If You Don’t Want to Be Sued, Don’t Be Rude: Maintain Good Rapport With Your Patients

Patients may perceive things very differently than we might think about health care they receive and family members also may perceive things differently than we would expect by what they observe when care is delivered to their loved ones. Therefore, we must assume the attitude of a healthcare provider is quickly filtered through the client’s lens of perception. From a client’s point of view, if things don’t go a planned, they may experience fear, feelings of disappointment, frustration, and even anger. Their anger is frequently directed at the healthcare provider in general. Little things appear large in the client’s eyes and any healthcare provider who happens to be present may be the target of the client’s fear, frustrations and possibly anger.

A nurse’s thoughts may include: “I can’t do anything about how they feel.” To a certain extent, this may be true; however, there are actions nurses can take and should keep in mind to offer reassurance their clients. I have also experienced that some clients can be extremely difficult to care for reasons that may not ever be clearly understood. Their attitude may be less than stellar but, nurses must always remember that the patient is the one who is seeking care for a health issue that may be extremely difficult for them to accept or cope with.

A diagnosis of coronary artery disease many times requires a change in lifestyle or habits. Lifestyle changes will impact individuals in a variety of ways: socially, financially, occupational impact, and self-esteem, any of which their emotions may be manifested in the form of anger and frustration toward anyone who happens to be around them. Many times, nurses become the sounding board for life’s stressors that our clients are experiencing and may be having difficulty coping with. I am certain there are many other real life situations nurses have experienced. We must reflect back to our training in therapeutic communication and revive some of the effective skills that will help client’s to cope with challenges in their life that have been exacerbated by a change in their health status.

Nurses should strive to have patience, communicate professionally, and have empathy. Remember, if the client “feels” you are rude, inconsiderate, impatient, or don’t care, your risk of being sued if significantly greater if things do not go as planned. NOW HEAR THIS: it doesn’t necessarily mean you did anything wrong. It may be all about the client’s perception!

Tips To Increase Rapport With Patients

1. Self-awareness and effective communication skills include the following:

Verbal communication is typically considered the spoken words.
Nonverbal communication includes gestures, expressions, and body language.
Nurses should use positive body language, such as sitting at the same eye level as the client with a relaxed posture that projects interest and attention. Leaning slightly forward will help engage the client. It is generally best to not cross your arms or legs during communication with your clients because this posture erects barriers to your interaction with them. Uncrossed arms and legs projects openness and a willingness to engage in the conversation. Make sure your verbal responses are consistent with your nonverbal messages.

2. Nurses assess and interpret all forms of patient communication.

Silence and Listening are a couple of the most difficult but often the most effective communication techniques to use during verbal interactions.
Passive listening is letting the client do the talking, but,
Active listening reflects on what the client is talking about.

3. Techniques that inhibit therapeutic communication include:

Advice – telling a patient what to do

Agreement – agreeing with a particular viewpoint of a client (the client may not want to change their mind if they thing it opposes what the nurse agrees to)

Challenges – disputing the client’s beliefs with arguments, logical thinking, or direct order (a nurse belittles a client).

Reassurance – telling a client that everything will be OK (this statement may not be true)

Disapproval – judging the client’s situation and behavior (nurse belittles the client).

Remember, a patient’s perception of the care they received is not necessarily what they got! Right or wrong. It starts with a perception which is “real” to the client.

I have been speaking to healthcare organizations and at national conferences for over 15 years. I have published resource books for legal nurse consultants and articles in peer-reviewed journals. I specialize in the legal aspects of healthcare related issues including nursing documentation to assure meaningful use entries meet the regulatory requirements.

Patient Safety: Vigilance, Cyber Awareness, and Take Action

Regulatory requirements, such as The Joint Commission and the Occupational Safety and Health Administration require safety inspections be carried out at regular intervals to assure patient safety. The Nurse Practice Act also requires nurses to safely operate all equipment and use medical devices properly during patient care. When new equipment is introduced to a patient care area, a competency verification should be conducted of the responsible staff who will be using the equipment. This competency verification is typically maintained in the personnel file of the employee for future reference if necessary.

Nurses are taught at some time during their training to always look at the electrical cords of all equipment because a frayed cord is a potential fire hazard. This remains to be true. The temperature of solutions used in heating and cooling pads or blankets may also pose a risk of injury to the patient if the fluid is too hot or too cold. Burns have resulted from improper regulation of temperature associated with a variety of patient care treatment devices. As crazy as it may sound, a simple non-invasive blood pressure cuff has caused patient harm. The device inflated to extreme pressures intermittently over a period of time that ultimately caused permanent nerve damage to the patient’s arm resulting in a clawed hand. A list of equipment frequently involved in patient care issues includes, but is not limited to, the following: volumetric infusion pumps, patient controlled analgesic pumps, blood glucose testing devices, heating pads, cooling/heating blankets, non-invasive blood pressure cuffs, nasal cannula tubing, leg immobilizers, patient lifts, and continuous positive airway pressure machines. An injury exposing the Achilles tendon of an elderly person resulted from a leg immobilizer. The patient’s skin was not checked on a regular basis and as ordered by the physician for breakdown.

Cyber Risk

It seems obvious that inspecting equipment and / or medical devices on periodic regular intervals is a patient safety issue. Inspecting or evaluating the proper functioning of medical equipment should be an added consideration at the time of, or immediately following a rapid response event. We live in a world where amazing cyber technology exists therefore, health care providers must now consider the possibility that technical equipment may have malfunctioned which may have originated from a cyber source. This possibility would never have been considered before. Hacking Healthcare IT in 2016 was published by the Institute for Critical Infrastructure describing how devices that are blue-tooth enabled and have access to the internet, such as automatic implantable cardioverter-defibrillator and pacemakers, patient controlled analgesic pumps, and insulin pumps are at risk for being hacked or reprogrammed.

Take Action:

1. Be hyper-vigilant and open to possibilities of contributing factors never considered before.

2. Conduct a survey of the equipment in the room at the time of the event and inspect it carefully as soon as possible after a Rapid Response or a Code situation. If in doubt, take equipment out of circulation; send it to biomedical engineering for inspection and record your action on an incident report, occurrence report, or a variance report (whatever your institution may call the form). Let the professionals trained in biomedical engineering determine when to return the equipment of concern back to available inventory.

3. Double check the medication rates programmed in the infusion pumps. Sometimes the programming is not correct and guess who is going to held accountable? That’s right You! Double check the pumps by calculating the math yourself.

4. Record the temperature on any equipment or device that displays a temperature. For example: fluid warmers, blanket/pad warmers, heating/cooling blankets, crib warmers, etc. When the temperature is recorded, the medical record conveys that the health care provider was paying attention to details which will support your clinical competence should it be questioned.

Actions Registered Nurses Should Take to Avoid Being Sued for Negligent Supervision of Subordinates

Charge nurses, preceptors, managers, and directors need to take note. Registered Nurses may find themselves addressing the allegation “failure to provide adequate supervision” if they are named in a lawsuit. Follow these 3 actions to assure this does not happen to you.

Action One. Know the competency of those you supervise. Nurses may supervise practical or vocational nurses, nursing assistants, new graduates of nursing programs, new employees during orientation, and nursing students (this list is not comprehensive). How does a nurse know the competency of those supervised?

Health care providers who hold a professional license would be practical nurses or vocational nurses and new licensed employees in orientation. Each employee completes a self-assessment as part of the hiring process. The education department provides the self-assessments with the nurse manager or director of each nursing department so a competency grid can be formulated and made available to all nursing staff for reference. A competency grid assists the charge nurse in making appropriate assignments based on the needs of the patients and according to the competencies of the assigned staff member. Likewise, nursing staff members can reference the competency grid specific to those being supervised to assure patient assignments and aspects of patient care are delegated appropriately. A team leader’s responsibility is to periodically follow-up during a shift to assure that patient care is provided according to the current and acceptable standard of care.

Action Two. Be aware that any person who holds a license is and will be held accountable for their personal actions. A supervisor may be considered negligent if specific aspects of patient care that were delegated are considered inappropriate. Negligence may also be alleged when follow-up with a subordinate is considered inadequate or not done at intervals frequent enough to assure the delivery of quality care. Registered nurses are required to oversee patient care that is delivered by others and intervene when warranted. The license granted by a state specific licensing board dictates the expectations and limitations of patient care provided by licensed healthcare providers. The registered nurse must know what various licenses permit and the limitations that exist of a license that is held by those they supervise.

Action Three. Team up with those who are unfamiliar to you; those who you do not know their competencies. Working alongside them for a short period of time provides you the opportunity to observe, discuss, and evaluate their skills and knowledge base so you are confident to appropriately delegate aspects of patient care.

The unlicensed assistive personnel may have the title nursing assistant, certified nursing assistant, graduate nurse, patient care tech, etc. The registered nurse will be held accountable for assuring that the skills and data collection are done correctly and timely with this level of employee. This requires coordination, observation, and timely follow-up. It may also require re-education of knowledge and skills. The easiest and most reliable method to accomplish coordination of care is to have effective communication.

When report is given to unlicensed assistive personnel, be very specific with directions or instructions. For example: Instead of saying “Take Mr. Smith’s blood pressure every four hours and let me know if it is high.” Say: “Take Mr. Smith’s blood pressure at 8 am, 12 (noon), and 4 pm and let me know immediately if either number of his blood pressure is higher than 175/90. Call me on my portable phone (make certain to write the number down), or page me overhead (assure they know how to use the paging system or they know who to ask to do this for them).” When you are specific with your instructions there is no room for judgement because unlicensed assistive personnel are not qualified to make any judgements regarding patient care. Make it a practice to give report with this kind of direction every single time. Remember this… unlicensed assistive personnel do not give unlicensed assistive personnel report; registered nurses give unlicensed assistive personnel report! The unlicensed assistive personnel can report on tasks done or not done to the oncoming shift unlicensed assistive personnel but the patient care report and direction of patient care must come from the registered nurse.

Communication is a two-way process.

The nurse:

Assesses the assistant’s understanding. How the task is to be accomplished. When and what information is to be reported including the expected observations to report and record, and specific client concerns that would require prompt reporting.
Prioritizes the tasks for the assistant and client situation.
Addresses any unique client requirements, characteristics and clear expectations of each.
Assesses the assistant’s understanding of expectations, providing clarification as needed.
Communicates willingness to be available to guide and support the assistant.
Assures appropriate accountability by verifying that the receiving person accepts the delegation and accompanying responsibility.

The nursing assistive personnel:

Asks questions regarding the delegation and seeks clarification of expectations as needed.
Informs the nurse if the assistant has not completed a task, function, or activity before.
Asks for additional training or asks to be supervised.
Affirms understanding of expectations.

Documentation:

Timely, complete, and accurate of care provided.
Facilitates communication with other members of the health care team.
Records the nursing care provided which should demonstrate adherence to standards of practice.

Apply critical thinking and professional judgment when following the Five Rights of Delegation to assure delegation or assignments are appropriate:

1. The right task

2. Under the right circumstances

3. To the right person

4. With the right directions and communication; and

5. Under the right supervision and evaluation