation combined with the inability to seek consent. Appropriate for: – Unconscious or delusional patient – Patient under the influence of alcohol or drugs – Patient incapable of giving expressed consent Treatment Without Consent Treatment or attempts to treat without consent may result in a lawsuit based on the following claims: – Assault or battery – Lack of informed consent – Negligently obtaining informed consent Workplace Violence Violence at work is the leading cause of death among all workers and the #1 killer of women in the workplace More assaults occur in healthcare and social services industries than in any other. Range of attack types Range of perpetrators Emotional toll potential Workplace Violence: Key Indicator Signs History of aggression Problematic behavior Changes in body language Dull, unresponsive, blank affect Confusion and agitation in an older patient Workplace Violence: Managing an Angry Patient 1. Look for the signs 2. Act fast 3. Don’t hesitate to contact security or the police if you feel threatened 4. Document Workplace Violence: Managing an Angry Patient Help them vent Spend extra time Maintain eye contact and listen Identify the underlying reason Explain consequences Keep your cool Show empathy Ask for the patient’s solution Respond calmly Treat them with respect Find some point of agreement Section II Communication with Other Healthcare Providers General Information Culture of Intimidation Teamwork and Collaboration Handoff Process Behaviors That Show Respect Listen and be fully attentive Acknowledge and express appreciation Exhibit empathy and understanding Display courtesy and consideration Be accountable and professional Disruptive Behaviors Definition: any behavior which either overtly or covertly compromises safe and quality patient care Examples include: – Verbal outbursts – Physical outbursts – Uncooperative attitudes – Condescending voice or tone intonations – Culture of intimidation Disruptive Behaviors Chain of Command = The Line of Authority The chain of command in its simplest definition is the line of authority and responsibility along which orders are passed within the nursing department, the hospital, and between different units. Every hospital, indeed, nearly every organization, has a chain of command. Nurses who ignore the chain of command may lose their jobs, and in some cases their licenses. Invoking the Chain of Command Invoke the chain of command when necessary to obtain attention to the patient’s condition and/or change in condition. Nurses are responsible to obtain the care and services necessary for the treatment of patients under their care. This responsibility continues to the point of resolution. Invoking the Chain of Command – 4 steps (1) Call on your head nurse or charge nurse, who can use their position to accelerate a response or get the necessary authorization. (2) Should this fail or if for some reason there is no head nurse or charge nurse available look to the Unit or Department Director of Nursing (DON). (3) If your scenario involves a physician and a patient is in jeopardy, remember that the Chief Nursing Officer (CNO) is your top advocate. – the CNO is usually directly beneath the hospital administrator, and therefore, has a great deal of authority to assist in finding a positive solution to the problem. If the CNO is not responsive, then the next step is to contact the medical director or the hospital administrator or CEO depending on the issue. (4) Always remember to document. If you are having trouble getting the appropriate authorization to administer medication or perform a procedure, be sure to notate this in the chart. If necessary and appropriate, you can also complete an incident report as defined by your hospital’s policies and procedures. Chain of Command - Communication Deterrents Nurses must use both nursing and medical chains of command if a patient service is not made available or if interventions performed are inadequate or ineffective. Discomfort with invoking the medical staff chain of command cannot be allowed to inhibit the nurse from seeking assistance when a physician or other licensed independent provider does not respond to calls. Even more challenging are events where the licensed independent provider has responded, but the nurse believes he or she has failed to appreciate the seriousness of the patient’s condition or where the appropriate treatment, medication, or clinical intervention were not initiated. Communication and “just culture” Nurses should report communication issues between nursing and medical staffs to identify and report instances of intimidation, bullying or other deterrents to invoking the chain of command. Nurses should notify leadership of situations, clinical services or individuals who prevent nursing staff from invoking the chain of command. Nurses can initiate discussions regarding “just culture” if the organization’s current culture does not support invoking the chain of command. Asking for help is not a sign of weakness. Culture of Intimidation Definition: Any intimidating or condescending behavior, usually by a superior Affects: – Nurses – Patients – Management – Other healthcare providers Culture of Intimidation: Statistics According to an Institute for Safe Medication Practices (ISMP) survey: – 88% of respondents encountered condescending language or voice intonation – 87% encountered impatience with questions – 79% encountered a reluctance or refusal to answer questions or phone calls – The Impact: 7% reported that they had been involved in a medication error during the past year in which intimidation played a role Culture of Intimidation: Tools and Strategies Advocate for the patient Be assertive Be firm and respectful to authority Use CUS words: Concerned, Uncomfortable, Safety Voice your concern at least two times If necessary, go up the chain of command Teamwork and Collaboration: Barriers to Effective Communication Gender Education Generational differences Large team size Instability of the workforce and assignments Absence of a common purpose Nurse-Physician relationship Teamwork and Collaboration: Overcoming Barriers Collegial Relationships Sharing Knowledge Understanding differences Increased effectiveness Improved quality of care Reduced Turnover rates Increased patient safety Improved group cohesion Improved nurse satisfaction Overcoming Communication Barriers Using the SBAR method of Communication SBAR, used in many hospitals, is a formalized method of communicating with other healthcare practitioners SBAR = Situation, Background, Assessment, Recommendation Purpose: – To report to a healthcare provider a situation that requires immediate action – To define the elements of a handoff – To provide a specific structure for communication Overcoming Communication Barriers Recommendations Use a a direct, honest, and respectful manner Remain cool, calm, and collected Appropriately set limits Seek third-party assistance Do not take things personally Handoff Process Defining the Process: Process of passing complete and accurate patient-specific information from one caregiver to another. Information should include: – patient’s condition – care, treatment, and anticipated changes – services delivered to the patient Handoff Process Identify critical hand-off points Importance of effective handoffs – Confirm responsibility for patient care – Provide critical shift change updates – Enhance continuity of care Handoffs: Strategies Use face-to-face communication Allocate enough time to the process Use standardized reporting methods Use precise language Read back critical information Smooth hand-offs between settings Get full use of information technology Confirm receipt of patient charts Joint Commission’s National Patient Safety Goals - 2006 Goal: Improve the effectiveness of communication among caregivers. Improve Communication Requirement: For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result. Improve Communication Requirement: Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization. Improve Communication Requirement: Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Improve Communication Requirement: All values defined as critical by the laboratory are reported to a responsible licensed caregiver within time frames established by the laboratory (defined in cooperation with nursing and medical staff). When the patient’s responsible licensed caregiver is not available within the time frames, there is a mechanism to report the critical information to an alternative responsible caregiver. Section III External Communication HIPAA Social Media Health Insurance Portability and Accountability Act (HIPAA) Protects a patient's rights to the confidentiality of his/her medical information Hospitals and providers may use this information only for: – Treatment, – Obtaining payment for care – Specified operational purposes like improving quality of care Must inform patients in writing of how their health data will be used; establish systems to track disclosure; and allow patients to review, obtain copies, and amend their own health information HIPAA: Protected Health Information (PHI) PHI - all individually identifiable health information held or transmitted by or to the covered entity in any form or media – Can be electronic, paper, or verbal Examples of PHI: – Name – Date of birth – Social security number – Device identifiers/serial numbers – Full-face photos Who can you disclose information to? HIPAA: Standards for Electronic Transactions Security When communicating with another clinician, remember this: – Others besides the addressee may process messages during addressee's usual business hours or during addressee's vacation or illness – Electronic messages can occasionally go to the wrong party – Electronic communication can be accessed from various locations – Information written by one clinician may be sent electronically to other care providers – The Internet does not typically provide a secure media for transporting confidential information unless both parties are using encryption technologies. HIPAA: Be Compliant Keep confidential all patient information. Share patient information on a "need- to-know" basis. Be mindful of your surroundings when discussing patient information. Avoid discussing patients in public places Keep confidential papers, reports, computer disks, and data in a secure place. Retrieve confidential papers from fax machines, copiers, mailboxes, conference rooms, and other publicly accessible locations as quickly as possible. Use technology such as fax machines and e-mail only to support patient care activities. Do not fax information to attorneys, employers, or patients. Always tear or shred paper copies of documents containing patient information. HIPAA: Be Compliant Don't share computer log-ins or passwords to systems containing PHI. Never leave medical records unattended in public areas. Dispose of items containing PHI appropriately. Be sure to log out of computer or data systems containing PHI. Follow security systems requirements for remote accessing of PHI. Activate the security settings of PDAs if they contain PHI. Avoid discussing patients in public places. HIPAA – An Example A nurse is participating in a research project and needs access to PHI to make clinical comparisons of response to treatment. Is this okay? HIPAA – Keep up to date Recommended websites for HIPAA: ANA Code of Ethics – http://www.nursingworld.org/ethics/ecode.htm U.S. Department of Health & Human Services – http://www.hhs.gov Centers for Medicare & Medicaid Services – http://www.cms.hhs.gov American Medical Association – http://www.ama-assn.org American Hospital Association – http://www.hospitalconnect.com/aha/key_issues/hipaa Social Media Opportunities Examples: Facebook, Twitter, MySpace, LinkedIn, personal blogs The three P’s of digital ethics: privacy, protection, and policy Many healthcare organizations have established a social media presence – Nurses can discuss issues related to Nursing: best practices, safety, clinical trials – Important teaching tool – YouTube and Twitter updates – Dedicated pages to keep up on the latest news and research Social Media Pitfalls Do not: – Share your work experiences on any social media sites – Reveal any information that can identify a patient – Give any medical advice – Share any experiences on challenging patients – Share any experiences on an interesting medical problem – Post any patient information • Five nurses were fired for allegedly discussing patient cases on Facebook • Two Wisconsin nurses were fired for posting a patient’s x-ray on Facebook page Proceed with Caution! Social Media Recommendations Use common sense Protect patient privacy Adhere to the legal and regulatory requirements such as those of Health Insurance Portability and Accountability Act (HIPAA) – Even if you don’t identify the patient, the HIPAA violation still exists – you don’t have the patient’s permission – Should you become a patient’s “friend” ? – Violating HIPAA regulations can lead to fines as high as $250,000 and time in jail. Social Media Recommendations Always remember to follow your facility’s guidelines regarding e-mail and other electronic communication when using social media – If your facility doesn’t have a policy regarding social media, assume e-mail and electronic policies, by extension, apply to social media sites. – Mayo Clinic’s guidelines around social media – Good rule of thumb: Would I be comfortable with this item being shared in a public forum with my employer, patients and colleagues? Social Media Safeguards Ask your employer for policies and procedures regarding these sites Participate in or request staff training – sessions should cover key concerns such as: – Rules and etiquette – Parameters for use during working and non-working hours – Potential legal perils – Patient confidentiality issues – Disciplinary consequences fpr misuse – Training session content and attendance should be documented. Nurse Claim Scenario Case Summary A 23-year-old woman with no significant medical history presented to the emergency room complaining of generalized body ache, with a fever of 102.6. CT Scan of the chest was abnormal, resulting in ED MD admitting the Pt to the intensive care unit. Pt was started on oxygen and antibiotic therapy. Blood cultures were drawn, indicating Streptococcus Pneumoniae, and antibiotics were appropriately adjusted. Nurse Claim Scenario Case Summary The attending MD noted that while the Pt was not in acute distress, her blood chemistry was abnormal with a potassium level of 2.9. MD ordered 30mEq of potassium to be added to each bag of the Pt’s intravenous fluid, infused at 80 milliliters per hour. Two days later, the Pt’s potassium level was noted to be 3.0, and the attending MD ordered 80 mEq of potassium to be administered by mouth. Nurse Claim Scenario Case Summary The Pt vomited the medication. The attending MD then ordered two doses of 40 mEq of intravenous potassium to infuse over a four-hour time period with the plan of increasing the potassium level between 4 and 4.5. Throughout the day, the defendant intensive care unit nurse documented the Pt’s heart rate in the Pt care record. Nurse Claim Scenario Case Summary The nurse did not notify MD of the pattern of rising heart rate. When the MD saw the Pt that day, he ordered the Pt to be transferred to the telemetry unit. According to hospital records, the attending MD was called at approximately 10:00 p.m. and was advised that the Pt had gone into cardiac arrest. The on-call emergency MD attempted to resuscitate, but was unable to obtain a heartbeat, and the Pt was pronounced dead. Nurse Claim Scenario Was the Nurse Deemed Negligent? • Do you think this nurse was negligent? • Do you think any other practitioners were negligent? • Do you think indemnity and/or expense payment was made on behalf of the nurse? If yes, how much? Nurse Claim Scenario Was the Nurse Deemed Negligent? The nurse was deemed negligent in the following areas: • Failure to notify the MD of the Pt’s increasing heart rate • Failure to clarify the potassium order, and the nurse administered an incorrect dosage of potassium at an incorrect rate • Failure to fully document her actions and the Pt’s condition during the transfer of the plaintiff to the telemetry unit • Lack of documentation of time of transfer • Lack of documentation of Pt’s condition at time of transfer Nurse Claim Scenario Was the Nurse Deemed Negligent (Cont.) ? • Failure to document that the Pt was on a monitor and receiving oxygen when transferred • Failure to notify the MD that the telemetry unit was in an overflow situation and verify whether the transfer should be completed Nurse Claim Scenario Payments made on Behalf of the Nurse? Indemnity payment – 6 figures Expense payment - < $10,000 (Often, the payments made on behalf of co-defendants is not available. In this case, it is known that payments made on behalf of multiple co-defendants totaled $1,400,000.) Nurse Claim Scenario Risk Management Recommendations • When assigned to a clinical area, the nurse’s training and experience should provide the skills necessary to demonstrate competencies required for performing the nursing role specific to the clinical specialty or area. Nurse Claim Scenario Risk Management Recommendations • If not, it is the responsibility of the nurse to: – Notify the charge nurse and/or supervisor that the assigned clinical area transcends the nurse’s training and experience. – Request close supervision and/or the assistance of an experienced nurse and also request that all treatments and medications be checked prior to administration. Nurse Claim Scenario Risk Management Recommendations – Obtain assistance for lack of complete understanding of any aspect of the patient’s condition, plan of care, progress notes, physician orders and/or medication orders. – Utilize the chain of command, including the director of nursing and/or hospital administrator, until provided with an assignment appropriate to his/her level of training and experience or until appropriate support and supervision by an experienced nurse is provided. Nurse Claim Scenario Risk Management Recommendations • Monitor and document the patient’s vital signs, symptoms, response to treatment and changes in condition in the patient care record. • Timely report all significant findings to the patient’s physician. • Adhere to physician medication orders, including the correct drug, dosage, route and administration times. • Contact the physician and/or pharmacist with questions, concerns or to obtain clarification regarding the medication(s) ordered for the patient. If the physician does not respond in a timely manner, follow the chain of command to the point of resolution. Nurse Claim Scenario Risk Management Recommendations • Manage any deviation from the physician’s order regarding administration of a medication as a medication error, including reporting, investigating and developing a plan of correction to prevent subsequent recurrences. • Perform and document formal handoff procedures when transferring a patient and report all significant patient information regarding the patient’s treatment, including a review of treatments, tests, medications and outstanding orders, to the accepting nurse. Nurse Claim Scenario Risk Management Recommendations • Manage any deviation from the physician’s order regarding administration of a medication as a medication error, including reporting, investigating and developing a plan of correction to prevent subsequent recurrences. • Perform and document formal handoff procedures when transferring a patient and report all significant patient information regarding the patient’s treatment, including a review of treatments, tests, medications and outstanding orders, to the accepting nurse. Resources Navigate Nursing. “Five Behaviors that Show Respect.” ADVANCE for Nurses. “Building Blocks of Teamwork.” Nursezone.com. “SBAR Improves Communication in Patient Handoffs.” Medleaugue.com. “SBAR.” Joint Commission Guide to Improving Staff Communication, Second Edition. 2009. Disclaimer The purpose of this presentation is to provide general information, rather than advice or opinion. It is accurate to the best of the speakers’ knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional and legal counsel. In addition, Aon, Affinity Insurance Services, Inc. (AIS), Nurses Service Organization (NSO) or Healthcare Provider Service Organization (HPSO) do not endorse any coverage, systems, processes or protocols addressed herein unless they are produced or created by AON, AIS, NSO, or HPSO, nor do they assume any liability for how this information is applied in practice or for the accuracy of this information. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and AON, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. To the extent this presentation contains any descriptions of CNA products, please note that all products and services may not be available in all states and may be subject to change without notice. Actual terms, coverage, amounts, conditions and exclusions are governed and controlled by the terms and conditions of the relevant insurance policies. The CNA Professional Liability insurance policy for Nurses and Allied Healthcare Providers is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA Company. CNA is a registered trademark of CNA Financial Corporation. © CNA Financial Corporation, 2012. NSO and HPSO are registered trade names of Affinity Insurance Services, Inc., a unit of Aon Corporation. Copyright © 2012, by Affinity Insurance Services, Inc. All rights reserved.