provided by Nurses Service Organization (NSO) - Feb. 9

A nurse’s ability to recognize and respond to changes in a patient’s condition is a crucial element of professional nursing practice. Failure to respond appropriately to clinical changes can lead to complications and even death.¹ In a study that investigated the impact of communication in malpractice lawsuits, communication failure was a factor in 32% of cases involving nurses, with most involving poor communication with other healthcare professionals about the patient’s status. These cases often result in huge financial consequences in cost of care and legal
damages.² 

Communication

Communication of a patient’s status has been the focus of much attention and research, and various communication frameworks have been generated to facilitate clinical communication among healthcare professionals about patient status.^3,4 Widely used examples include SBAR (situation, background, assessment, and recommendation) and ISBARR (introduction, situation, background, assessment, recommendation, and read back).

In some cases, however, it is not about the nurses’ ability to communicate with primary care providers. Rather, they are about the competence and decision-making skills needed that enables a nurse to assess a patient’s condition and determine the appropriate intervention, including when to escalate care and seek the expertise of appropriate personnel.

Barriers to Communication

Many factors can play into why nurses may not communicate a patient’s status promptly or at all. These include a busy schedule, a reluctance to “bother” the primary care provider, or a failure to recognize the circumstances under which a primary care provider should be notified due to a lack of clinical competence.² Nurses need to recognize the severity and emergent nature of a patient’s condition.

A nurse’s failure to recognize an emergency indicates a lack of competence in nursing fundamentals and a lack of knowledge about the possible physiologic consequences. This gap in knowledge can contribute to a catastrophic deterioration in the patient’s condition.

Critical thinking extends beyond mere information, attentiveness, and assessment. How do nurses acquire the decision-making and critical-thinking skills necessary for their practice? The clinical competence needed to make decisions, especially in acute situations, develops over time as the nurse advances from novice to expert.⁵ 

Implications for practice

To determine appropriate interventions and recognize when it is necessary to escalate care, nurses must:

• accept only patients that they are capable of caring for.⁶
• develop the education and skills necessary to recognize when the interventions they initiate are not effective.¹
• escalate the patient’s care to a more experienced nurse or the healthcare provider when they find that a patient’s status change is beyond their capability.⁷
• follow the facility’s chain of command. A nurse’s vigilance, recognition of an urgent situation, evaluation of changes in the patient’s condition, and steps taken to escalate appropriately should be evident in the medical record.⁸ Documentation should include the persons consulted and the actions that resulted from the consultation.⁹
• be aware that nurses can be held legally liable for actions they omit as well as actions they fail to take in a timely manner.⁷

Guidelines for practice

Keep these general guidelines in mind:

• When documenting adverse events, follow your facility’s policies and procedures. The record should be objective, including only clinical facts without any guesses, assumptions, speculations about the cause of the event, or personal opinions.¹⁰
• Listen to family members’ concerns. They are often at the bedside much longer than the clinical staff. They know the patient and are likely already engaging in the care of the patient at home. They are a valuable source of information and their concerns should be taken seriously.¹¹
• Nurses should consider carrying their own liability insurance, both for the purposes of legal liability and for any disciplinary actions taken by the board of nursing.¹²

The failure to report changes in a patient’s condition can have serious health consequences for the patient as well as legal and financial implications for all involved in the care of the patient. But by meeting the standards of professional nursing care, nurses can and should avoid these costly consequences.

REFERENCES

1. Massey D, Chaboyer W, Anderson V. What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nurs Open. 2016;4(1):6-23.
2. Crico Strategies. Malpractice risks in communication failures. 2015 Annual benchmarking report. www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures.
3. Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation. www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx.
4. Cudjoe KG. Add identity to SBAR. Nurs Made Incredibly Easy. 2016;14(1):6-7.
5. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407.
6. Buppert C. A “safe harbor” for unsafe nursing assignments. Medscape. April 26, 2019.
7. Nurses Service Organization. Failure to report changes in the patient’s medical condition to practitioner. 2012. www.nso.com/Learning/Artifacts/Legal-Cases/Failure-to-report-changes-in-the-patients-medical-condition-to-practitioner.
8. Thielen J. Failure to rescue as the conceptual basis for nursing clinical peer review. J Nurs Care Qual. 2014;29(2):155-163.
9. American Nurses Association. ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. Silver Spring, MD: American Nurses Association; 2010. 
10. Austin S. Stay out of court with proper documentation. Nursing. 2011;41(4):24-29.
11. Sherman DW. A review of the complex role of family caregivers as health team members and second-order patients. Healthcare (Basel). 2019;7(2):63.
12. Brous E. Reciprocal enforcement and other collateral issues with licensure discipline. J Nurse Pract. 2017;13(2):118-122.

By Omobola Awosika Oyeleye, EdD, JD, MSN, MEd, RN-BC, CNE, CHSE
This article has been adapted for space and originally appeared in the November 2019 issue of Nursing © 2019 Wolters Kluwer Health, Inc.

This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

Along with incalculable loss, the coronavirus (COVID-19) outbreak has had devastating effects on the mental health of people with COVID-19, their families, and the community at large. Healthcare workers face tremendous stress, both emotionally and physically, from the grueling work hours and the threat of contracting the virus at work.

This article addresses the potential mental health issues for healthcare workers that may emerge from this pandemic as well as treatment options and self-care activities that promote recovery.

COVID-19 and mental health

Nurses working on the front lines of the COVID-19 pandemic may experience various mental health problems. Here are a few examples:

• Chronic stress. Nurses are continuously fearful of contracting COVID-19, infecting others, encountering prejudice from the public due to working as a nurse, and dealing with inadequate supplies of PPE.¹ Stress becomes chronic when it is overwhelming and cannot be resolved, resulting in relationship, health, and sleep problems.^2-5 People with chronic stress experience intense emotions that can feel overwhelming and result in thinking negatively.⁶ Nurses on the front lines in COVID-19 hotspots report feeling like a graduate nurse again, filled with uncertainty and worry.⁷
• Acute stress disorder. Nurses with acute stress disorder may have trouble sleeping, worry constantly, and experience persistent negative thoughts about their role in the traumatic event, such as thinking “I should have done more to help.”⁸ When we experience trauma, we detach from the memory. We ignore our emotions to protect against the pain, but these emotions reappear over time and impact our lives.⁹ The nurse may respond to a minor irritation as if it were a life-threatening event.¹⁰ Nurses may feel they are in a dreamlike state that impacts their ability to think, process their emotions, and respond appropriately to situations.11 If signs and symptoms of acute stress disorder persist for more than a month, posttraumatic stress disorder (PTSD) may be diagnosed.¹²
• PTSD. Nurses are not strangers to caring for critically ill patients who die.⁸ However, the number of patients dying amid a surge in COVID-19 cases is causing healthcare workers to feel powerless, which can lead to PTSD. PTSD can develop after direct or indirect exposure to a traumatic event, such as hearing about a traumatic event involving a family member, friend, or colleagues. Those with PTSD experience recurrent intense and disturbing thoughts and feelings stemming from one or more traumatic events.^10,13,14 Nurses with PTSD may relive an event through flashbacks or nightmares, and they may feel sadness, fear, anger, guilt, shame and detachment or estrangement from other people.¹⁴ Many traumatized individuals have a robust and unconscious inclination to go inward, often to re-experience their distressing thoughts, painful memories, and uncomfortable sensations.¹⁵ They may have an exaggerated, startled response to certain situations and develop problems with concentration and sleep.⁵ 

The nursing team’s role

When nurses struggle personally, we tend to be critical of our colleagues or management and withdraw from others. Such a change in personality is often an indicator of struggle. It is often a team member who will notice that you are not your usual self and may be struggling with anxiety and stress. Asking yourself or a colleague three simple questions can raise awareness about a possible problem:

• Am I ok? Are you ok?
• Do you feel you cannot give anymore?
• Do you feel your work is ineffective?¹⁶

If you are struggling, speak with your colleagues, acknowledging those feelings and thoughts in the first instant. If you feel you are not performing effectively in your workplace, talk with your manager and state your opinions on being ineffective. Everyone has limits, and sometimes just taking a week off might be sufficient. 

Nurses who continue to feel this way should discuss it with their primary healthcare provider and their employer and review the options available. A range of supports may be available from your employer or your professional organization.^17,18 Some nurses may want the support of a counselor. It is a strength to realize that you are struggling with your mental health and need help.

Early psychological intervention does make a difference.¹⁹ Each of us has a limit to stress, and it is important not to compare your stress levels to those of another person. There is strength in being vulnerable and showing our thoughts and emotions. Brené Brown defines vulnerability as uncertainty, risk, and emotional exposure.²⁰

Topping off emotional reserves

Nurses on the COVID-19 front lines are plagued by drained emotions loneliness, and fear. These are normal reactions to an unfamiliar, uncertain environment. Transitioning away from work at the end of the day is essential for nurses to top off their emotional reserves.

If you have had a particularly stressful day, acknowledging and discarding any negative thoughts or feelings can help improve sleep quality. Having a ritual to signal the end of work is essential. Here are some suggestions:

• Take a shower. Visualize all the worries of the day disappearing down the drain.
• Write down any thoughts or feelings in a notepad.
• Watch a favorite TV program.
• Read a book.
• Listen to your favorite music.
• Contact a friend.
• Write down three things you were grateful for today.

The COVID-19 pandemic is an unprecedented event in our lifetimes that will have untold mental health implications for nurses and other healthcare professionals on the front lines, both in the short and long term. Although scientists and healthcare professionals know more about the disease and how to treat it now, nurses in current COVID-19 hotspots will still be treating patients with a serious and rapidly spreading disease while possibly contending with shortages of PPE, equipment, and treatments.²¹

 Nurses will need to receive support from their team, practice optimal self-care strategies, take measures to replenish their emotional reserves, and learn how to transition mentally from work to home after their shift. Recognizing stress and learning how to cope will help nurses protect their mental health as we move forward during this pandemic.

REFERENCES

1.  Wann W. America is running short on masks, gowns and gloves. Again. The Washington Post. 2020. www.washingtonpost.com/health/2020/07/08/ppe-shortage-masks-gloves-gowns.
2. Mariotti A. The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future Sci OA. 2015;1(3):FSO23.
3. American Psychological Association. How stress affects your health. 2019. www.apa.org/helpcenter/stress-facts.
4. Heidt T, Sager HB, Courties G, et al. Chronic variable stress activates hematopoietic stem cells. Nat Med. 2014;20(7):754-758.
5. Kabat-Zinn J. Full Catastrophe Living. 15th anniversary ed. New York, NY: Piatkus; 2004:249.
6. Newman MG, Llera SJ, Erickson TM, Przeworski A, Castonguay LG. Worry and generalized anxiety disorder: a review and theoretical synthesis of evidence on nature, etiology, mechanisms, and treatment. Annu Rev Clin Psychol. 2013;9:275-297.
7. Gonzalez D, Nasseri S. ‘Patients have panic in their eyes’: voices from a Covid-19 unit. The New York Times. 2020. www.nytimes.com/2020/04/29/nyregion/coronavirus-nyc-hospitals.html?searchResultPosition=1.
8. Hayes C. Coronavirus: front-line NHS staff ‘at risk of PTSD’. BBC News. 2020. www.bbc.com/news/uk-52258217.
9. Muller R. Trauma and the Struggle to Open Up. New York, NY: WW Norton & Company; 2018:33.
10. Van Der Kolk B. The Body Keeps the Score. London: Penguin; 2014:156-157, 166.
11. Bolton EE, Jordan AH, Lubin RE, Litz BT. Prevention of posttraumatic stress disorder. In: Gold SN, ed. APA Handbooks in Psychology. APA Handbook of Trauma Psychology: Trauma Practice. Washington, DC: American Psychological Association; 2017:483-497.
12. Psychology Today. Acute stress disorder. 2019. www.psychologytoday.com/ie/conditions/acutestress-disorder.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
14. American Psychiatric Association. What is posttraumatic stress disorder? 2020. www.psychiatry.org/patients-families/ptsd/what-is-ptsd.
15. Levine P, Blakeslee A, Sylvae J. Reintegrating fragmentation of the primitive self: discussion of “somatic experiencing.” Psychoanal Dialogues.2018;28(5):620-628.
16. Highfield J. Am I OK? Intensive Care Society. 2020. www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx.
17. World Health Organization. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. 2020. www.who.int/publications/i/item/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-ofhealth-workers-including-key-considerations-foroccupational-safety-and-health.
18. American Association of Critical-Care Nurses. Well-being Initiative. 2020. www.aacn.org/nursingexcellence/well-being-initiative.
19. World Health Organization. WHO guidelines on conditions specifically related to stress. 2013. www.who.int/mental_health/emergencies/stress_guidelines/en.
20. Brené Brown. Vulnerability. 2020. www.brenebrown.com/definitions.
21. Frank S. As coronavirus slams Houston hospitals, it’s like New York “all over again.” The New York Times. 2020. www.nytimes.com/2020/07/04/us/coronavirus-houston-newyork.html.

BY Gráinne Ráinne Clancy, BN, MIACP; D’Arcy D. Gaisser, DNP, MS, RN, ANP-BC; and Grace Wlasowicz, PhD, RN, PMHNP-BC, ANCC NP

This article has been adapted for space and originally appeared in the September 2020 issue of Nursing © 2020 Wolters Kluwer Health, Inc.

This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.