2021 Kentucky Renewal Bundle

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The following course content

This 2021 Kentucky License Renewal Bundle meets all renewal requirements for Kentucky LPNs and RNs. Upon completion of this course, you will receive a certificate of completion for 14 contact hours. 
This course includes multiple interesting topics in one easy course.

Course Outline:   

1. Pediatric Abusive Head Trauma – Kentucky 
2. Opioid Abuse 
3. LGBTQ Cultural Competence 
4. Coronavirus: Nursing Considerations 
5. Effective Communication in Nursing 
6. Nursing Ethics 
7. Ensuring Patient Confidentiality in Nursing 
8. A Nurse’s Guide: How to Deal with Difficult Patients 
9. How to Reduce New Nurse Turnover 

Pediatric Abusive Head Trauma – Kentucky 

Introduction 

Pediatric Abusive Head Trauma (AHT), also known as Shaken Baby Syndrome, includes an array of symptoms and complications resulting from injury to a child or infant’s head and brain after violent or intentional shaking or impact. There are approximately 1,300 reported cases of AHT each year and it is the leading cause of child abuse deaths nationally. For those children who survive, most suffer lifelong complications and disabilities (7).   

This serious and tragic injury may be a challenge to diagnose because obvious signs of injury may not be easily detectable right away, and those responsible for the injuries may avoid taking the child for treatment (4). Therefore, it is incredibly important for healthcare professionals who work in pediatrics or emergency medicine to be able to identify at-risk individuals and recognize signs and symptoms of potential victims of AHT. It is also 100% preventable, and proper training on how to mitigate the risks and situations that lead to AHT can help healthcare professionals reduce the incidence of this horrific injury.  

Epidemiology/Risk Factors  

Though pediatric abusive head trauma most often occurs in children under age 5, the majority of these injuries are in children under the age of 1 year. There is a slight difference in incidence between genders, with 57.9% of victims being male and 41.9% being female. There is a peak occurrence of AHT between 3 and 8 months (4). Babies of this age are particularly vulnerable for a multitude of reasons, including large head size, weak neck muscles, fragile and developing brains, and the discrepancy in strength between infant and abuser. Sleep deprivation paired with longer and louder crying spells of very young infants sets the stage for high levels of caregiver frustration, which often precedes AHT injuries. The perpetrator is almost always a parent or caregiver (7).  

Besides infant age, there are many social factors that increase the risk of AHT, including a lack of childcare experience, young or poorly supported parents, single-parent homes, low socioeconomic status, low education level, and a history of violence. These factors paired with a lack of prenatal care or parenting classes often leads to poorly prepared parents who have not been taught to anticipate crying spells or how to deal with the frustration in a safe manner (7).  

Unfortunately, Kentucky has one of the highest rates of child abuse in the country. In 2019, there were more than 130,000 reports of suspected abuse or neglect, and 15,000 of those had substantial evidence to support abuse had occurred. Of those, nearly 76 were nearly fatal or fatal, and 32 of those were due to pediatric abusive head trauma(1).

Case Study 

A Nursery nurse on a Labor, Delivery, and Postpartum unit is providing discharge information to the parents of a 2 day old baby girl, Violet, who is going home today. This is the first child for both parents. They are 19 years old, living in an apartment together while the mother works part time as a waitress and the father works full time for a lawn mowing company. The child’s maternal grandmother lives nearby and will be helping the mother care for the baby the first few weeks and then watching the baby a few days per week when the mother returns to work.   

Pathophysiology

While anyone can sustain a head injury, the relatively large size of young children’s heads paired with their weak and underdeveloped neck muscles is what makes them particularly susceptible to AHT. When a child’s head moves around forcefully, the brain moves around within the skull, which can tear blood vessels and nerves, causing permanent damage. Bruising and bleeding may occur when the brain collides with the inside of the skull or fractured pieces of skull. Finally, swelling of the brain may occur, which builds up pressure inside the skull and makes it difficult for the body to properly circulate oxygen to the brain (6).   

It should be noted that bouncing or tossing a child in play, sudden stops or bumps in the car, and falls from furniture (or less than 4 feet) do not involve the force required to mimic the injuries of AHT (7).  

Also important to understand is that AHT is a broad term used to describe the injury, but there are a collection of various mechanisms of injury within AHT. Among these different causes are Shaken Baby Syndrome (SBS), blunt impact, suffocation, intentional dropping or throwing, and strangulation. It is recommended to classify all of these injuries as AHT so as to avoid any confusion or challenges in court if multiple mechanisms of injury were involved (4).

Diagnosis of Pediatric Abusive Head Trauma  

Parents or caregivers who have inflicted injury onto a child may delay seeking treatment for fear of consequences. It is important to gather a thorough history and be on the lookout for inconsistent stories, changing details, or mechanism of injury that does not match the severity of symptoms (7).   

Symptoms that typically lead caregivers to seek treatment for their child include:  

• Decrease in responsiveness or change in level of consciousness  
• Poor feeding  
• Vomiting  
• Seizures  
• Apnea  
• Irritability  

Upon exam, these children may exhibit:   

• Bradycardia  
• Bulging fontanel  
• Irritability or lethargy   
• Apnea  
• Bruising  

A lack of any external injuries or obvious illnesses when presenting with these symptoms should alert the healthcare professional to the possibility of AHT, particularly in young children or infants. Additionally, unexplained fractures, particularly of the skull or long bones, bruising around the head or neck, or any bruising in a child less than 4 months are red flags (4).   

An ophthalmology consult to assess for retinal hemorrhage should be obtained. The force used with AHT can cause a shearing effect with the retina and is visible with a simple fundal exam of the eye. This type of injury does not typically occur with accidental or blunt head trauma and is typically considered highly indicative of abuse. That same shearing force often causes bleeding within the brain, and subdural hematomas are often revealed on CT or MRI (4).   

Any of the above criteria, or other suspicious story or injuries, should be reported for further investigation. Mild injuries are harder to detect but only occur around 15% of the time. Severe injury from AHT accounts for 70% of cases (4).

Case Study cont. 

Baby Violet is now 5 weeks old and is brought to the ED by her parents. Her mother reports that she has been eating poorly and acting strange since this morning. Her father reports he thinks she has been sleeping excessively for 2 days now. On exam, the baby is found to have a bulging fontanel, slow heart rate, and a bruise on the side of her head. Her mother states she sustained that bruise when she rolled off of her changing table yesterday.   

Outcomes and Sequelae 

For children diagnosed with even mild to moderate AHT, the prognosis is fairly grim. Up to 25% of children with AHT end up dying from their injuries, and for those who survive, 80% will have lifelong disabilities of varying severity (7).    

The most common complications and disabilities include: blindness, hearing loss, developmental delays, seizures, muscle weakness or spasticity, hydrocephalus, learning disabilities, and speech problems. Lifelong skilled care and therapies are often needed for these children, accruing over $70 million in healthcare costs in the United States annually (4).

Legal Considerations in the State of Kentucky 

In the state of Kentucky, anyone with a reasonable suspicion that abuse or neglect is occurring is mandated by law to report the incident, and there are legal consequences (from misdemeanor all the way to felony) for willfully failing to make a report. For healthcare professionals, this is particularly important to note, as you will come in contact with many different types of families, injuries, and stories, and must remain vigilant in assessing for abuse (5).  

A report of suspected abuse should be made at the first available opportunity and can be made by contacting the child abuse hotline (1-877-KYSAFE1), local law enforcement, Kentucky State Police, or the Cabinet for Health and Family Services. The child’s name, approximate age and address, as well as the nature and description of injuries, and the name and relationship of the alleged abuser should all be included in the report (9).   

Once a report has been made, the Department for Community Based Services will determine if an investigation is warranted. If the home is deemed to be unsafe or there is a threat of immediate danger to a child, the child will be removed from the home, but in all other cases, every effort will be made to maintain the family (5).

Case Study cont. 

It is later determined that Baby Violet was violently shaken by her mother during a crying spell one evening. During legal proceedings for the incident, it is revealed that the grandmother witnessed this abuse.   

Prevention 

While accurate detection of AHT is incredibly important, another key consideration for this injury and its poor outcomes, is that these incidents are 100% preventable. Much of the time, AHT is preceded by extreme frustration by a parent or caregiver when an infant is crying for long periods or is inconsolable. Proper education and preparedness about when and why this occurs, and what to do when it does, can help prevent AHT from occurring. For healthcare professionals who regularly care for infants, children, and expecting or new parents, there is a huge potential for positive impact (2).  

Identifying those most at risk is a great starting place and new parenting courses, educational discussion and pamphlets, as well as regular check-ins are extremely beneficial for at-risk families. Young or inexperienced families, families without a lot of external support, or those with low socioeconomic status or poor education should be looked at first.   

Once the most at risk families have been identified, provide them with information and services that may help reduce risks. These interventions are useful for anyone with an infant or small child, but special attention and close follow up should be given to those with more risk factors (8).   

• Educate about infant crying: The PURPLE Crying program is particularly useful for this and includes facts and common symptoms of excessive or colicky infant crying. PURPLE stands for:   
  • Peak of Crying, with crying increasing weekly after birth and peaking around 8 weeks   
  • Unexpected, where crying may come and go with no apparent cause  
  • Resists soothing, where your baby won’t settle no matter what you try  
  • Pain like face, where your baby looks like they are in pain even if nothing is wrong  
  • Long-lasting, with crying lasting as long as 5 hours  
  • Evening, with excessive crying being more common in the evening or at night (8)  
• Enhance parenting skills: Let parents know it is okay to feel frustrated. Take a deep breath, count to 10, place your infant in a safe place and walk away for a few minutes to collect yourself. Many parents don’t know that this is okay to do (3).   
• Strengthen socioeconomic support: Make sure families are aware of and utilizing access to supportive services like WIC to help ease financial strain.   
• Emphasize social support and positive parenting: Ask about nearby help in the form of relatives or friends. Encourage them to reach out for emotional support, or even a break from caring for the infant. Connect families with community resources like motherhood support groups or playdates. Schedule for early childhood home visits (2).

Conclusion  

Though the goal is for there to be no scenarios where children suffer head trauma at the hands of an abuser, there is a long way to go before that objective can be reached. In the meantime, healthcare professionals must be vigilant in maintaining a high level of suspicion for pediatric abusive head trauma whenever they are caring for children. Understanding contributing risk factors, as well as signs and symptoms, and how to properly assess for and diagnose pediatric abusive head trauma will lead to more accurate detection, appropriate treatment, and hopefully better outcomes. On the other end of things, those in a position to influence parenting education and community health standards should consider the ways in which caregiver frustration might be better handled to prevent the abuse from even occurring. There is much work to be done when it comes to AHT, but well informed medical professionals is an essential step in the right direction. 

Opioid Abuse

What are Opiates? 

Opiates are powerful substances which are commonly used to alleviate both acute and chronic pain. The history of opiate use / abuse goes back many thousands of years. The first recorded reference is from 3,400 B.C. when opium was cultivated in southwest Asia. There were even wars fought over the previous flow in the mid 1800s (1). The most famous historical event related to opium were the advent of “opium dens.” These were underground “dens” where opium was bought, sold, and used (1). Much like today, the addictive properties of opium overcame many individuals and caused great harm to the world and communities. Indeed, the opiate epidemic of the 2000’s is not the first in modern history, though it is much different and more severe than previous epidemics. 

Today opiates are used for both acute and chronic pain. The ability to quickly, reliably, and (when used appropriately) safely reduce pain is what makes the drug class so valuable. Many common drugs are opiate derivatives or synthetics including morphine, codeine, oxycodone, heroin, hydromorphone, and fentanyl. 

In the United States Opiates are considered controlled substances and most of them are classified as schedule II (with heroin classified as schedule I) (2). Opiates will always have a place in medicine and treatment of pain and are incredibly useful, however, the current opiate epidemic in America makes clear the potential consequences of opiate abuse. 

Preventing Abuse, Misuse, and Harm 

Every day 130 Americans die of opiate overdose (3). Additionally, there are 4.3 million Americans each month who engage in the non-medical (non-prescribed or illicit) use of opiates (5).  However, it is key to remember that opiate-related deaths are not the only negative consequences. There are many overdoses which do not end in death, and on the other end of the spectrum many negative affects do not cause death. Addiction can cause loss of job, damage to relationships, psychologic distress, homelessness, and many more negative side-effects. 

So how do healthcare professionals help reduce the impact of opiate addiction and misuse? The approach must be multi-modal, aimed at primary, secondary, and tertiary prevention.  

• Primary prevention includes appropriate opiate prescribing, risk stratification with patients, and preventing opiate addiction. 
• Secondary prevention is aimed at mitigating the effects of opiate addiction. This includes rehabilitation and cessation of opiates in addicted individuals, ideally in favor of non-opiate treatment options. 
• Tertiary prevention is the reduction in harm from opiate addiction and overdose. This includes resuscitation of overdose patients and helping patients recover from the effects of opiate addiction. 

Appropriate Prescribing 

The Centers for Disease Control and Prevention (CDC) offers excellent guidance on how to appropriate prescribe opiates, though it will continue to require a great deal of knowledge and effort from individual prescribers and managers of chronic pain. For the purposes of this article, we will focus on the CDC recommendations. Below we will discuss the 12 key points of opiate management, per the CDC. 

Opioids Are Not First-Line Therapy 

“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” (5) 

Author’s Input 

Many patients experience pain. Indeed, it is one of the most common complaints in primary care offices. When dealing with chronic pain, we should consider ALL non-opiate therapies for patients prior to prescribing opiates. This can include physical therapy, meditation, exercise / movement, treatment of underlying depression and/or psychiatric issues, meditation, modification of aggravating factors, and many more interventions. In some cases, none of these alone or combination will be enough to provide satisfactory relief, but we must utilize non-opiate and non-pharmacological solutions as much as possible to reduce opioid abuse, and dose (if opiates are necessary). 

Establish Goals for Pain and Function 

“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety “(5). 

Author’s Input 

Many patients erroneously believe that cessation of pain is the goal of therapy. This is not based in fact nor is it reasonable, as many patients (even with opiate therapy) will not have complete remission of pain. The goal of the clinician should be to work with the patient to provide the minimal risk intervention that will provide acceptable pain control. 

Discuss Risks and Benefits 

“Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy” (5). 

Author’s Input 

A prescription for an opiate should never be written to a patient without a through discussion of the risks and benefits. The clinician must first be convinced that the risk to benefit favors prescribing an opiate. Then, they must discuss their rationale with the patient. An individual assessment regarding the risks should be provided to each and every patient. 

Prescribe Immediate-Release Opioids First 

“When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/ long-acting (ER/LA) opioids” (5). 

Author’s Input 

Extended-release opioids have been associated with higher rates of overdose and higher potential for Opioid abuse. Immediate-release opioids should be utilized first, whenever possible. 

Clinicians Should Prescribe the Lowest Effective Dosage 

“Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”  

Author’s Input 

The clinician must keep in mind that the “minimum required dose” may change over time. As a patient implements more non-pharmacologic interventions the required dose may decrease. Conversely, there can be some degree of tachyphylaxis with opiates and the required dose may also increase. Dose titration requires careful clinician judgement. 

Prescribe Short Durations for Acute Pain 

“Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed” (5). 

Author’s Input 

It is well established that chronic opioid therapy is not the most effective therapy for pain management. Clinicians should consider adjuncts for ongoing or chronic pain patients. 

Evaluate Benefits and Harms Frequently 

“Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids” (5). 

Author’s Input 

It is important that clinicians consider changing circumstances. A patient’s health status or life circumstances may change such that opiate therapy benefits no longer outweigh the harm, or vice-versa. 

Use Strategies to Mitigate Risk 

“Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day)” (5). 

Author’s Input 

Naloxone therapy should be considered for all patients who are at high risk of Opioid overdose. 

Review Prescription Drug Monitoring Program Data 

“Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months” (5). 

Author’s Input 

Each state has robust data regarding prescription medication; utilizing this data can help reduce opioid misappropriation and concurrent prescriptions (doctor shopping). 

Use Urine Drug Testing 

“When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs,” (5). 

Author’s Input 

The author recommends that clinicians take great care in this area. Indeed, drug testing can help identify those who are already abusing other substances, but it can also harm the trusting relationship developed between a patient and clinician. The patient should be re-assured that the testing is performed for their own good and out of concern for their own health, rather than punitively or because the clinician “mistrusts” them, as these may be the default thoughts of many patients. 

Avoid Concurrent Opioid and Benzodiazepine Prescribing 

“Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently ‘whenever possible’ “(5). 

Author’s Input 

The highest risk of overdose of opioid abuse is commonly seen when opiates and benzodiazepine (or any combination of sedating medications) are prescribed concurrently, especially in conjunction with alcohol. For this reason, clinicians should strongly consider avoiding such risks and only prescribing this combination when absolutely necessary. 

Offer Treatment for Opioid Abuse Disorder (OAD) 

“Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid abuse disorder” (5). 

Author’s Input 

In acute cares settings, clinicians often view OAD as a secondary illness and it is frequently left unaddressed. However, there are now effective treatments for OAD. Given the significant morbidity, mortality, and associated quality of life issues, patients with OAD should be offered treatment, even if it not the primary reason for treatment.

Risk Factors for Opiate Harm or Misuse 

The risk to benefit has been discussed many times previously and is often referenced by the CDC. The benefits of opiate therapy are typically obvious (reduced pain, increased quality of life, etc.), but the risks are less often discussed. So how do nurses know who is at higher risk of the negative effects of opiates? 

According to the CDC, the major risk factors are: 

• Illegal drug use; prescription drug use for non-medical reasons. 
• History of substance use disorder or overdose. 
• Mental health conditions (e.g., depression, anxiety). 
• Sleep-disordered breathing. • Concurrent benzodiazepine use (6). 

Mortality from opiates is highest in those who are middle-aged, have psychiatric conditions, and/or have previously abused substances (7). It is important that clinicians utilize this information when consider risk and benefits associated with opiate therapy.

Signs of Abuse, Diversion, and Addiction  

Clinicians should remain vigilant for signs of opiate use disorder, as it can occur in any patient (even those not prescribed opiates). Opiate use disorder is characterized in the DSM-5 as a desire to utilize opiates despite social and professional consequences (12). It includes dependence and addiction, with addiction being on the severe end of the spectrum (12). Opiate use disorder can be diagnosed when at least two of the following are observed in a 12-month period: 

1. Opioids are often taken in larger amounts or over a longer period than was intended. 
2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use. 
3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects. 
4. Craving, or a strong desire or urge to use opioids. 
5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home. 
6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids. 
7. Important social, occupational, or recreational activities are given up or reduced because of opioid use. 
8. Recurrent opioid use in situations in which it is physically hazardous. 
9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 
10. Exhibits tolerance (discussed in the next section). 
11. Exhibits withdrawal (discussed in the next section) (centers for disease control, reference 13). 

Urine drug screening can be useful in patients with suspected opiate abuse disorder as it may identify concurrently abused substances. If a patient is found to have opiate abuse disorder the “risk” side of the “risk-to-benefit” equation is now shifted, and the continued use should be carefully weighed against the potential for negative effects, including addiction. Addiction is defined as continued use despite adverse events or consequences (12). 

For those prescribed opiates, clinicians should have candid conversations about the risks of continued use for those with OAD. The CDC offers some creative examples of how to discuss the condition with patients, which nurses may find helpful in their interactions (these are only examples, and the wording depends on the patient’s specific scenario and needs): 

“Trouble controlling the use of opioid medication makes it unsafe, and long-term risk over time is substantial.” 

“The medicine has become a problem in itself. You have developed a known complication of therapy that we should not ignore.” 

“Continuing the current medication is not a reasonable option due to the risks, but there are options for treating what we call opioid use disorder, also known as OUD.” 

“It seems as if you are running out of your medication more quickly than anticipated.” 

“Sometimes people become too comfortable with the medications and start to take them for reasons other than pain.” 

“You meet the criteria for opioid use disorder, also known as OUD. It’s helpful to put a name on it because it opens up a variety of approaches to help with your specific circumstance.” (All derived from source 13). 

So, once we identify a patient with OAD, what do we do? At this point, as above, a candid conversation with the patient must occur. A treatment plan should be formulated, which would include a careful consideration for discontinuing for the opiate (if possible). This provides an excellent transition into our next section, opiate alternatives. 

Opiate Alternatives 

Opiate alternatives can be broadly classified as pharmacologic and non-pharmacologic. We will first discuss pharmacologic alternatives. 

Pharmacologic: 

Acetaminophen

Commonly known as Tylenol ™ is over the counter and has a very favorable safety profile when used correctly. Acetaminophen is considered first-line therapy in any pain management regimen (9). 

NSAIDs (Nonsteroidal anti-inflammatory drugs)

NSAIDs can be immensely powerful in pain management, as many pain conditions are related to inflammation. However, patient tolerance can be an issue with chronic NSAID exposure. Indeed, many clinicians shy away from NSAIDS due to the perceived risk profile (9). 

Tricyclic Antidepressants

TCAs provide significant pain relief to many patients, as they have the unique ability to change the perceptions of pain (5). However, tricyclics have many side-effects of their own and thus have been phased out in lieu of newer antidepressants. This in the pain realm they should be considered for certain patients, particularly those with concurrent untreated depression. 

SSRI Antidepressants

SSRIs are typically tolerated better than tricyclics (9) but again are not recommend for first-line analgesia. They are typically reserved for those with concurrent psychiatric illness which may benefit from the overall effect of the drug, and on a case-by-case basis for selected patients. 

Muscle Relaxants

Medications such as gabapentin can be extremely useful especially in pain originating from musculoskeletal causes. However, the mechanism of action is poorly understood (9) and side effects can be troublesome. In one study approximately 25% of patients taking muscle relaxants for chronic pain discontinued the agents due to adverse effects. 

Topicals

Many topical agents now exist, including NSAIDS (9). Topicals are typically considered analgesic-sparing rather than standalone treatment (9). The American College of Rheumatology has excellent and detailed guidance on how to utilize topicals, which deserves a course of its own. 

Corticosteroids

Corticosteroids have very potent anti-inflammatory effects (9) and have a proven role in pain management. Short-term therapy is typically favored over long-term therapy due to the potential issues of long-term systemic therapy (osteoporosis, immunosuppression, risk of serious or fatal infections, weight gain, muscle weakness, diabetes, Cushing’s syndrome, hypertension, glaucoma, and cataracts). Though some serious adverse events can occur with short-term therapy (psychosis, anxiety, avascular necrosis, etc.) (9). corticosteroids can be beneficial for patients with acute pain. Perhaps the best use of these agents is in targeted (injectable) delivery. 

Non-Pharmacologic: 

These therapies will be discussed less in-depth, as they typically require referrals for treatment. However, it is important that nurses are aware of the of the existence of these therapies and can make appropriate referrals and recommendations. Physical therapy consults are invaluable as they often utilize many of the tools below and are more knowledge about non-pharmacologic therapies in general. 

• psychological interventions (including distraction, stress management, hypnosis, and other cognitive-behavioral interventions) 
• acupuncture and acupressure 
• transcutaneous electrical nerve stimulation 
• physical therapies (including massage, heat/cold, physiotherapy, osteopathy, and chiropractic) (10)

Conclusion 

Nurses should view the non-pharmacologic therapies as “tools” available to help patients dealing with acute and chronic pain. Though opiate therapy is a valuable tool as well, its potential negative effects are often under-considered, and the rate of opiate prescription currently is excessive (10). 

When evaluating patients with pain, nurses should work with patients and providers to ensure that the patient is on an optimal pain regimen, which ideally should include both pharmacologic and non-pharmacologic therapies. Seeking referral and consultation from relevant professionals can also be powerful in pain management (physical therapists, chiropractors, psychiatrists, etc.). 

LGBTQ+ Cultural Competence

Introduction    

Lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals represent a rapidly growing segment of the U.S. population [1]. This rapid growth brings with it risk for stigmatization [1]. Implicit physician biases may result in LGBTQ patients receiving a lower standard of care or restricted access to services as compared to the general population [2]. Even when institutions and providers make commitments to equitable care explicit, implicit biases operating outside of conscious awareness may undermine that commitment. There is an urgent need to ensure that health care providers are prepared to identify and address their own implicit biases to ensure they do not contribute to the health care disparities experienced by LGBTQ and other vulnerable populations. Only by addressing their own implicit biases will health care providers be able to provide patient care in accordance with LGBTQ cultural competence. 

LGBTQ individuals face significant disparities in physical and mental health outcomes [3]. Compared to their heterosexual counterparts, LGBTQ patients have higher rates of anal cancer [4], asthma, cardiovascular disease [5,6,7,8], obesity [6], substance abuse [8,9,10], cigarette smoking [11], and suicide [12]. Sexual minority women report fewer lifetime Pap tests [13,14,15], transgender youth have less access to health care [16], and LGBTQ individuals are more likely to delay or avoid necessary medical care [17] compared to heterosexual individuals. These disparities are due, in part, to lower health care utilization by LGBTQ individuals [3, 18,19,20]. Perceived discrimination from health care providers and denial of health care altogether are common experiences among LGBTQ patients and have been identified as contributing factors to health disparities [21,22,23,24]. Disparities in health care access and outcomes experienced by LGBTQ patients are compounded by vulnerabilities linked to racial identity [25,26,27] and geographic location [28]. 

Biases among health care professions students and providers toward LGBTQ patients are common [29, 30] despite commitments to patient care equality. These biases, also known as negative stereotypes, may be either explicit or implicit [31]. These biases contribute to a lack of LGBTQ cultural competence in patient care. A large study of heterosexual, first-year medical students demonstrated that about half of students reported having negative attitudes towards lesbian and gay people (i.e., explicit bias) and over 80% exhibited more negative evaluations of lesbian and gay people compared to heterosexual people that were outside of their conscious awareness (i.e., implicit bias) [29]. Research in social-cognitive psychology on intergroup processes defines explicit biases as attitudes and beliefs that are consciously accessible and controlled; they are typically assessed via self-report measures and are limited by an individual’s awareness of their attitudes, motivation to reveal these attitudes, and ability to accurately report these attitudes [32, 33]. In contrast, the term implicit bias refers to attitudes and beliefs that are unconscious (i.e., outside of conscious awareness) and automatic [34, 35]. Implicit bias can be assessed with the Implicit Association Test (IAT) [36], which measures the strength of association between concepts [37]. 

Health care provider biases are correlated with poorer access to services, quality of care, and health outcomes [31, 38,39,40]. Explicit biases held by health professionals towards racial/ethnic minorities, women, and older adults are known to affect clinical assessments, medical treatment, and quality of care [41]. Importantly, implicit bias measures are more strongly associated with real-world behaviors than explicit bias measures [42] and are linked to intergroup discrimination [43]. Health care provider’s implicit biases towards vulnerable patient groups may persist despite an absence of negative explicit attitudes [44], resulting in preconceived notions about patient adherence, poor doctor-patient communication, and micro-aggressions, all of which can interfere with optimal care. With less time and limited information processing capacity, provider’s decisions are increasingly governed by stereotypes and implicit biases [45]. Medical student and provider biases may contribute to health disparities in vulnerable populations by negatively impacting communication with patients and decisions about patient care [33, 35]. Taken together, these findings suggest that medical students and healthcare providers are likely to underestimate or to be unaware of their implicit biases towards LGBTQ patients, particularly when they are rushed or fatigued, which could impact their behavior and judgments in ways that contribute to health disparities experienced by LGBTQ populations. By learning about and addressing their implicit biases, health care providers can work towards demonstrating LGBTQ cultural competence and providing optimal care (Introduction section courtesy of Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P.- reference 45).

Terminology 

Understanding the standard terminology utilized is pivotal to treating and interacting with LGBTQ patients. Below are listed some of the common terms and how they should be referenced. 

Ally – A person not identifying as LGBTQ, but who promotes equality and support of LGBTQ peoples in a variety of ways. 

Androgynous – Identifying as neither masculine nor feminine. 

Bisexual – A person who is emotionally, romantically, or sexually attracted to more than one sex, gender, or gender identity. 

Cisgender – A person who identifies with their gender which as assigned at birth. For example, a person assigned female gender at birth who identifies as female. 

Gay – A person who is emotionally, romantically and/or sexually attracted to those of the same gender. 

Gender-fluid – A person who identifies as a fluid or unfixed gender identity. 

Lesbian – A woman who is emotionally, sexually, and/or romantically attracted to other women. 

LGBTQ – Acronym for “lesbian, gay, bisexual, transgender, and queer.” 

Non-binary – Adjective describing person(s) who do not identify exclusively as man nor woman. 

Pansexual – A person who has the potential for romantic, emotional, and/or sexual attraction to people of any gender. 

Queer – Often used interchangeably with “LGBTQ,” or to express fluid identities or orientations. 

Sexual Orientation – An inherent or enduring emotional, romantic, or sexual attraction to other people. 

Transgender –Umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. It does not imply any specific sexual orientation and transgender persons may identify as straight, gay, lesbian, bisexual, etc. 

*Definitions largely derived from (46). 

Best Practices 

Below we will list and discuss the best practices for ensuring a positive, equitable healthcare experience for LGBTQ persons, according to the Joint Commission (this is not a comprehensive list, just highlights). 

Create a welcoming environment that is inclusive of LGBT patients and demonstrates LGBTQ cultural competence. 

• Prominently display the hospital nondiscrimination policy and/or patient bill of rights. 
• Waiting rooms and common areas should be inclusive of LGBTQ patients and families. 
• Unisex or single-stall restrooms should be available. 
• Ensure that visitation policies are fair and do not discriminate (even inadvertently) against LGBTQ patients and families. 
• Foster an environment that supports and nurtures all patients and families. 

Avoid assumptions about sexual orientation and gender identity. 

• Refrain from making assumptions about a person’s sexual orientation and/or gender identity. 
• Be cognizant of bias, stereotypes, and other communication barriers. 
• Recognize that self-identification and behaviors do not always align. 

Facilitate disclosure of sexual orientation and gender identity but be aware that disclosure is an individual process. 

• Honor and respect patient’s decisions to provide or not provide sexual and/or gender information. 
• All forms should contain inclusive, gender-neutral language that allows patients to self-identify. 
• Use neutral and inclusive language when communicating with patients. 
• Listen to and respect patients’ choice of language when they describe their own sexual orientation. 
• Conduct confidential patient satisfaction surveys that include questions regarding sexual orientation and gender identity. 

*Information largely derived from Joint Commission field guide, reference 47.  

For more information on best-practices in the workforce, visit the Joint Commission website by clicking here.

Establishing Relationships with LGBTQ Patients 

When interacting with patients, one should not assume gender or sexuality. Addressing a patient who identifies as a female as a male can cause grave harm to the relationship. Instead, nurses should use open-ended questions. For example, rather than saying “Hi sir, what brings you to the hospital,” a nurse might say, “Welcome, what brings you to the hospital today (48)?” 

If a nurse uses the incorrect pronoun, the best practice is to apologize and ask the patient what pronoun and name they prefer. For example, a nurse may say, “I apologize for assuming your gender. How would you like to be addressed? (48). 

In conversation, the nurse should use the name and/or pronoun the patient prefers without drawing special attention to the subject (48). For example, if a male patient prefers to be identified as his partner’s wife, you should follow suit. 

The core of relationship-building with LGBTQ patients is no different than any other patient, fundamentally. If nurses have a basic understanding of best practices and a healthy dose of respect and compassion for LGBTQ patients, a positive relationship is likely to develop. 

Health Disparities of LGBTQ Patients 

LGBT Americans are at higher risk of substance use, sexually transmitted diseases, cancer, cardiovascular disease, obesity, bullying, isolation, anxiety, depression, and suicide when compared to the general population (49). LGBT youth are frequently bullied at schools (49). In fact, early victimization and subsequent emotional distress accounted for 50% of the disparities between LGBT youth (49). In other words, LGBT Americans are discriminated against and disadvantaged from a very young age. 

When home life also reflects a lack of LGBTQ cultural competence, more problems arise. A major cause of LGBT distress is family rejection. Disclosure of gender identity or sexuality can cause very significant interpersonal conflicts among family and friends of LGBT persons (49). This explains some hesitancy and should help nurses understand the importance of respecting privacy, while giving options to patients about disclosing sexuality and gender.

Providing an Inclusive and Accepting Care Environment 

LGBTQ patients often experience difficulty in finding healthcare environments in which they feel accepted and understood (48). Past negative experiences, lack of knowledge among healthcare providers, and limited access to healthcare in general may become major barriers for LGBTQ persons when seeking care (48). 

The core tenant of providing an inclusive environment is understanding the needs of LGBTQ patients and working diligently to create an environment which does not disadvantage or discourage them from seeking care. 

Policies and procedures at institutions should be designed to reflect a non-discriminatory environment. For example, many hospital policies dictate that only legal family spouses or partners can visit in specific circumstances. Policies such as this are inherently discriminatory toward LGBTQ patients, as they may not have legal spousal status due to social, legal, or personal reasons. 

Exercises on LGBTQ Cultural Competence 

To help solidify your learning, please complete the following exercises at your own pace. The answers/guidance for each are provided below. 

Scenario 1 

A patient enters your emergency department, and you assume the patient identifies as a female. You introduce yourself and say, “Ma’am, how can we help you? What brings you in today?” 

The patient appears dismayed but answers the question. The nurse is confused and does not understand why the patient appears distressed. What is the best course of action? 

Answer: The nurse should apologize to the patient and ask the patient how they would like to be addressed. Then, the nurse should update the patient’s records to reflect such, to reduce further confusion.  

If the nurse does not address the issue, the patient may feel uncomfortable and develop a negative association with healthcare, which can lead to disparities in the future.  

Scenario 2 

A patient in your ICU has had a deterioration while his husband was in the room. After a family meeting, a member of the healthcare team makes a derogatory remark about the patient’s sexuality. What is the next best action for the nurse? 

Answer: Pre-conceived phobias and stigmatizations can cause significant distress to LGBTQ patients, even if not stated directly to them. These types of remarks are abusive and should not be tolerated. The nurse should confront the co-worker (if safe) and consider reporting the comments to the Human Resources department.  

Scenario 3 

A LGBTQ patient is being admitted and prefers not to disclose their sexuality. However, the nurse is unable to proceed with the admission process without this information. What could be done to rectify this system-level issue? 

Answer: The nurse should work with administration to ensure that all charting and paperwork allows individuals to self-report sexuality and/or gender if they want. However, healthcare systems should not force patients to “come out” unless it is absolutely medically necessary.

Conclusion 

LGBTQ cultural competence must be ingrained in our healthcare systems in order to foster excellent relationships between members of the LGBTQ community and medical staff. Hospitals and healthcare systems have a great deal of work to do in becoming LGBTQ-friendly. The efforts must continue until LGBTQ patients and families do not feel disadvantaged, anxious, or frustrated when interacting with healthcare systems. As the patient’s ultimate advocate, nurses are at the front-line and should advocate for patients both individually and from a policy perspective. Nurses should work with and spearhead efforts to ensure that healthcare policies reflect best-practice and do not discriminate against LGBTQ patients in any way. 

Coronavirus: Nursing Considerations

Introduction 

The outbreak of the Coronavirus and its slow spread into the United States have caused panic throughout the world over the course of a year. This has caused stress, panic, worry, isolation, and death, leading to many structural breakdowns within the healthcare system, government, and families throughout the world and, more specifically, the United States.  

As a healthcare provider, it is imperative to stay informed and up to date on the latest trends, evidence-based practice, and protocols relating to the COVID-19 pandemic as it continues to evolve. As healthcare providers, we are burnt out—mentally, physically, and emotionally—however, it is still our duty to remain steady, and deliver high-quality care to every patient, every time.  

What is the Coronavirus? Specifically, what is SARS-COV-2? 

Coronaviruses are a group of viruses that have been known to cause moderate to severe respiratory symptoms that may mimic influenza. These symptoms include cough, runny nose, sore throat, body aches, and pneumonia. 

Coronaviruses have been affecting humans for several years, but there has not been an outbreak of epidemic proportions since the SARS epidemic of 2003. Coronaviruses are aptly named for the crown-like appearance the virus takes on when examined under a microscope (“corona” is Latin for “crown”) (1). Coronaviruses can range from asymptomatic, to causing symptoms of the common cold, to more severe disease such as severe acute respiratory syndrome (SARS).  

In late December of 2019, several cases of unknown origin were reported out of China, which in early January 2020 were announced to have been caused by a novel coronavirus. This virus was later deemed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite attempts to contain the disease within its country of origin, the virus has now spread globally, and COVID-19 was declared a pandemic by the World Health Organization in March of 2020.  

Signs and Symptoms  

The coronavirus disease affects each person differently. Many patients will experience mild disease, while others may develop more severe respiratory symptoms that require hospitalization. Patients present to the emergency department with a variety of symptoms. Nurses have the responsibility to appropriately triage patients, based on severity of the illness, to assist in the efficiency of managing a higher influx of patients, while simultaneously preventing the viral spread of the infection to those patients who have not yet been exposed to COVID-19. 

The prevention of an overwhelmed healthcare system includes highly skilled clinical assessment in conjunction with various laboratory and imaging testing, including chest x-ray, blood analysis, and testing for the identification of SARS-CoV-2. 

Symptoms include:  

• Fever 
• Cough 
• Shortness of breath  
• Headache  
• Sore throat  
• Nausea/vomiting 
• Runny nose  
• Myalgia  
• Abdominal Pain

Preventative Actions  

There are several ways to contribute to the prevention of the spread of COVID-19, including per the Centers for Disease Control and Prevention (CDC, 10):  

• Avoid touching eyes, nose, and mouth. 
• Avoid close contact with people who are sick. 
• Stay at home when you are sick.  
• Cover your cough or sneeze with a tissue, then dispose of it properly. 
• Use a face covering when physical distancing.  
• Clean and disinfect frequently touched objects and surfaces.  
• Perform hand hygiene with soap and water or use alcohol-based sanitizer.

What is Considered Close Contact? 

Understanding the distinction of close contact is important in the context of triaging and discharging patients; not all exposures are considered close contact. 

Please see the criteria below for determining a high-risk exposure (10): 

• Patient was within 6 feet of a person with confirmed COVID-19 for a total of 15+ min within a 24-hour period. 
• Patient has cared for someone at home who is sick with COVID-19. 
• Patient has shared food or drinking utensils with a person with confirmed COVID-19. 
• Patient had direct physical contact with a person with confirmed COVID-19 (hugging or kissing). 

If someone who has tested positive within the last three months for COVID-19 and recovered has been in close contact with a patient who has suspected or been diagnosed with COVID-19, they do not have to re-test unless they develop new symptoms. 

*Those awaiting test results should self-quarantine.

Quarantine vs. Isolation. What is the Difference? 

Quarantine refers to keeping someone who has been exposed away from others to prevent potential spread.

Isolation refers to keeping those actively infected away from other individuals to reduce spread. This keeps someone infected with the virus away from others, even in their home (10). 

Current Guidelines for Quarantine and Isolation  

Who Should Quarantine? 

Patients should quarantine at home if they have been in close contact with someone who has tested positive for COVID-19, excluding those who have had COVID-19 in the past 3 months (10). 

Ideally, patients should stay home and monitor for symptoms for 14 days after their last exposure to a close contact. Recognizing that this can be difficult, the CDC allows options for reducing quarantine time (see below). 

If possible, instruct patients to stay away from those at high risk of severe illness from COVID-19. 

Options to Reduce Quarantine 

These guidelines have been released by the CDC, giving the authority to reduce quarantine to the local health departments (10). The theory behind reducing quarantine is that it will increase compliance and minimize the burden on society, while balancing a reduction in virus spread. However, it is important that patients understand the importance of proper quarantine. 

Patients who are exposed and do not develop symptoms may end quarantine 10 days after exposure if no test is administered. 

Patients who are exposed and do not develop symptoms may end quarantine 7 days after exposure and after receiving a negative test (test must occur on or after day 5). 

*If patients develop symptoms during quarantine, even with a negative test, they should be considered COVID-19 positive. 

Options for Testing  

There are several different tests available for COVID-19. They can be used for diagnosing acute infection, to guide contract tracing, and in some cases to determine if a patient has previously been infected by the SARS-CoV-2 virus. It is important for nurses to understand the limits of testing. 

Testing for active infection (symptomatic or asymptomatic) is an important strategy for controlling the spread of the virus. It is important to know when it is appropriate to test a patient. 

In general, testing should be considered for the following:  

• People with symptoms of COVID-19 
• People who have close contact with someone who is COVID-19 positive. 
• People who are asked or referred by their healthcare provider or local health department. 

*Patients with recent COVID-19 disease (past 3 months) do not require testing for subsequent exposures unless symptoms are present. 

**Based on CDC data (3). 

Viral Test 

Viral tests are diagnostic and use samples from the respiratory system, such as nasal or oral swabs, to determine the presence of infection with SARS-CoV-2. 

• This type of test tells you if a patient is currently infected with the disease. 
• Recommended to diagnose acute infection in symptomatic and asymptomatic patients. 

There are currently two types of authorized SARS-CoV-2 viral diagnostic tests that use different technological principles: molecular and antigen. Each of these detects a different part of the SARS-CoV-2 particle. 

Antibody Test 

• This type of test can show you if a patient was previously exposed or infected with SARS-CoV-2 and carries the antibodies. 
• Detects the presence of IgG or IgM against SARS CoV-2. 
• Not authorized by the Food and Drug Administration (FDA) to diagnose SARS-CoV-2 infection. 
• Used to support a clinical assessment of persons who present in the later stages of illness when used in conjunction with viral testing (2, 3, 4). 

Pharmacologic Treatment 

For pharmacological treatment, it is important to understand that we are in our infancy of understanding SARS-COV2-2 and COVID-19 infection. Though there are a plethora of low-quality studies demonstrating benefit for some agents, most experts feel that we should wait for more conclusive data before utilizing agents on a large scale. 

• Remdesivir is currently the only drug approved by the FDA for the treatment of COVID-19. It is recommended for non-intubated hospitalized patients requiring supplemental oxygen. 
• Dexamethasone is the only recommended treatment in patients requiring increasing amounts of supplemental oxygen and in intubated patients.

Diagnosis and Management 

Imaging can be useful in the diagnosis and prognosis of COVID-19 but is not required for a clinical diagnosis. Early in the disease, imaging may not correlate with the severity of the disease. 

Because COVID-19 usually manifests itself as pneumonia, radiological imaging has a profound role in assisting the diagnosis of the disease, management, and follow up. In the early stages of the disease process, the results can be un-impressive and assumed as negative findings (5). In the advanced stages, radiological findings typically reveal patchy ground-glass opiates, with infiltrates favoring the bases and periphery of the lung fields. The infiltrates are typically bilateral, and pleural effusions can be present (6). Lung inflammation may progress to the level of fibrosis in respiratory failure (5). 

Patients with COVID-19 experiencing hypoxia should receive supplemental oxygen with a target oxygen saturation of 92% to 96% (18). Patients requiring oxygen fall into the category of moderate-critical illness of COVID-19. Severe illness in COVID-19 patients typically occurs one week after symptom onset. The most common symptoms presenting in these patients are dyspnea accompanied by hypoxemia (9). These patients with severe disease usually require supplemental oxygen and should be monitored closely for respiratory status because these patients may be at risk for progressing to critical illness with acute respiratory distress syndrome (ARDS).

COVID-19 Vaccines 

Currently, three vaccines are authorized and recommended to prevent COVID-19 in the United States  

• Pfizer/BioNTech’s COVID-19 vaccine (mRNA) 
• Moderna’s COVID-19 vaccine (mRNA) 
• Janssen Covid-19 vaccine (adenoviral vector) 

Many people have questions related to the new COVID vaccines. As healthcare providers, you play a critical role in helping patients to understand the vaccine and the varying risks and benefits. 

All vaccines are recommended for intramuscular injection into the deltoid.  

The mRNA vaccines are recommended for two doses one month apart.  

The adenoviral vector vaccine is recommended as a single dose administration. 

Effects of Long COVID 

Although it may feel like COVID-19 has been around for quite a long time, the reality is that our understanding of the disease is just getting underway. As the pandemic continues to progress, there is a growing recognition that people are experiencing the long-term repercussions of the SARS-CoV-2 virus, which may persist for months or even years. 

Contrary to widespread belief, health status is not protective against developing Long COVID. Current data shows that young, healthy patients experience Long COVID at similar rates to those with advanced age and poor health status. Even those with mild to moderate illness not hospitalized are showing delayed or long-term symptoms (7). 

We are slowly learning more about how COVID-19 is chronically affecting patients. The long-term effects are not limited to the lungs and have been reported to affect all organ systems. The most common symptom reported is crippling fatigue. You can find a list of the common Long COVID symptoms in the chart below (7).

COVID-19 Variants  

All viruses mutate over time—some mutate more than others. A new strain occurs when there is a mutation in the genes of the virus. There have been three new strains of the virus seen throughout the world to date since September of 2020. The mutations in the new strains are affecting spike proteins, which are on the surface of the SARS-CoV-2 virus, which gives it its “spiny” appearance. These proteins allow for the virus to attach to human cells and invade the body, leading to illness (8). 

One of the main concerns is whether any of the variants could affect treatment and prevention. Mutations may allow the coronaviruses to escape the antibodies in currently available therapies and those induced by vaccines. There is new evidence from laboratory studies that some immune responses driven by current vaccines could be less effective against some of the new strains. It is not yet known if those who have already received the COVID-19 vaccine could get sick with the new variants (8).   

Conclusion 

As time continues, and we as a country and world try to manage our day to day lives with the current and aftereffects of the pandemic, it is imperative that nurses be up to date and armed with the latest knowledge of the virus in order to manage and care for their patients efficiently and effectively. Improving patient outcomes and saving lives of patients experiencing current or long-term effects of the SARS-CoV-2 virus.  

Effective Communication in Nursing 

Introduction/Needs Assessment 

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

Types of Communication 

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

Non-Verbal 

This form of communication relies solely on the utilization of body language, including body and facial mannerisms, and completely lacks spoken words or sounds (2). We perform and identify non-verbal communication in nursing daily without giving it a second thought. We may see a newborn sucking on their hands, providing us a non-verbal cue that they are hungry. When assessing a patient holding their abdomen, we would look to initially target that area because they have communicated (non-verbally) that this is where they are experiencing discomfort. Smiling when the next shift nurse is walking in the door communicates to them that you are happy to see them, and that it’s about time for you to go home!  

Since we perform non-verbal communication so often, it can become an incredibly powerful tool or an extremely negative one. This form of communication in nursing can be used positively to show our patients and co-workers that we have compassion, and we are engaged. Negative forms can make patients uncomfortable with sharing their medical history and result in a lower quality of patient care. Additionally, it can lead to dysfunctional teamwork among staff. 

Verbal 

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

Written 

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

Receiving Communication 

The most common communication perception is usually directed to producing communication through non-verbal, verbal, or written forms. While the production of communication is important, the reception of it potentially holds even greater value. In nursing, ensuring our communication is received correctly affects every clinical, orientation, or job experience we have encountered thus far. Think about it…  

• Taking notes in class or during a shift. 
• When a preceptor or instructor educates you on a brand-new skill or piece of equipment. 
• Teaching your patient, family, or student about a new diagnosis.  
• Watching your patient breathe for rate, depth, and effort. 

We must provide and receive communication in nursing through verbal, non-verbal, or written forms successfully. If communication fails, we will experience extremely negative effects throughout our entire nursing system. 

Hearing & Listening 

Hearing describes the process or act of perceiving sounds or spoken words (2). We hear sounds upon auscultation, varying frequencies of alarms, and patient concerns when they are voiced. Hearing all these sounds are heavily dependent on how they are used. To achieve successful implementation of these sounds, we must also listen to these sounds and words. To listen, we must hear and then interpret these sounds carefully (2). We interpret these sounds and words by asking additional questions, performing additional assessments, or paraphrasing the information presented.

Communication Transmission Threads 

Communication in nursing occurs multiple times a day between a wide range of communication threads. The type of communication through non-verbal, verbal, and written communication produced and received, must be effectively performed. Success and implementation are heavily dependent on the communication between the nurse and the communication thread.  

Nurse-Nurse 

Communication among nurses is continuous throughout a shift while working within a team environment. Whether it is us passing our documentation on to another nurse for review or vice versa, there is consistent communicative flow of all variants (non-verbal, verbal, and written) between the team in order to provide care for patients. 

Nurse-Ancillary Staff 

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

Charge Nurse-Team 

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

Nurse-Patient 

The nurse-to-patient communication thread is one of the ultimate and most important exchanges in the nursing profession. Patients need us, so we must be able to keep consistent and effective communication flow with them because any assessment, report, and administration of medication is contingent upon it. 

Nurse-Family 

The thread between the nurse and the patient’s family can be the foundation for your nurse-to-patient communication and its effectiveness. The family could be the responsible party or guardian for your patient and could potentially serve as your sole historian for patient information if the patient is unable to communicate at the time of data collection. Ensuring that the family is aware of and understands discharge instructions can further help them to recognize any potential signs or symptoms that could result in calling a physician or visiting the emergency room in the future. 

Barriers & Improvements to Communication 

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

Language Barriers 

Utilizing available resources for language barriers through interpreter staff members or interpretation devices can ensure effective communication pathways between two individuals. 

Cultural Differences 

Identification of cultural differences during admission and cultural awareness will allow for effective communication management throughout each culture you are presented with. 

Patient Acuity, Staffing Levels, Time Constraints 

Patient acuity, staffing levels, and time constraints can be improved by utilizing staff huddles and working together with administration in order to overcome conflicts.  

Emergent Situations 

Emergent situations that arise during your shift can be relieved through adequate knowledge of the policies and procedures and by performing debriefs after the situation resolves. Debriefings hold valuable insight into reflections of the emergent situations we face as nurses, especially on communication performance. 

In each thread and form of communication in nursing, we must remember the following items to receive information. While producing communication, we must always be clear, concise, and accurate with the correct corresponding tone when expressed to others. When we are receiving the information, we must ensure we are understanding, investigating, and acting according to the communication presented to us. Utilizing various communication platforms, including emails, boards, and group messaging apps, can help to assist in ensuring education is received.

Benefits of Effective Communication in Nursing 

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

Nursing Ethics

Introduction 

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

History 

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

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

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

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

Professional Ethics 

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

Nursing Ethics, Principles and Values 

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

Autonomy 

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

Beneficence 

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

Justice 

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

Non-Maleficence 

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

Fidelity 

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

Veracity 

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

Accountability 

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

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

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

Foundations of Nursing Ethics 

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

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

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

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

An interesting factor to note is that the ICN Worldview focuses on co-worker relationships: “Nurse bullying occurs in almost all care settings and units, from the patient floor to the executive suite. In fact, 60% of nurse managers, directors, and executives in one 2018 study4 said they experienced bullying in the workplace, and 26% considered the bullying “severe” (7). Workplace intimidation is any intimidating or disruptive behavior that interferes with effective healthcare communication and threatens patient safety; it is often categorized as horizontal or relational aggression. Improving how management addressed such issues in nursing may be critical not only for staff turnover, but for patient outcomes.   

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

Application 

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

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

Traditionalists or Silent Generations (1922- 1946):  

• Respect authority, are hardworking, and are sacrificial for their work. 
• Many have delayed retirement (8). 

Baby Boomers (1946-1964): 

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

Generation X (1965-1977): 

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

Generation Y (1978-1991): 

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

Generation Z (1992-2010): 

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

No matter what generation you fall into, it is important to understand the different personality and learning styles of everyone.  

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

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

End-of-Life 

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

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

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

The ANA Code of Ethics 

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

Respect for Human Dignity

The nurse must show respect for the individual and consider multiple factors (belief systems, gender/sexual identification, values, right to self-determination, and support systems) when planning and providing care. The nurse ensures patients are fully informed and prepared to make decisions about their healthcare and to carry out advance healthcare planning.

Commitment to Patients

The nurse must always remember that the primary responsibility is to the patient and help resolve conflicts between the patient and others and avoid conflicts of interest or breach of professional boundaries. 

Protection of Patients’ Rights

The nurse must be aware of legal and moral responsibilities related to the patients’ rights to privacy and confidentiality (as outlined by HIPAA regulations) and research participation.  

Accountability

The nurse bears primary responsibility for the care of the patient and must practice according to the Code of Ethics and the state nurse practice act and any regulations or standards of care that apply to nursing and healthcare. 

Professional Growth

The nurse must strive always to promote health, safety and wellbeing of self and others. The nurse must, in all circumstances, maintain personal integrity and report violations of moral standards. The nurse has a right to refuse to participate in actions or decisions that are morally objectionable but cannot do so if this refusal is based on personal biases against others rather than legitimate moral concerns. 

Improvement of Healthcare Environment

The nurse must recognize that some virtues are expected of nurses, including those associated with wisdom, honesty, and caring for others, and that the nurse has ethical obligations toward others. The nurse is also responsible for creating and sustaining a moral working environment.  

Advancement of the Profession

The nurse must contribute to the profession through practicing within accepted standards, engaging in scholarly activities, and carrying out or applying research while ensuring the rights of the patients are protected. 

Health Promotion Efforts

The nurse recognizes that health is a universal right for all individuals and collaborates with others to improve general health and reduce disparities. The nurse remains sensitive to cultural diversity and acts against human rights violations, such as genocide, and other situations that may endanger human rights and access to care. 

Participation in Goals of the Profession

The nurse must promote and share the values of the profession and take action to ensure that social justice is central to the profession of nursing and healthcare.

Conclusion 

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

Ensuring Patient Confidentiality in Nursing

Introduction 

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

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

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

The Privacy Rule 

The Health Information Portability and Accountability Act of 1996 (HIPAA) became the groundwork for the Standards for Privacy of Individually Identifiable Health Information (Privacy Rule) issued by the U.S. Department of Health and Human Services (HHS). It was designed to meet the requirements set by HIPAA regarding how healthcare providers used and disclosed a patient’s private health information. It also addressed patients having the right to know and dictate how their health information is utilized. Overall, the Privacy Rule’s goal was to set clear boundaries when it came to properly protecting health care information while allowing the exchange of pertinent information to protect the health and well-being of the public (2). 

Many groups are included under HIPAA’s term of “covered entities.” These entities have connections to personal health care information on a variety of levels. Groups such as healthcare providers, health plans, healthcare clearinghouses, and business associates are all covered entities. The protected information they encounter is anything that can or is believed to identify an individual: name, date of birth, address, and Social Security Number. Any past, present, or futured mental or physical health, condition, or payment and health care provisions for an individual are also classified as protected information (4).

De-Identifying Patients 

There are many steps involved in de-identifying a patient for those who use or share patient information, as it applies to HIPAA. De-identifying a patient is the act of removing as many identifiers as one can in order to eliminate the chances of an individual being recognized through the scenario or situation (3).  

There are two methods to de-identifying:  

Formal Evaluation by a Qualified Expert.

A qualified expert must be a person with significant knowledge and experience with knowing scientific and statistical standards or methods to ensure patient information is not identifiable. They do this by determining if the risk of using the information is very small. They often document what methods they use to make the determination (3).  

The Act of Removing Individual Identifiers.

Many of these identifiers are things one would expect to be removed when identifying a patient, such as a name, age, date of birth, home address, Social Security Number, full-face photos, and phone numbers. However, some of them include any form of vehicle identifier—serial or license plate numbers—internet protocol (IP) addresses, biometric identifiers like finger or voiceprints, serial numbers or device identifiers, and web universal resource locators (URLs). An entire list of the 18 identifiers is located on the Department of Health and Human Services website (3).   

Neither of these methods are 100% perfect in their goal, but they decrease a patient’s chance of being identified significantly. Once the patient has been de-identified, the information is no longer restricted by the Privacy Rule since all patient identifiers have been removed. This means that the information can be used without worry of violation (3). 

Professional Statements  

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

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

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

Disclosure  

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

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

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

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

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

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

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

Consequences of Disclosure Violations 

Healthcare providers may be subjected to a variety of consequences when it comes to the violation of HIPAA or the Privacy Rule. The healthcare provider and the facility in which they work may be subjected to civil suits in a variety of ways. Disclosing sensitive information or photos about the patient are a breach of legal duty—intentional or unintentional—are both forms of civil suits that can occur. Nurses may face disciplinary action from their state’s board of nursing. With the ever-growing form of social media, boards of nursing have been cracking down on improper use of social media and breaches in patient confidentiality. Job loss and fines are other consequences that may occur by themselves or in addition to any of the others listed above (6).

Patient Confidentiality in the Technology Era 

There are many forms of technology today and there are many ways patient confidentiality can be violated by using it. Cell phones have become a staple in nearly everyone’s day-to-day life, so it would make sense that both healthcare providers and patients alike have them. While they are useful, cell phones can also cause problems. Unintentional or intentional filming or recording of patients or medical information can happen by staff, family members, or other patients. Family members or friends may call to ask about a patient, and it is important for the nurse to know hospital policy when it comes to verifying the identity of those calling and what information can be given over the phone. Verifying with the patient who can be told what information is important as well (6). 

Since charting has become electronic, many nurses are using computers, laptops, or tablets to complete their charting. Healthcare providers need to ensure that privacy is always maintained when utilizing these devices.  

Even though most things can be transferred via email, call, or secured text message, some information still needs to be transmitted via fax machine. Since there is room for human error, coversheets should be used along with a clear identifier that the information being sent is confidential. If a number is used often, it is encouraged that it is preprogrammed into the fax machine to help decrease the chance of the number being mistyped (6).  

Best Practices of Patient Confidentiality 

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

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

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

Summary  

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

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

Introduction 

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

Consider Anger 

Depending on your personal life, you will likely have your own opinion about anger as an emotion. Generally, it does not feel good to experience it in ourselves, nor is it pleasant to be around others who are feeling this way. Becoming angry is a part of being human, and as a healthcare professional, we must learn more about it so we are aware of how to deal with difficult patients. Perhaps approaching this from a philosophical standpoint will further help us to see beyond our patient’s immediate anger and we can work to develop a plan to resolve the conflict. 

Anger as a Motivator 

First off, anger can be motivating.  

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

Catharsis 

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

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

Control 

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

Stress & Trauma 

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

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

Explore Your Thoughts/Feelings/Opinions/Triggers 

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

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

Common Practice 

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

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

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

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

Distraction 

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

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

Giving Advice 

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

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

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

Threatening  

Although this should only be used when absolutely necessary, nurses must be able to learn and understand how to deal with difficult patients through utilizing threatening tactics. Where I work, some patients simply live for the three smokes a day that they’re allowed. An example of this threatening tactic sounds something along the lines of, “if you don’t do what I say, you’re not going to get your cigarette.” Please note that this approach should not be utilized all the time, but in some cases, it can seem like the only way to get through to your difficult patients.  However, keep in mind that it is a way of trying to control the other person and is also a missed opportunity to increase trust between the patient and the nurse. 

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

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

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

Anatomy Review 

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

The Hormone Cascade 

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

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

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

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

Tips for Handling Patients When They are Angry 

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

Safety First 

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

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

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

What to Say or Not to Say 

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

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

Tips to improve listening skills: 

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

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

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

Boundaries 

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

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

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

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

Not Taking Things Personally 

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

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

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

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

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

Take Care of Yourself 

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

Case Studies 

Case Study #1 

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

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

The above is based on an episode that I experienced about a year ago. This patient is still at the facility I work at, and I have not seen any such outbursts from her since. I can also attest to experiencing very good rapport with her since this event. 

Case Study #2 

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

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

Conclusion 

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

How to Reduce New Nurse Turnover

Introduction 

Before graduating from nursing school, I was accepted into a six-month program to train for the cardiac medical ICU. I took the initial competencies and classroom trainings and was assigned an experienced preceptor on the ICU floor. My preceptor very quickly informed me that I was bothering patients by being too attentive. Soon after, she let the rest of my colleagues know that she would be retiring because the job had become dangerous now that so many new nurses were joining our unit. That was just the first week on the floor.  

Throughout my first year of nursing, I was anxiety-ridden and questioned staying. Despite my rough start, I made it through and have enjoyed over 20 years as a nurse; however, many of my classmates not only resigned before their first year was over, but a few left nursing altogether.  

During my tenure as a nurse, I have learned that incivility and bullying are all too common. In a 2017 report, Nurses Eat Their Young: A Novel Bullying Educational Program for Student Nurses, the author references research that indicated bullying and incivility among peers occurred to at least 30% of nurses. Among new nurses, 73% reported experiencing incivility or bullying in their first month in practice (3). Below, I have listed just one example from a nursing blog that showcases how bullying and incivility haven’t changed much from my experiences with it over 20 years ago.  

“I have an orientation with a nurse educator. And she’s kind of a bully; I have to say. She puts me in uncomfortable situations. She dismisses anything I say; she gives me ridiculous and menial assignments while excluding me from doing tasks with her directly related to my new role, that I could learn better. Yet, she talks over and over about the things I already know. She gives me contradicting information. At this point, my self-esteem has got even lower than when I started” (15). 

In response: “This is the issue I have with the profession… more than likely, they pounced on you because you’re new, and they’re asserting their dominance/reinforcing cliques (them vs. us). Either behavior making for toxic workplace culture… And I say this from experience” (15). 

New Graduate Nurse Turnover Rates  

The overall nurse turnover rate has increased 5% over the last decade; however, the new graduate nurse turnover rate alone has increased that much in just four years (4,10).  

After only their first year, the new nurses’ turnover rates continue to rise until almost half of them have either left their departments or nursing in its entirety (4).  

Of further concern, in a 2020 The Nursing Solutions, Inc. nurse turnover report, they project a significant increase in nurse deficits as a result of the COVID-19 pandemic (11). The report surveyed over 1000 nurses, and the results determined that 96% of respondents showed signs of burnout, and 56% reported they would be leaving either direct patient care specialties or the nursing profession in its entirety through resignation or retirement (11).

Reasons for New Nurse Turnover 

There are various reasons as to why new nurses are leaving the field and contributing to the increase in nurse turnover; however, there is one trend that has remained consistent for decades. The initial peer-to-peer and orientation/precepting relationships established can truly make or break a new nurse.  

Researchers often correlate the incivility and bullying of nurses to a lacking collegial or peer-to-peer relationships. Many nurses who cite bullying or incivility in the workplace often claim they are leaving the job due to their preceptors. For nurses with years of experience under our belt, since collegial relationships are a primary driver of turnover and retention for new nurses, we must assume responsibility for our part as peers and work to reduce the continuous rise in new nurse turnover. 

Effects of New Graduate Nurse Turnover 

There is no argument that the cost of increasing new nurse turnover rates has all-encompassing effects. New graduates may lack the full in-person experience of nursing and are not fully prepared to meet all practice-based standards; this requires more hands-on training and nursing experience. Nurse-sensitive outcomes, including falls, pressure ulcers, and nosocomial infections, suffer in the hands of continual learners (8). Higher rates of mortality have been linked to higher turnover rates (6). 

Although the training and precepting of new nurses is necessary on all accounts, it can be challenging and demanding for the already short-staffed and stressed nurses with experience. With the combination of continuous training and increased workload demands, patient satisfaction and community trust in the organization begins to erode (8). Employee morale for both new and experienced nurses suffer due to the increase in expectations and workload (6). In high patient volume scenarios, training and precepting may take the back burner to cover patient census, which leads to missed learning opportunities and perpetuates a lack of clinical expertise as the new nurses move forward in their career. This lack of knowledge can lead to intolerance or ridicule by the better-prepared nurse and possible disciplinary action for the up-and-coming nurse.  

The cost for recruitment and hiring of new nurses along with the costs for filling vacated positions with travel and contracted nurses are estimated to be 5% of a hospital’s annual budget (6). Since labor cost accounts for up to 50% of the budget, productivity remains a top priority despite increased workload demands; leaving staff and administrators disconnected in determining actions that may positively affect patient and staff satisfaction.  

I understand that these are not new statistics, and few nurses would knowingly jeopardize their safety and patient care. However, the fact remains that the culture persists, and the new nurses that receive this type of treatment pass it on. As part of the change process, our first action may start with recalling what it was like for us as new graduate nurses.

Challenges for New Nurses 

New nurses typically receive the “short end of the stick” when joining an organization, as the employer will most likely fill them in the neediest shifts, including nights, rotating, weekend, and holiday shifts. While this is not ideal for the new nurse, we accept it as part of the dues that they must make.  

The Nursing Times Workforce reports that many nurses come into the field with anxiety (12). When I first became a nurse, I, too, experienced anxiety. I ended up mentioning my feelings to one of my colleagues who supportively advised me that my anxiety was a good sign; it indicated that I would be a more cautious nurse. I took comfort in this, but as I now reflect, I do not believe it to be the whole truth. 

Cautiousness is a characteristic in and of itself, and although it can present as anxiety, the feeling of dread can be resolved with positive experiences that lead to confidence. The anxiety that I felt, and what new nurses typically describe tends to be fear-based, whether it is real or perceived. On top of this, up to 18% of hospital nurses report symptoms of depression which is double the general population (12).  

When you couple this anxiety with incivility, bullying, or general lack of support, it becomes easy to see how the rates of new nurse turnover continue to rise. Below are just a few examples of sub-Reddit postings from current new nurses and the challenges they are facing with their mental health: 

“My anxiety/depression has worsened to the point where I can’t sleep the night before I work and I’m constantly overthinking or worrying about my job. I’m miserable and on edge, and I feel like this just can’t be worth it. I was looking to move out of bedside nursing and was curious what my options are, especially with less than a year of experience” (17). 

“Hello! I work dayshift med surg. My biggest issue is when I get home, I’m anxious. I think about my shift and worry I forgot something. I get nervous that when I come back the next day, the night nurse will pick me apart because I missed things. I sleep terribly in between shifts. I just always worry about what I did. Need advice. Does this happen to anyone else? Best tips to not worry?” (18). 

“I am fresh off orientation and am beginning to suffer from anxiety attacks while at home. I wake up in sweats thinking about my unit. I feel weak because my peers are not feeling these same things. It’s disheartening knowing that I worked my butt off in nursing school to end up feeling like crap every day. I don’t know what to do. I hear it gets better, but now I’m questioning if I should’ve ever become a nurse. Caring for people is all I wanted to do, but maybe I wasn’t cut out for this” (19). 

Bullying and Incivility 

The American Nurses Association defines bullying as “repeated, unwanted harmful actions intended to humiliate, offend and cause distress in the recipient” (2).  

As previously mentioned, bullying is a prevalent issue in the field of nursing, and there are many speculations as to why it is common for nurses to bully their colleagues. One being, that nurses tend to garner less respect from other disciplines such as doctors or pharmacists. Other reasons may be due to the natural competitiveness of the healthcare professions, or the inability to control most of their work environment and patient outcomes so overstepping and bullying fellow nurses is their only constant form of control or normalcy (7). Common examples of bullying in nursing include verbal abuse and harassment. 

Incivility is a form of bullying, except the intent is more ambiguous; so much so that it often goes unrecognized and can even be disguised as a learning opportunity. Incivility often gets ignored by management out of empathy for the experienced nurses being under stress, or out of fear of confronting a trained nurse and causing them to leave – contributing to the chronic short-staffing in healthcare facilities. Nurses who experience this behavior tend to pass it on as a rite of passage, leading to the perpetuation of nurses’ culture “eating their young” (4). Some signs of the behavior include (15):

How to Support New Nurses 

In the article, “4 Compelling Theories Why Nurses ‘Eat Their Young,’” Maura Hohman says, “The number one most powerful behavior is for the witness to speak up and support the person who is being targeted (7).” While this is easier said than done, there is evidence that developing a script to confront individuals when this occurs can be useful (3). At the very least, it shows support for the new nurse. Other essential activities to improve instances of incivility and bullying in the workplace while reducing the new nurse turnover rate include:  

• Becoming familiar with your organization’s policies and procedures on incivility, bullying, and workplace violence. If your organization does not address this issue, it is your responsibility to recommend and participate in developing the needed policies. The American Nurses Association’s “Nurses Bill of Rights” is a useful reference (2).  
• Advocating for education on recognizing and preventing incivility and bullying through your professional association, nursing schools, and organization (3).  
• Practicing “Just Culture.” Unless the same error occurs repeatedly, the new nurse’s intent is your primary tool for guiding consequences. Never blame or name if unnecessary when reporting an error. Limit your information to the facts only. Mistakes are to be investigated for the root cause, which is rarely person-related, and almost always process, culture, and system design.  
• Learning opportunities are just that; don’t chastise. If you are angry or irritated, consider your real intent. Learning opportunities are rarely cultivated in an emotional environment.  
• Being a supporter of other nurses.  
• American Nurses Association’s civility best practices include: 
• Strive to develop clear verbal and non-verbal communication. Be direct when needed and always respectful.  
• Treat others with kindness, as well as collegiality, and always dignity.  
  • Be mindful that every individual suffers, and your actions and words affect others.  
  • Avoid gossip and call it out when you hear it from others.  
  • Rely on facts; never speculate and be slow to conclude until evidence has been discovered.  
  • Be collaborative and share information when appropriate.  
  • Offer assistance and accept appropriate refusal graciously.  
  • Be aware, accountable, and responsible for your actions. 
  •  Speak directly to the person with whom you have an issue.  
  • Seek other points of view, perspectives, and experiences. Listen to others with interest.  
  •  Apologize when necessary.

Recognizing Burnout and Opportunities to Reduce New Nurse Turnover 

Since a lack of collegial relationships and peer-to-peer support are contributing factors leading to burnout and turnover, there is a lot you can do to prevent both. Besides following the steps above, recognizing burnout and signs of pending turnover are essential to quick intervention. The symptoms of burnout are noticeable in this at-risk population who may begin:  

• Not participating in social activities.  
• Not participating in improvement activities or opposing workplace changes.  
• Calling off shifts, especially when they have been highly dependable.   
• Arriving late for their shift.  
• Taking excessive breaks or leaving the floor for support personnel activities when not necessary. 
• Presenting with a negative attitude or being insensitive to patients and families. 
• Verbalizing overwhelming anxiety or dread at coming to work (14). 

If you notice these behaviors, it is time to intervene in order to avoid nurse turnover. One of the best strategies is to become a mentor or friend to them. Having someone to vent to helps relieve stress, and your engagement will go a long way in building positive experiences for the new nurse (14). If you have an employee assistance program, refer them to your human resources depart and inform them of all the available resources that you know of. Employee assistance programs offer confidential counseling for many personal and work-related concerns. If the situation persists, get your manager involved. It is their job to know and offer additional supportive resources to their employees.  

Conclusion 

There are many contributing factors to new nurse turnover. It is the responsibility of healthcare organizations, professional associations, and nursing educators to work together to improve the barriers that are causing this consistent increase in nurse turnover rates that are further contributing to the global nursing shortage. In order to deliver quality patient care, improve health outcomes, and increase workplace satisfaction we need nurses.  

No matter how much experience you have, there are ways you can contribute to ending this increasing new nurse turnover, and that is by becoming an advocate and mentor for them. Speak up to support a new nurse and become familiar with your organization’s incivility, bullying, and workplace violence policies.

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