Emergency Preparedness, Response, and Recovery
Ernstmeyer & Christman- Nursing Mental Health and Community Concepts- OpenRN
A disaster is defined as a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability, and capacity that lead to human, material, economic, and environmental losses and impacts.[1] Every community must prepare to respond to disasters that include natural events (e.g., tornadoes, hurricanes, floods, wildfires, earthquakes, or disease outbreaks), man-made events (e.g., harmful chemical spills, mass shootings, or terrorist attacks), or infectious disease outbreaks. See Figure 18.2[2] for an image of the effects of the natural disaster Hurricane Katrina.
Emergency preparedness is the planning process focused on avoiding or reducing the risks and hazards resulting from a disaster to optimize population health and safety. Disaster management refers to the integration of emergency response plans throughout the life cycle of a disaster event. Because disasters cause physical and psychological effects in a community, emergency preparedness and disaster management emphasize collaboration and cooperative aid among health care institutions and community agencies to ensure a coordinated and effective response.[3]
Read the American Nurses Association resource regarding Disaster Preparedness.
Emergency preparedness and disaster management are based on four key concepts: preparedness, mitigation, response, and recovery. This process guides decision-making when an emergency or disaster occurs in a community.[4] After the disaster event has concluded, evaluation of the effectiveness of the response occurs as part of planning emergency preparedness. See Figure 18.3[5] for a diagram that illustrates this theoretical framework for emergency preparedness. Each of these concepts is further discussed in the following subsections.
Preparedness
Preparedness includes planning, training personnel, and providing educational activities regarding potential disastrous events. Planning includes evaluating environmental risks and social vulnerabilities of a community. Environmental risk refers to the probability and consequences of an unwanted accident in the environment in which community members live, work, or play. Risk assessment also includes assessing social vulnerabilities that affect community resilience.[6]
Social vulnerability refers to the characteristics of a person or a community that affect their capacity to anticipate, confront, repair, and recover from the effects of a disaster.[7] Populations living in a disaster-stricken area are not affected equally. Many factors can weaken community members’ ability to respond to disasters, including poverty, lack of access to transportation, and crowded housing. Evidence indicates that those living in poverty are more vulnerable at all stages of a catastrophic event, as are racial and ethnic minorities, children, elderly, and disabled people.[8] Socially vulnerable communities are more likely to experience higher rates of mortality, morbidity, and property destruction and are less likely to fully recover in the wake of a disaster compared to communities that are less socially vulnerable. Community health nurses must plan emergency responses to disasters that address these social vulnerabilities to decrease human suffering and financial loss.
The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR) created a Social Vulnerability Index database and mapping tool designed to assist state, local, and tribal disaster management officials in identifying the locations of their most socially vulnerable populations. Geographic patterns of social vulnerabilities can be used in all phases of emergency preparedness and disaster management. See Figure 18.4[9] for an image of social vulnerability mapping.
Mitigation
Mitigation refers to actions taken to prevent or reduce the cause, impact, and consequences of disasters. Health care institutions and community health agencies plan three Cs to mitigate the effects of a disaster:
- Communication: An emergency communication plan identifies tools, resources, teams, and strategies to ensure effective actions during emergencies.
- Coordination: Coordination plays a crucial role in efficiency and effectiveness of disaster management by providing a big picture of an emergency and reducing uncertainty levels among responders.
- Collaboration: Collaboration allows responders to act together smoothly and helps reduce impact of the disaster.
Response
The response phase occurs in the immediate aftermath of a disaster. When a disaster occurs, actions are taken to save lives, treat injuries, and minimize the effect of the disaster. Immediate needs are addressed, such as medical treatment, shelter, food, and water, as well as psychological support of survivors. Personal safety and well-being in an emergency and the duration of the response phase depend on the level of a community’s preparedness. Examples of response activities include implementing disaster response plans, conducting search and rescue missions, and taking actions to protect oneself, family members, pets, and other community members.[10]
While the immediate actions of responding to a disaster are treating physical injuries, psychological effects must be addressed as well. To minimize psychological effects, nurses and first responders can provide support to victims of the disaster by following these tips from the Substance Abuse and Mental Health Services Administration (SAMHSA)[11]:
- Promote safety: Ensure basic needs are met and provide simple instructions about how to receive these basic needs.
- Promote calm: Listen to people express their feelings and provide empathy and compassion even if they are angry, upset, or acting out. Offer objective information about the situation and efforts being made to help those affected by the disaster.
- Promote connectedness: Help people connect with friends, family members, and other loved ones. Keep families and family units together as best as possible, especially by keeping children with those whom they feel safe.
- Promote self-efficacy: Give suggestions about how people can help themselves and guide them toward the resources available. Encourage families and individuals to help meet their own needs.
- Promote help and hope: Know what services available and direct people are to those services and continue to update people about what is being done. When people are worried or scared, remind them that help is on the way.
Disaster Response Protocols
When thinking about responding to a disaster, first responders and emergency personnel come to mind such as law enforcement, fire departments, and emergency medical technicians (EMTs). However, nurses are also called upon to assist in emergencies or disasters and must be competent in responding. Nurses may be involved in triaging individuals for treatment.
To respond effectively when a disaster occurs, emergency responders perform triage by prioritizing treatment for individuals affected by the disaster or emergency. Field triage sorts victims affected by the event and ranks victims based on the severity of their symptoms. Disaster triage determines the severity of injuries suffered by victims and then systematically distributes them to local health care facilities based on their severity.
Simple Triage and Rapid Treatment (START) is an example of a triage system established by the U.S. Department of Health and Human Services that prioritizes treatment of victims by using standard colors indicating the severity of symptoms and prognosis. See Figure 18.5[12] for the START algorithm. The following colors indicate severity of injury and prognosis:
- RED: Emergent needs
- Life-threatening needs, such as alterations in airway, breathing, and circulation; impairment in neurological systems; or severe, life-threatening injuries.
- They may have less than 60 minutes to survive.
- These patients will be seen first or immediately.
- YELLOW: Urgent, but delayed needs
- Life-threatening needs; status is not anticipated to change quickly or significantly in the next hours, so transport can be delayed.
- GREEN: Non-urgent needs, often referred to as the “walking wounded”
- Minor injuries; status is not likely to deteriorate over the next several days.
- Many individuals can assist with obtaining their own care.
- BLACK: The person has died or is expected to die soon
- This person is unlikely to survive given the severity of their injuries, level of available care, or both.
- Palliative care and pain relief should be provided.
Providing Care for Those Exposed to Environmental Hazards
Nurses may be involved in caring for clients who have been exposed to chemicals or other environmental hazards. See Table 18.3 for assessment findings and interventions for a variety of exposures. Chelation therapy is a treatment indicated for heavy metal poisoning such as mercury, arsenic, and lead. Chelators are medications that bind to the metals in the bloodstream to increase urinary excretion of the substance.
Some chemical exposures require decontamination to treat the individual, as well as to protect others around them, including first responders, nurses, and other patients. Decontamination is any process that removes or neutralizes a chemical hazard on or in the patient to prevent or mitigate adverse health effects to the patient; protect emergency first responders, health care facility first receivers, and other patients from secondary contamination; and reduce the potential for secondary contamination of response and health care infrastructure. For example, if a farmer enters a rural hospital’s emergency department after chemical exposure to an insecticide spray, decontamination may be required. See Figure 18.6[13] for an image of decontamination.
The decision to decontaminate an individual should take into account a combination of these key indicators[14]:
- Signs and symptoms of exposure displayed by the patient
- Visible evidence of contamination on the patient’s skin or clothing
- Proximity of the patient to the location of the chemical release
- Contamination detected on the patient using appropriate detection technology
- The chemical and its properties
- Request by the patient for decontamination, even if contamination is unlikely
Table 18.3 Assessment Findings and Interventions for Exposure to Various Environmental Hazards
| Chemical or Hazard | Assessment Findings | Interventions |
|---|---|---|
| Carbon Monoxide (CO) Poisoning
(Auto exhaust and improperly vented or malfunctioning furnaces or fuel-burning devices)[15] |
Primarily decreased mental status from confusion to coma
May have cherry-red appearance of the lips and skin *Note: Pulse oximetry does not reflect accurate oxygenation levels because CO binds to hemoglobin. |
|
| Lead Poisoning
(Lead-contaminated paint dust, water, or food and bullets in wild game)[16],[17] |
Abdominal pain, constipation, fatigue, joint pain, muscle pain, headache, anemia, memory deficits, psychiatric symptoms, elevated blood pressure, decreased kidney function, decreased sperm count, increased mortality
*Note: Some symptoms may be irreversible. |
|
| Formaldehyde Poisoning
(Construction and agriculture products and disinfectants)[18] |
Eye and skin irritation, abdominal pain, bronchospasm, shortness of breath, decreased respiratory rate, acute kidney failure |
|
| Arsenic Poisoning
(Contaminated groundwater, tobacco smoke, hide tanning, and pressure treated wood)[19],[20] |
Nausea/vomiting, abdominal pain, diarrhea, paresthesias, muscle cramping, skin pigmentation changes, skin lesions and cancers, cardiac dysrhythmias, death |
|
| Mercury
(Thermometers, sphygmomanometers, fluorescent light bulbs, amalgam tooth fillings, and contaminated fish)[21] |
Acute inhalation exposure in occupational settings may cause cough, dyspnea, chest pain, excessive salivation, inflammation of gums, severe nausea/vomiting, diarrhea, dermatitis |
|
| Radon Gas
(Naturally occurring gas resulting from the decay of trace amounts of uranium found in the earth’s crust)[22] |
Persistent cough, hoarseness, wheezing, shortness of breath, coughing up blood, chest pain, frequent respiratory infections like bronchitis and pneumonia, loss of appetite, weight loss, fatigue, lung cancer |
|
| Infectious Disease
(HIV, hepatitis, sexually transmitted diseases, and COVID-19) |
Symptoms are based on disease process |
|
| Frostbite
(Overexposure of skin to cold)[23] |
White or grayish color of exposed skin, may be hard or waxy to touch; lack of sensitivity to touch or numbness and tingling; clear or blood-filled blisters after thawing; cyanosis after rewarming indicates necrosis |
|
| Organophosphates
(Insecticides and bioterrorism nerve agents)[24] |
Acute onset of symptoms related to cholinergic excess: bradycardia, increased salivation, tearing, urination, vomiting and diarrhea, diaphoresis, paralysis, respiratory failure, hypotension, seizures
Intermediate syndrome: neck flexion weakness, cranial nerve abnormalities, muscle weakness |
|
| Bioterrorism
(Anthrax, smallpox, nerve agents, and ricin)[25] |
Symptoms are based on the agent |
|
Access up-to-date, evidence-based information for suspected poisoning at the Poison Control Center or call 1-800-222-1222.
Read more about Patient Decontamination in a Mass Chemical Exposure Incident by the U.S. Department of Homeland Security and the U.S. Department of Health and Human Services.
Recovery
During the recovery period, restoration efforts occur concurrently with regular operations and activities. The recovery period from a disaster can be prolonged. Examples of recovery activities include the following[26]:
- Preventing or reducing stress-related illnesses and excessive financial burdens
- Rebuilding damaged structures
- Reducing vulnerability to future disasters
When people are affected by a disaster, they may respond in a variety of different ways. It is natural and expected to respond to a disaster with emotions such as fear, worry, sadness, anxiety, depression, and despair. Many people exhibit resiliency, the ability to cope with adversity and recover emotionally from a traumatic event.[27] However, the mental health of the population must be considered and monitored during recovery from any disastrous event. For example, some people may relive previous traumatic experiences or revert to using substances to cope. Behavioral health responses such as post-traumatic stress disorder (PTSD), substance use disorder, and increased risk for suicide should always be considered when assessing individuals’ responses to a disaster.
Effects from trauma extend beyond the physical damages from any disaster. It may take time for individuals to recover physically and emotionally. Survivors of a community disaster should be encouraged to take steps to support each other to promote adaptive coping. Use the following box to read additional information in the “Tips for Survivors of a Traumatic Event” handout by the Substance Abuse and Mental Health Services Administration (SAMHSA).
Read the SAMHSA handout on “Tips for Survivors of a Traumatic Event” PDF.
Review concepts related to loss and the stages of grief in the “Grief and Loss” chapter of Open RN Nursing Fundamentals.
Agencies Providing Emergency Assistance
Many federal, state, and local agencies provide support to communities during disasters. The Federal Emergency Management Agency (FEMA) is the agency that promotes disaster mitigation and readiness and coordinates response and recovery following the declaration of a major disaster. FEMA defines a disaster as an event that results in large numbers of deaths and injuries; causes extensive damage or destruction of facilities that provide and sustain human needs; produces an overwhelming demand on state and local response resources and mechanisms; causes a severe long-term effect on general economic activity; and severely affects state, local, and private sector capabilities to begin and sustain response activities.[28] FEMA employees represent every U.S. state, local, tribal, and territorial area and are committed to serving our country before, during, and after disasters.
Disasters are declared using established guidelines and procedures. Because all disasters are local, they are initially declared at the local level. This declaration is typically made by the local mayor. When the mayor determines that capabilities of local resources have been or are expected to be exceeded, state assistance is requested. If the state chooses to respond to a disaster, the governor of the state will direct implementation of the state’s emergency plan. If the governor determines that the resource capabilities of the state are exceeded, the governor can request that the president declare a major disaster in order to make federal resources and assistance available to qualified state and local governments. This ordered sequence is important to ensure appropriate financial assistance.[29]
A state of emergency is declared when public health or the economic stability of a community is threatened, and extraordinary measures of control may be needed. For example, an infectious disease outbreak like COVID-19 can cause the declaration of a state of emergency. A county or municipal agency is designated as the local emergency management agency, and local law specifies the chain of command in emergencies. Use the following box to access more information about federal and local agencies that provide emergency assistance.
Examples of Organizations That Provide Emergency Assistance
Federal
Local
Local county emergency management divisions
- National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020-2030: Charting a path to achieve health equity. National Academies Press. https://doi.org/10.17226/25982 ↵
- “LA_1603_9thDistDam121.jpg” by Booher, Andrea, Photographer is in the Public Domain. ↵
- Savage, C. L. (2020). Public/community health and nursing practice: Caring for populations (2nd ed.). FA Davis. ↵
- Emergency Management Institute. (2013). ISS-111.A: Livestock in disasters. Federal Emergency Management Agency. https://training.fema.gov/emiweb/downloads/is111_unit%204.pdf ↵
- “Environmental Health and Emergency Preparedness” by Dawn Barone for Open RN is licensed under CC BY 4.0 ↵
- Flanagan, B. E., Hallisey, E. J., Adams, E., & Lavery, A. (2018). Measuring community vulnerability to natural and anthropogenic hazards: The Centers for Disease Control and Prevention's social vulnerability index. Journal of Environmental Health, 80(10). 34–36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179070/ ↵
- Flanagan, B. E., Hallisey, E. J., Adams, E., & Lavery, A. (2018). Measuring community vulnerability to natural and anthropogenic hazards: The Centers for Disease Control and Prevention's social vulnerability index. Journal of Environmental Health, 80(10). 34–36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179070/ ↵
- Flanagan, B. E., Hallisey, E. J., Adams, E., & Lavery, A. (2018). Measuring community vulnerability to natural and anthropogenic hazards: The Centers for Disease Control and Prevention's social vulnerability index. Journal of Environmental Health, 80(10). 34–36. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179070/ ↵
- This image is derivative of Flanagan, B. E., Hallisey, E. J., Adams, E., & Lavery, A. (2018). Measuring community vulnerability to natural and anthropogenic hazards: The Centers for Disease Control and Prevention's social vulnerability index. Journal of Environmental Health, 80(10), 34–36. Access the report at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179070/ ↵
- Emergency Management Institute. (2013). ISS-111.A: Livestock in disasters. Federal Emergency Management Agency. https://training.fema.gov/emiweb/downloads/is111_unit%204.pdf ↵
- Substance Abuse and Mental Health Services Administration. (2005). Psychological first aid for first responders. [Handout]. U.S. Department of Health & Human Services. https://store.samhsa.gov/product/Psychological-First-Aid-for-First-Responders/NMH05-0210 ↵
- “StartAdultTriageAlgorithm.png” by unknown author at CHEMM is in the Public Domain. ↵
- “decontamination26.jpg” by Benjamin Crossley CDP/FEMA is in the Public Domain. ↵
- U.S. Department of Homeland Security, & U.S. Department of Health & Human Services. (2014). Patient decontamination in a mass chemical exposure incident: National planning guidance for communities. http://www.phe.gov/Preparedness/responders/Documents/patient-decon-natl-plng-guide.pdf ↵
- Clardy, P. F., & Manaker, S. (2021, June 17). Carbon monoxide poisoning. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- World Health Organization. (2021, October 11). Lead poisoning. https://www.who.int/news-room/fact-sheets/detail/lead-poisoning-and-health ↵
- Goldman, R. H., & Hu, H. (2021, November 4). Lead exposure and poisoning in adults. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- Agency for Toxic Substances and Disease Registry. (2014, October 21). Medical management guidelines for formaldehyde. Centers for Disease Control and Prevention. https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=216&toxid=39 ↵
- World Health Organization. (2018, February 15). Arsenic. https://www.who.int/news-room/fact-sheets/detail/arsenic ↵
- Goldman, R. H. (2020, October 8). Arsenic exposure and poisoning. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- Beauchamp, G., Kusin, S., & Elinder, C. (2022, February 1). Mercury toxicity. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- National Radon Defense. (n.d.). Radon symptoms. https://www.nationalradondefense.com/radon-information/radon-symptoms.html ↵
- Zafren, K., & Mechem, C. C. (2021, February 1). Frostbite: Emergency care and prevention. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- Bird, S. (2021, September 23). Organophosphate and carbamate poisoning. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- Adalja, A. A. (2022, January 10). Identifying and managing casualties of biological terrorism. UpToDate. Accessed April 3, 2022, from www.update.com ↵
- Emergency Management Institute. (2013). ISS-111.A: Livestock in disasters. Federal Emergency Management Agency. https://training.fema.gov/emiweb/downloads/is111_unit%204.pdf ↵
- Substance Abuse and Mental Health Services Administration. (2022, March 23). Disaster preparedness, response, and recovery. U.S. Department of Health & Human Services. https://www.samhsa.gov/disaster-preparedness ↵
- Emergency Management Institute. (2013). ISS-111.A: Livestock in disasters. Federal Emergency Management Agency. https://training.fema.gov/emiweb/downloads/is111_unit%204.pdf ↵
- Emergency Management Institute. (2013). ISS-111.A: Livestock in disasters. Federal Emergency Management Agency. https://training.fema.gov/emiweb/downloads/is111_unit%204.pdf ↵
The first IPEC competency is related to values and ethics and states, “Work with individuals of other professions to maintain a climate of mutual respect and shared values.”[1] See the box below for the components related to this competency. Notice how these interprofessional competencies are very similar to the Standards of Professional Performance established by the American Nurses Association related to Ethics, Advocacy, Respectful and Equitable Practice, Communication, and Collaboration.[2]
Components of IPEC’s Values/Ethics for Interprofessional Practice Competency[3]
- Place interests of clients and populations at the center of interprofessional health care delivery and population health programs and policies, with the goal of promoting health and health equity across the life span.
- Respect the dignity and privacy of clients while maintaining confidentiality in the delivery of team-based care.
- Embrace the cultural diversity and individual differences that characterize clients, populations, and the health team.
- Respect the unique cultures, values, roles/responsibilities, and expertise of other health professions and the impact these factors can have on health outcomes.
- Work in cooperation with those who receive care, those who provide care, and others who contribute to or support the delivery of prevention and health services and programs.
- Develop a trusting relationship with clients, families, and other team members.
- Demonstrate high standards of ethical conduct and quality of care in contributions to team-based care.
- Manage ethical dilemmas specific to interprofessional client/population-centered care situations.
- Act with honesty and integrity in relationships with clients, families, communities, and other team members.
- Maintain competence in one’s own profession appropriate to scope of practice.
Nursing, medical, and other health professional programs typically educate students in “silos” with few opportunities to collaboratively work together in the classroom or in clinical settings. However, after being hired for their first job, these graduates are thrown into complex clinical situations and expected to function as part of the team. One of the first steps in learning how to function as part of an effective interprofessional team is to value each health care professional’s contribution to quality, client-centered care. Mutual respect and trust are foundational to effective interprofessional working relationships for collaborative care delivery across the health professions. Collaborative care also honors the diversity reflected in the individual expertise each profession brings to care delivery.[4]
Cultural diversity is a term used to describe cultural differences among clients, family members, and health care team members. While it is useful to be aware of specific traits of a culture, it is just as important to understand that each individual is unique, and there are always variations in beliefs among individuals within a culture. Nurses should, therefore, refrain from making assumptions about the values and beliefs of members of specific cultural groups.[5] Instead, a better approach is recognizing that culture is not a static, uniform characteristic but instead realizing there is diversity within every culture and in every person. The American Nurses Association (ANA) defines cultural humility as, “A humble and respectful attitude toward individuals of other cultures that pushes one to challenge their own cultural biases, realize they cannot possibly know everything about other cultures, and approach learning about other cultures as a lifelong goal and process.”[6] It is imperative for nurses to integrate culturally responsive care into their nursing practice and interprofessional collaborative practice.
Read more about cultural diversity, cultural humility, and integrating culturally responsive care in the “Diverse Patients” chapter of Open RN Nursing Fundamentals, 2e.
Nurses value the expertise of interprofessional team members and integrate this expertise when providing client-centered care. Some examples of valuing and integrating the expertise of interprofessional team members include the following:
- A nurse is caring for a client admitted with chronic heart failure to a medical-surgical unit. During the shift the client’s breathing becomes more labored and the client states, “My breathing feels worse today.” The nurse ensures the client’s head of bed is elevated, oxygen is applied according to the provider orders, and the appropriate scheduled and PRN medications are administered, but the client continues to complain of dyspnea. The nurse calls the respiratory therapist and requests a STAT consult. The respiratory therapist assesses the client and recommends implementation of BiPAP therapy. The provider is notified and an order for BiPAP is received. The client reports later in the shift the dyspnea is resolved with the BiPAP therapy.
- A nurse is working in the Emergency Department when an adolescent client arrives via ambulance experiencing a severe asthma attack. The paramedic provides a handoff report with the client's current vital signs, medications administered, and intravenous (IV) access established. The paramedic also provides information about the home environment, including information about vaping products and a cat in the adolescent’s bedroom. The nurse thanks the paramedic for sharing these observations and plans to use information about the home environment to provide client education about asthma triggers and tobacco cessation after the client has been stabilized.
- A nurse is working in a long-term care environment with several unlicensed assistive personnel (UAP) who work closely with the residents providing personal cares and have excellent knowledge regarding their baseline status. Today, after helping Mrs. Smith with her morning bath, one of the UAPs tells the nurse, “Mrs. Smith doesn’t seem like herself today. She was very tired and kept falling asleep while I was talking to her, which is not her normal behavior.” The nurse immediately assesses Mrs. Smith and confirms her somnolescence and confirms her vital signs are within her normal range. The nurse reviews Mrs. Smith’s chart and notices that a new prescription for furosemide was started last month but no potassium supplements were ordered. The nurse notifies the provider of the client’s change in status and receives an order for lab work including an electrolyte panel. The results indicate that Mrs. Smith’s potassium level has dropped to an abnormal level, which is the likely cause of her fatigue and somnolescence. The provider is notified, and an order is received for a potassium supplement. The nurse thanks the AP for recognizing and reporting Mrs. Smith’s change in status and successfully preventing a poor client outcome such as a life-threatening cardiac dysrhythmia.
Effective client-centered, interprofessional collaborative practice improves client outcomes. View supplementary material and reflective questions in the following box.[7]
View the “How does interprofessional collaboration impact care: The patient’s perspective?” video on YouTube regarding clients' perspectives about the importance of interprofessional collaboration.
Read Ten Lessons in Collaboration. Although this is an older publication, it provides ten lessons to consider in collaborative relationships and practice. The discussion reflects many components of collaboration that have been integral to nursing practice in interprofessional teamwork and leadership.
Reflective Questions
- What is the difference between client-centered care and disease-centered care?
- Why is it important for health professionals to collaborate?
The second IPEC competency relates to the roles and responsibilities of health care professionals and states, “Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of clients and to promote and advance the health of populations.”[8]
See the following box for the components of this competency. It is important to understand the roles and responsibilities of the other health care team members; recognize one’s limitations in skills, knowledge, and abilities; and ask for assistance when needed to provide quality, client-centered care.
Components of IPEC’s Roles/Responsibilities Competency[9]
- Communicate one’s roles and responsibilities clearly to clients, families, community members, and other professionals.
- Recognize one’s limitations in skills, knowledge, and abilities.
- Engage with diverse professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific health and health care needs of clients and populations.
- Explain the roles and responsibilities of other providers and the manner in which the team works together to provide care, promote health, and prevent disease.
- Use the full scope of knowledge, skills, and abilities of professionals from health and other fields to provide care that is safe, timely, efficient, effective, and equitable.
- Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention.
- Forge interdependent relationships with other professions within and outside of the health system to improve care and advance learning.
- Engage in continuous professional and interprofessional development to enhance team performance and collaboration.
- Use unique and complementary abilities of all members of the team to optimize health and client care.
- Describe how professionals in health and other fields can collaborate and integrate clinical care and public health interventions to optimize population health.
Nurses communicate with several individuals during a typical shift. For example, during inpatient care, nurses may communicate with clients and their family members; pharmacists and pharmacy technicians; providers from different specialties; physical, speech, and occupational therapists; dietary aides; respiratory therapists; chaplains; social workers; case managers; nursing supervisors, charge nurses, and other staff nurses; assistive personnel; nursing students; nursing instructors; security guards; laboratory personnel; radiology and ultrasound technicians; and surgical team members. Providing holistic, quality, safe, and effective care means every team member taking care of clients must work collaboratively and understand the knowledge, skills, and scope of practice of the other team members. Table 7.4 provides examples of the roles and responsibilities of common health care team members that nurses frequently work with when providing client care. To fully understand the roles and responsibilities of the multiple members of the complex health care delivery system, it is beneficial to spend time shadowing those within these roles.
Table 7.4. Roles and Responsibilities of Members of the Health Care Team
| Member | Role/Responsibilities |
|---|---|
| Unlicensed Assistive Personnel (UAP) (e.g., certified nursing assistants [CNA], patient-care technicians [PCT], certified medical assistants [CMA], certified medication aides, and home health aides) | Work under the direct supervision of the RN. (Read more about Unlicensed Assistive Personnel (UAP) in the “Delegation and Supervision” chapter.) |
| Licensed Practical/Vocational Nurses (LPN/VN) | Assist the RN by performing routine, basic nursing care with predictable outcomes. (Read more details in the “Delegation and Supervision” chapter.) |
| Registered Nurses (RN) | Use the nursing process to assess, diagnose, identify expected outcomes, plan and implement interventions, and evaluate care according to the Nurse Practice Act of the state they are employed. |
| Charge Nurses or Nursing Supervisors | Supervise members of the nursing team and overall client care on the unit (or organization) to ensure quality, safe care is delivered. |
| Directors of Nursing (DON), Chief Nursing Officer (CNO), or Vice President of Patient Services | Ensure federal and state regulations and standards are being followed and are accountable for all aspects of client care. |
| Clinical Nurse Specialist (CNS) | Practice in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. |
| Nurse Practitioners (NP) or Advanced Practice Registered Nurses (APRN) | Work in a variety of settings and complete physical examinations, diagnose and treat common acute illness, manage chronic illness, order laboratory and diagnostic tests, prescribe medications and other therapies, provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance, and refer clients to other health professionals and specialists as needed. NPs have advanced knowledge with a graduate degree and national certification. |
| Certified Registered Nurse Anesthetists (CRNA) | Administer anesthesia and related care before, during, and after surgical, therapeutic, diagnostic, and obstetrical procedures, as well as provide airway management during medical emergencies. |
| Certified Nurse Midwives (CNM) | Provide gynecological exams, family planning guidance, prenatal care, management of low-risk labor and delivery, and neonatal care. |
| Medical Doctors (MD) | Licensed providers who diagnose, treat, and direct medical care. There are many types of physician specialists such as surgeons, pulmonologists, neurologists, cardiologists, nephrologists, pediatricians, and ophthalmologists. |
| Physician Assistants (PA) | Work under the direct supervision of a medical doctor as licensed and certified professionals following protocols based on the state in which they practice. |
| Doctors of Osteopathy (DO) | Licensed providers similar to medical physicians but with different educational preparation and licensing exams. They provide care, prescribe, and can perform surgeries. |
| Dieticians | Assess, plan, implement, and evaluate interventions related to specific dietary needs of clients, including regular or therapeutic diets. Formulate diets for clients with dysphagia or other physical disorders and provide dietary education such as diabetes education. |
| Physical Therapists (PT) | Develop and implement a plan of care as a licensed professional for clients with dysfunctional physical abilities, including joints, strength, mobility, gait, balance, and coordination. |
| Occupational Therapists (OT) | Plan, provide, and evaluate care for clients with dysfunction affecting their independence and ability to complete activities of daily living (ADLs). Assist clients in using adaptive devices to reach optimal levels of functioning and provide home safety assessments. |
| Speech Therapists (ST) | Develop and initiate a plan of care for clients diagnosed with communication and swallowing disorders. |
| Respiratory Therapists (RT) | Specialize in treating clients with respiratory disorders or conditions in collaboration with providers. Provide treatments such as CPAP, BiPAP, respiratory treatments and medications like aerosol nebulizers, chest physiotherapy, and postural drainage. They also intubate clients, assist with bronchoscopies, manage mechanical ventilation, and perform pulmonary function tests. |
| Social Workers (SW) | Provide a liaison between the community and the health care setting to ensure continuity of care after discharge. Assist clients with establishing community resources, health insurance, and advance directives. |
| Psychologists and Psychiatrists | Provide mental health services to clients in both acute and long-term settings. As physician specialists, psychiatrists prescribe medications and perform other medical treatments for mental health disorders. Psychologists focus on counseling. |
| Nurse Case Managers or Discharge Planners | Ensure clients are provided with effective and efficient medical care and services, during inpatient care and post-discharge, while also managing the cost of these services. |
The coordination and delivery of safe, quality client care demands reliable teamwork and collaboration across the organizational and community boundaries. Clients often have multiple visits across multiple providers working in different organizations. Communication failures between health care settings, departments, and team members is the leading cause of client harm.[10] The health care system is becoming increasingly complex requiring collaboration among diverse health care team members. For example, when a COPD exacerbation client is discharged from the acute care setting, their condition may necessitate home resources or care in order to optimize their recovery. This may require the coordination of home oxygen resources, a walker, or home visits in order to assess their transition and recovery. Nurses must understand that community resources are individualized to their regional area and advocating for client needs and resource gaps is an important part of their role.
The goal of good interprofessional collaboration is improved client outcomes, as well as increased job satisfaction of health care team professionals. Clients receiving care with poor teamwork are almost five times as likely to experience complications or death. Hospitals in which staff report higher levels of teamwork have lower rates of workplace injuries and illness, fewer incidents of workplace harassment and violence, and lower turnover.[11]
Valuing and understanding the roles of team members are important steps toward establishing good interprofessional teamwork. Another step is learning how to effectively communicate with interprofessional team members.
Community Resource Care Coordination Case Scenario
Patient Background
Name: Mr. Gerald Hermso
Age: 72
Medical History: Chronic Heart Failure (CHF), Hypertension, Type 2 Diabetes, Hyperlipidemia
Recent Hospitalization: Mr. Hermso was admitted to the hospital due to a CHF exacerbation characterized by shortness of breath, fatigue, and fluid retention. After stabilization with diuretics, beta-blockers, and lifestyle adjustments, Mr. Hermso is ready for discharge.
Discharge Planning Goals:
- Ensure Mr. Hermso's safe transition from hospital to home.
- Minimize the risk of readmission.
- Provide ongoing support for managing CHF at home.
Discharge Coordinator’s Role:
The discharge coordinator plays a crucial role in organizing Mr. Hermso's transition from the hospital to his home. This includes identifying and coordinating community resources that can support his ongoing care.
- Assessment of Needs: The coordinator reviews Mr. Hermso's medical records and discharge plan, including prescribed medications, follow-up appointments, dietary restrictions, and physical activity recommendations. The coordinator assesses Mr. Hermso's living situation. Does he live alone? Does he have any support systems such as family or friends who can assist him? Identify any potential barriers to Mr. Hermso managing his condition at home, such as mobility issues, medication management challenges, or limited access to transportation.
- Collaboration with Nursing Staff: The discharge coordinator collaborates with the nurse assigned to Mr. Hermso to ensure all his needs are met. The nurse provides insights into Mr. Hermso's physical and psychological readiness for discharge. Together, they develop a plan to address his needs post-discharge.
- Community Resources Identification: The discharge coordinator arranges for a home health nurse to visit Mr. Hermso several times a week to monitor his vital signs, administer medications, and provide education on CHF management. The coordinator sets up a service with a local pharmacy for medication delivery and synchronization, ensuring that Mr. Hermso receives his prescriptions on time. The nurse will teach Mr. Hermso how to use a pill organizer. A referral is made to a community dietitian who specializes in CHF to provide Mr. Hermso with personalized meal planning that aligns with his dietary restrictions. The coordinator arranges for Mr. Hermso to receive telehealth equipment, including a scale and blood pressure monitor, so that his weight and blood pressure can be monitored remotely. The nurse will educate Mr. Hermso on using this equipment. The coordinator refers Mr. Hermso to a local cardiac rehab program, where he can receive supervised exercise and education on heart health. If Mr. Hermso lacks transportation, the coordinator connects him with local transportation services that can take him to follow-up appointments and rehab sessions. The coordinator links Mr. Hermso with a local CHF support group where he can connect with others who have similar experiences, providing emotional and social support.
Nurse's Role:
- Patient Education: The nurse provides detailed education on CHF management, including recognizing early signs of exacerbation, the importance of medication adherence, dietary restrictions (e.g., low-sodium diet), and the need for regular physical activity. The nurse teaches Mr. Hermso how to use his new telehealth equipment and ensures he understands how to log and report his readings.
- Care Coordination: The nurse ensures that all community resources are in place before discharge. This includes confirming home health services, medication delivery, and transportation arrangements. The nurse reviews the discharge plan with Mr. Hermso and his family (if applicable) to ensure they understand the follow-up schedule and how to access the resources provided.
- Follow-up: The nurse schedules a follow-up call within 48 hours of discharge to check on Mr. Hermso’s progress, answer any questions, and address any emerging issues.
Outcome:
- Immediate Post-Discharge: Mr. Hermso transitions home with a solid support system in place. He has access to home health services, medication management, dietary support, and telehealth monitoring.
- Long-term Monitoring: Through consistent follow-up and engagement with community resources, Mr. Hermso is better equipped to manage his CHF at home, reducing the likelihood of readmission and improving his overall quality of life.
The third IPEC competency focuses on interprofessional communication and states, “Communicate with clients, families, communities, and professionals in health and other fields in a responsive and responsible manner that supports a team approach to the promotion and maintenance of health and the prevention and treatment of disease.”[12] See Figure 7.1[13] for an image of interprofessional communication supporting a team approach. This competency also aligns with The Joint Commission’s National Patient Safety Goal for improving staff communication.[14] See the following box for the components associated with the Interprofessional Communication competency.
Components of IPEC’s Interprofessional Communication Competency[15]
- Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function.
- Communicate information with clients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible.
- Express one’s knowledge and opinions to team members involved in client care and population health improvement with confidence, clarity, and respect, working to ensure common understanding of information, treatment, care decisions, and population health programs and policies.
- Listen actively and encourage ideas and opinions of other team members.
- Give timely, sensitive, constructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others.
- Use respectful language appropriate for a given difficult situation, crucial conversation, or conflict.
- Recognize how one’s uniqueness (experience level, expertise, culture, power, and hierarchy within the health care team) contributes to effective communication, conflict resolution, and positive interprofessional working relationships.
- Communicate the importance of teamwork in client-centered care and population health programs and policies.
Transmission of information among members of the health care team and facilities is ongoing and critical to quality care. However, information that is delayed, inefficient, or inadequate creates barriers for providing quality of care. Communication barriers continue to exist in health care environments due to interprofessional team members’ lack of experience when interacting with other disciplines. For instance, many novice nurses enter the workforce without experiencing communication with other members of the health care team (e.g., providers, pharmacists, respiratory therapists, social workers, surgical staff, dieticians, physical therapists, etc.). Additionally, health care professionals tend to develop a professional identity based on their educational program with a distinction made between groups. This distinction can cause tension between professional groups due to diverse training and perspectives on providing quality client care. In addition, a health care organization’s environment may not be conducive to effectively sharing information with multiple staff members across multiple units.
In addition to potential educational, psychological, and organizational barriers to sharing information, there can also be general barriers that impact interprofessional communication and collaboration. See the following box for a list of these general barriers.[16]
General Barriers to Interprofessional Communication and Collaboration[17]
- Personal values and expectations
- Personality differences
- Organizational hierarchy
- Lack of cultural humility
- Generational differences
- Historical interprofessional and intraprofessional rivalries
- Differences in language and medical jargon
- Differences in schedules and professional routines
- Varying levels of preparation, qualifications, and status
- Differences in requirements, regulations, and norms of professional education
- Fears of diluted professional identity
- Differences in accountability and reimbursement models
- Diverse clinical responsibilities
- Increased complexity of client care
- Emphasis on rapid decision-making
There are several national initiatives that have been developed to overcome barriers to communication among interprofessional team members. These initiatives are summarized in Table 7.5a.[18]
Table 7.5a. Initiatives to Overcome Barriers to Interprofessional Communication and Collaboration[19]
| Action | Description |
|---|---|
| Teach structured interprofessional communication strategies | Structured communication strategies, such as ISBARR, handoff reports, I-PASS reports, and closed-loop communication should be taught to all health professionals. |
| Train interprofessional teams together | Teams that work together should train together. |
| Train teams using simulation | Simulation creates a safe environment to practice communication strategies and increase interdisciplinary understanding. |
| Define cohesive interprofessional teams | Interprofessional health care teams should be defined within organizations as a cohesive whole with common goals and not just a collection of disciplines. |
| Create democratic teams | All members of the health care team should feel valued. Creating democratic teams (instead of establishing hierarchies) encourages open team communication. |
| Support teamwork with protocols and procedures | Protocols and procedures encouraging information sharing across the whole team include checklists, briefings, huddles, and debriefing. Technology and informatics should also be used to promote information sharing among team members. |
| Develop an organizational culture supporting health care teams | Agency leaders must establish a safety culture and emphasize the importance of effective interprofessional collaboration for achieving good client outcomes. |
Communication Strategies
Several communication strategies have been implemented nationally to ensure information is exchanged among health care team members in a structured, concise, and accurate manner to promote safe client care. Examples of these initiatives are ISBARR, handoff reports, closed-loop communication, and I-PASS. Documentation that promotes sharing information interprofessionally to promote continuity of care is also essential. These strategies are discussed in the following subsections.
ISBARR
A common format used by health care team members to exchange client information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat back.[20],[21]
- Introduction: Introduce your name, role, and the agency from which you are calling.
- Situation: Provide the client’s name and location, the reason you are calling, recent vital signs, and the status of the client.
- Background: Provide pertinent background information about the client such as admitting medical diagnoses, code status, recent relevant lab or diagnostic results, and allergies.
- Assessment: Share abnormal assessment findings and your evaluation of the current client situation.
- Request/Recommendations: State what you would like the provider to do, such as reassess the client, order a lab/diagnostic test, prescribe/change medication, etc.
- Repeat back: If you are receiving new orders from a provider, repeat them to confirm accuracy. Be sure to document communication with the provider in the client’s chart.
Nursing Considerations
Before using ISBARR to call a provider regarding a changing client condition or concern, it is important for nurses to prepare and gather appropriate information. See the following box for considerations when calling the provider.
Communication Guidelines for Nurses[22]
- Have I assessed this client before I call?
- Have I reviewed the current orders?
- Are there related standing orders or protocols?
- Have I read the most recent provider and nursing progress notes?
- Have I discussed concerns with my charge nurse, if necessary?
- When ready to call, have the following information on hand:
- Admitting diagnosis and date of admission
- Code status
- Allergies
- Most recent vital signs
- Most recent lab results
- Current meds and IV fluids
- If receiving oxygen therapy, current device and L/min
- Before calling, reflect on what you expect to happen as a result of this call and if you have any recommendations or specific requests.
- Repeat back any new orders to confirm them.
- Immediately after the call, document with whom you spoke, the exact time of the call, and a summary of the information shared and received.
Read an example of an ISBARR report in the following box.
Sample ISBARR Report From a Nurse to a Health Care Provider
I: “Hello Dr. Smith, this is Jane Smith, RN from the Med-Surg unit.”
S: “I am calling to tell you about Ms. White in Room 210, who is experiencing an increase in pain, as well as redness at her incision site. Her recent vital signs were BP 160/95, heart rate 90, respiratory rate 22, O2 sat 96% on room air, and temperature 38 degrees Celsius. She is stable but her pain is worsening.”
B: “Ms. White is a 65-year-old female, admitted yesterday post hip surgical replacement. She has been rating her pain at 3 or 4 out of 10 since surgery with her scheduled medication, but now she is rating the pain as a 7, with no relief from her scheduled medication of Vicodin 5/325 mg administered an hour ago. She is scheduled for physical therapy later this morning and is stating she won’t be able to participate because of the pain this morning.”
A: “I just assessed the surgical site, and her dressing was clean, dry, and intact, but there is 4 cm redness surrounding the incision, and it is warm and tender to the touch. There is moderate serosanguinous drainage. Her lungs are clear, and her heart rate is regular. She has no allergies. I think she has developed a wound infection.”
R: “I am calling to request an order for a CBC and increased dose of pain medication.”
R: “I am repeating back the order to confirm that you are ordering a STAT CBC and an increase of her Vicodin to 10/325 mg.”
View or print an ISBARR reference card.
Handoff Reports
Handoff reports are defined by The Joint Commission as “a transfer and acceptance of client care responsibility achieved through effective communication. It is a real-time process of passing client specific information from one caregiver to another, or from one team of caregivers to another, for the purpose of ensuring the continuity and safety of the client’s care.”[23] In 2017 The Joint Commission issued a sentinel alert about inadequate handoff communication that has resulted in client harm such as wrong-site surgeries, delays in treatment, falls, and medication errors.[24]
The Joint Commission encourages the standardization of critical content to be communicated by interprofessional team members during a handoff report both verbally (preferably face to face) and in written form. Critical content to communicate to the receiver in a handoff report includes the following components[25]:
- Sender contact information
- Illness assessment, including severity
- Client summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
- To-do action list
- Contingency plans
- Allergy list
- Code status
- Medication list
- Recent laboratory tests
- Recent vital signs
Several strategies for improving handoff communication have been implemented nationally, such as the Bedside Handoff Report Checklist, closed-loop communication, and I-PASS.
Bedside Handoff Report Checklist
See Figure 7.2[26] for an example of a Bedside Handoff Report Checklist to improve nursing handoff reports by the Agency for Healthcare Research and Quality (AHRQ).[27] Although a bedside handoff report is similar to an ISBARR report, it contains additional information to ensure continuity of care across nursing shifts.
Print a copy of the AHRQ Bedside Shift Report Checklist.[28]
Closed-Loop Communication
The closed-loop communication strategy is used to ensure that information conveyed by the sender is heard by the receiver and completed. Closed-loop communication is especially important during emergency situations when verbal orders are being provided as treatments are immediately implemented. See Figure 7.3[29] for an illustration of closed-loop communication.
- The sender initiates the message.
- The receiver accepts the message and repeats back the message to confirm it (i.e., “Cross-Check”).
- The sender confirms the message.
- The receiver notified the sender the task was completed (i.e., “Check-Back”).
See an example of closed-loop communication during an emergent situation in the following box.
Closed-Loop Communication Example
Doctor: "Administer 25 mg Benadryl IV push STAT."
Nurse: "Give 25 mg Benadryl IV push STAT?"
Doctor: "That's correct."
Nurse: "Benadryl 25 mg IV push given at 1125."
I-PASS
I-PASS is a mnemonic used to provide structured communication among interprofessional team members. I-PASS stands for the following components[30]:
I: Illness severity
P: Patient summary
A: Action list
S: Situation awareness and contingency plans
S: Synthesis by receiver (i.e., closed-loop communication)
See a sample I-PASS Handoff in Table 7.5b.[31]
Table 7.5b. Sample I-PASS Verbal Handoff[32]
| I | Illness Severity | This is our sickest client on the unit, and he's a full code. |
|---|---|---|
| P | Patient Summary | AJ is a 4-year-old boy admitted with hypoxia and respiratory distress secondary to left lower lobe pneumonia. He presented with cough and high fevers for two days before admission, and on the day of admission to the emergency department, he had worsening respiratory distress. In the emergency department, he was found to have a sodium level of 130 mg/dL likely due to volume depletion. He received a fluid bolus, and oxygen administration was started at 2.5 L/min per nasal cannula. He is on ceftriaxone. |
| A | Action List | Assess him at midnight to ensure his vital signs are stable. Check to determine if his blood culture is positive tonight. |
| S | Situations Awareness & Contingency Planning | If his respiratory distress worsens, get another chest radiograph to determine if he is developing an effusion. |
| S | Synthesis by Receiver | Ok, so AJ is a 4-year-old admitted with hypoxia and respiratory distress secondary to a left lower lobe pneumonia receiving ceftriaxone, oxygen, and fluids. I will assess him at midnight to ensure he is stable and check on his blood culture. If his respiratory status worsens, I will repeat a radiograph to look for an effusion. |
Listening Skills
Effective team communication includes both the delivery and receipt of the message. Listening skills are a fundamental element of the communication loop. For nursing staff, this involves listening to clients, families, and coworkers. Active listening involves not just hearing the individual words that someone states, but also understanding the emotions and concerns behind the words. Employing active listening reflects an empathetic approach and can improve client outcomes and foster teamwork.
Nurses often serve as the communication bridge between clients, families, and other health care team members. By listening attentively to colleagues, nurses can ensure that important information is accurately conveyed, reducing the risk of misunderstandings and enhancing the overall efficiency of care delivery. This collaborative environment fosters a culture of mutual respect and support, ultimately leading to better health care outcomes.
In order to develop active listening skills, individuals should practice mindfulness and practice their communication techniques. Listening skills can be cultivated with eye contact, actions such as nodding, and demonstration of other nonverbal strategies to demonstrate engagement. Maintaining an open posture, smiling, and attentiveness are all nonverbal strategies that can facilitate communication. It is important to take measures to avoid distractions, offer a summation of the communication, and ask clarifying questions to further develop the communication.
Documentation
Accurate, timely, concise, and thorough documentation by interprofessional team members ensures continuity of care for their clients. It is well-known by health care team members that in a court of law the rule of thumb is, “If it wasn’t documented, it wasn’t done.” Any type of documentation in the electronic health record (EHR) is considered a legal document. Abbreviations should be avoided in legal documentation and some abbreviations are prohibited. Please see a list of error prone abbreviations in the box below.
Read the current list of error-prone abbreviations by the Institute of Safe Medication Practices. These abbreviations should never be used when communicating medical information verbally, electronically, and/or in handwritten applications. Abbreviations included on The Joint Commission’s “Do Not Use” list are identified with a double asterisk (**) and must be included on an organization’s “Do Not Use” list.
Nursing staff access the electronic health record (EHR) to help ensure accuracy in medication administration and document the medication administration to help ensure client safety. Please see Figure 7.4[33] for an image of a nurse accessing a client’s EHR.
Electronic Health Record
The electronic health record (EHR) contains the following important information:
- History and Physical (H&P): A history and physical (H&P) is a specific type of documentation created by the health care provider when the client is admitted to the facility. An H&P includes important information about the client’s current status, medical history, and the treatment plan in a concise format that is helpful for the nurse to review. Information typically includes the reason for admission, health history, surgical history, allergies, current medications, physical examination findings, medical diagnoses, and the treatment plan.
- Provider orders: This section includes the prescriptions, or medical orders, that the nurse must legally implement or appropriately communicate according to agency policy if not implemented.
- Medication Administration Records (MARs): Medications are charted through electronic medication administration records (MARs). These records interface the medication orders from providers with pharmacists and are also the location where nurses document medications administered.
- Treatment Administration Records (TARs): In many facilities, treatments are documented on a treatment administration record.
- Laboratory results: This section includes results from blood work and other tests performed in the lab.
- Diagnostic test results: This section includes results from diagnostic tests ordered by the provider such as X-rays, ultrasounds, etc.
- Progress notes: This section contains notes created by nurses, providers, and other interprofessional team members regarding client care. It is helpful for the nurse to review daily progress notes by all team members to ensure continuity of care.
- Nursing care plans: Nursing care plans are created by registered nurses (RNs). Documentation of individualized nursing care plans is legally required in long-term care facilities by the Centers for Medicare and Medicaid Services (CMS) and in hospitals by The Joint Commission. Nursing care plans are individualized to meet the specific and unique needs of each client. They contain expected outcomes and planned interventions to be completed by nurses and other members of the interprofessional team. As part of the nursing process, nurses routinely evaluate the client’s progress toward meeting the expected outcomes and modify the nursing care plan as needed. Read more about nursing care plans in the “Planning” section of the “Nursing Process” chapter in Open RN Nursing Fundamentals, 2e.
Read the American Nurses Association’s Principles for Nursing Documentation.
Now that we have reviewed the first three IPEC competencies related to valuing team members, understanding team members’ roles and responsibilities, and using structured interprofessional communication strategies, let’s discuss strategies that promote effective teamwork. The fourth IPEC competency states, “Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate client/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable.”[34] See the following box for the components of this IPEC competency.
Components of IPEC’s Teams and Teamwork Competency[35]
- Describe the process of team development and the roles and practices of effective teams.
- Develop consensus on the ethical principles to guide all aspects of teamwork.
- Engage health and other professionals in shared client-centered and population-focused problem-solving.
- Integrate the knowledge and experience of health and other professions to inform health and care decisions, while respecting client and community values and priorities/preferences for care.
- Apply leadership practices that support collaborative practice and team effectiveness.
- Engage self and others to constructively manage disagreements about values, roles, goals, and actions that arise among health and other professionals and with clients, families, and community members.
- Share accountability with other professions, clients, and communities for outcomes relevant to prevention and health care.
- Reflect on individual and team performance for individual, as well as team, performance improvement.
- Use process improvement to increase effectiveness of interprofessional teamwork and team-based services, programs, and policies.
- Use available evidence to inform effective teamwork and team-based practices.
- Perform effectively on teams and in different team roles in a variety of settings.
Developing effective teams is critical for providing health care that is client-centered, safe, timely, effective, efficient, and equitable.[36] See Figure 7.5[37] for an image illustrating interprofessional teamwork.
Nurses collaborate with the interprofessional team by not only assigning and coordinating tasks, but also by promoting solid teamwork in a positive environment. A nursing leader, such as a charge nurse, identifies gaps in workflow, recognizes when task overload is occurring, and promotes the adaptability of the team to respond to evolving client conditions. Qualities of a successful team are described in the following box.[38]
Qualities of A Successful Team[39]
- Promote a respectful atmosphere
- Define clear roles and responsibilities for team members
- Regularly and routinely share information
- Encourage open communication
- Implement a culture of safety
- Provide clear directions
- Share responsibility for team success
- Balance team member participation based on the current situation
- Acknowledge and manage conflict
- Enforce accountability among all team members
- Communicate the decision-making process
- Facilitate access to needed resources
- Evaluate team outcomes and adjust as needed
TeamSTEPPS®
TeamSTEPPS® is an evidence-based framework used to optimize team performance across the health care system. It is a mnemonic standing for Team Strategies and Tools to Enhance Performance and Patient Safety. The Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD) developed the TeamSTEPPS® framework as a national initiative to improve client safety by improving teamwork skills and communication.[40]
View this video about the TeamSTEPPS® framework[41]:
TeamSTEPPS® is based on establishing team structure and four teamwork skills: communication, leadership, situation monitoring, and mutual support.[42] See Figure 7.6[43] for an image of the TeamSTEPPS® framework followed by a description of each TeamSTEPPS® skill. The components of this model are described in the following subsections.
Team Structure
A nursing leader establishes team structure by assigning or identifying team members' roles and responsibilities, holding team members accountable, and including clients and families as part of the team.
Communication
Communication is the first skill of the TeamSTEPPS® framework. As previously discussed, it is defined as a “structured process by which information is clearly and accurately exchanged among team members.” All team members should use these skills to ensure accurate interprofessional communication:
- Provide brief, clear, specific, and timely information to other team members.
- Seek information from all available sources.
- Use ISBARR and handoff techniques to communicate effectively with team members.
- Use closed-loop communication to verify information is communicated, understood, and completed.
- Document appropriately to facilitate continuity of care across interprofessional team members.
These communication strategies are further described in the “Interprofessional Communication” section of this chapter.
Leadership
Leadership is the second skill of the TeamSTEPPS® framework. As previously discussed, it is defined as the “ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources.” An example of a nursing team leader in an inpatient setting is the charge nurse.
Effective team leaders demonstrate the following responsibilities[44]:
- Organize the team.
- Identify and articulate clear goals (i.e., share the plan).
- Assign tasks and responsibilities.
- Monitor and modify the plan and communicate changes.
- Review the team's performance and provide feedback when needed.
- Manage and allocate resources.
- Facilitate information sharing.
- Encourage team members to assist one another.
- Facilitate conflict resolution in a learning environment.
- Model effective teamwork.
Three major leadership tasks include sharing a plan, monitoring and modifying the plan according to situations that occur, and reviewing team performance. Tools to perform these tasks are discussed in the following subsections.
Sharing the Plan
Nursing team leaders identify and articulate clear goals to the team at the start of the shift during inpatient care using a “brief.” The brief is a short session to share a plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, and anticipate outcomes and contingencies. See a Brief Checklist in the following box with questions based on TeamSTEPPS®.[45]
Brief Checklist
During the brief, the team should address the following questions[46]:
___ Who is on the team?
___ Do all members understand and agree upon goals?
___ Are roles and responsibilities understood?
___ What is our plan of care?
___ What are staff and provider's availability throughout the shift?
___ How is workload shared among team members?
___ Who are the sickest clients on the unit?
___ Which clients have a high fall risk or require 1:1?
___ Do any clients have behavioral issues requiring consistent approaches by the team?
___ What resources are available?
Monitoring and Modifying the Plan
Throughout the shift, it is often necessary for the nurse leader to modify the initial plan as client situations change on the unit. A huddle is a brief meeting before and/or during a shift to establish situational awareness, reinforce plans already in place, and adjust the teamwork plan as needed. Read more about situational awareness in the “Situation Monitoring” subsection below.
Reviewing the Team's Performance
When a significant or emergent event occurs during a shift, such as a “code,” it is important to later review the team’s performance and reflect on lessons learned by holding a “debrief” session. A debrief is an informal information exchange session designed to improve team performance and effectiveness through reinforcement of positive behaviors and reflection on lessons learned.[47] See the following box for a Debrief Checklist.
Debrief Checklist[48]
The team should address the following questions during a debrief:
___ Was communication clear?
___ Were roles and responsibilities understood?
___ Was situation awareness maintained?
___ Was workload distribution equitable?
___ Was task assistance requested or offered?
___ Were errors made or avoided?
___ Were resources available?
___ What went well?
___ What should be improved?
Situation Monitoring
Situation monitoring is the third skill of the TeamSTEPPS® framework and defined as the “process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning.” Situation monitoring refers to the process of continually scanning and assessing the situation to gain and maintain an understanding of what is going on around you. Situation awareness refers to a team member knowing what is going on around them. The team leader creates a shared mental model to ensure all team members have situation awareness and know what is going on as situations evolve. The STEP tool is used by team leaders to assist with situation monitoring.[49]
STEP
The STEP tool is a situation monitoring tool used to know what is going on with you, your clients, your team, and your environment. STEP stands for Status of the clients, Team members, Environment, and Progress toward goal. See an illustration of STEP in Figure 7.7.[50] The components of the STEP tool are described in the following box.[51]
STEP Tool[52]
Status of Clients: “What is going on with your clients?”
__ Patient History
__ Vital Signs
__ Medications
__ Physical Exam
__ Plan of Care
__ Psychosocial Issues
Team Members: “What is going on with you and your team?”(See the “I’M SAFE Checklist” below.)
__ Fatigue
__ Workload
__ Task Performance
__ Skill
__ Stress
Environment: Knowing Your Resources
__ Facility Information
__ Administrative Information
__ Human Resources
__ Triage Acuity
__ Equipment
Progression Towards Goal:
__ Status of the Team's Clients
__ Established Goals of the Team
__ Tasks/Actions of the Team
__ Appropriateness of the Plan and are Modifications Needed?
Cross-Monitoring
As the STEP tool is implemented, the team leader continues to cross monitor to reduce the incidence of errors. Cross-monitoring includes the following[53]:
- Monitoring the actions of other team members.
- Providing a safety net within the team.
- Ensuring that mistakes or oversights are caught quickly and easily.
- Supporting each other as needed.
I’M SAFE Checklist
The I’M SAFE mnemonic is a tool used to assess one’s own safety status, as well as that of other team members in their ability to provide safe client care. See the I’M SAFE Checklist in the following box.[54] If a team member feels their ability to provide safe care is diminished because of one of these factors, they should notify the charge nurse or other nursing supervisor. In a similar manner, if a nurse notices that another member of the team is impaired or providing care in an unsafe manner, it is an ethical imperative to protect clients and report their concerns according to agency policy.[55]
I’m SAFE Checklist[56]
__ I: Illness
__M: Medication
__S: Stress
__A: Alcohol and Drugs
__F: Fatigue
__E: Eating and Elimination
Read an example of a nursing team leader performing situation monitoring using the STEP tool in the following box.
Example of Situation Monitoring
Two emergent situations occur simultaneously on a busy medical-surgical hospital unit as one client codes and another develops a postoperative hemorrhage. The charge nurse is performing situation monitoring by continually scanning and assessing the status of all clients on the unit and directing additional assistance where it is needed. Each nursing team member maintains situation awareness by being aware of what is happening on the unit, in addition to caring for the clients they have been assigned. The charge nurse creates a shared mental model by ensuring all team members are aware of their evolving responsibilities as the situation changes. The charge nurse directs additional assistance to the emergent clients while also ensuring appropriate coverage for the other clients on the unit to ensure all clients receive safe and effective care.
For example, as the “code” is called, the charge nurse directs two additional nurses and two additional assistive personnel to assist with the emergent clients while the other nurses and unlicensed assistive personnel are directed to “cover” the remaining clients, answer call lights, and assist clients to the bathroom to prevent falls. Additionally, the charge nurse is aware that after performing a few rounds of CPR for the coding client, the unlicensed assistive personnel must be switched with another team member to maintain effective chest compressions. As the situation progresses, the charge nurse evaluates the status of all clients and makes adjustments to the plan as needed.
Mutual Support
Mutual support is the fourth skill of the TeamSTEPPS® framework and defined as the “ability to anticipate and support team members' needs through accurate knowledge about their responsibilities and workload.” Mutual support includes providing task assistance, giving feedback, and advocating for client safety by using assertive statements to correct a safety concern. Managing conflict is also a component of supporting team members’ needs.
Task Assistance
Helping other team members with tasks builds a strong team. Task assistance includes the following components[57]:
- Team members protect each other from work-overload situations.
- Effective teams place all offers and requests for assistance in the context of client safety.
- Team members foster a climate where it is expected that assistance will be actively sought and offered.
Example of Task Assistance
In a previous example, one client on the unit was coding while another was experiencing a postoperative hemorrhage. After the emergent care was provided and the hemorrhaging client was stabilized, Sue, the nurse caring for the hemorrhaging client, finds many scheduled medications for her other clients are past due. Sue reaches out to Sam, another nurse on the team, and requests assistance. Sam agrees to administer a scheduled IV antibiotic to a stable third client so Sue can administer oral medications to her remaining clients. Sam knows that on an upcoming shift, he may need to request assistance from Sue when unexpected situations occur. In this manner, team members foster a climate where assistance is actively sought and offered to maintain client safety.
Feedback
Feedback is provided to a team member for the purpose of improving team performance. Effective feedback should follow these parameters[58]:
- Timely: Provided soon after the target behavior has occurred.
- Respectful: Focused on behaviors, not personal attributes.
- Specific: Related to a specific task or behavior that requires correction or improvement.
- Directed towards improvement: Suggestions are made for future improvement.
- Considerate: Team members’ feelings should be considered and privacy provided. Negative information should be delivered with fairness and respect.
Advocating for Safety with Assertive Statements
When a team member perceives a potential client safety concern, they should assertively communicate with the decision-maker to protect client safety. This strategy holds true for ALL team members, no matter their position within the hierarchy of the health care environment. The message should be communicated to the decision-maker in a firm and respectful manner using the following steps[59]:
- Make an opening.
- State the concern.
- State the problem (real or perceived).
- Offer a solution.
- Reach agreement on next steps.
Examples of Using Assertive Statements to Promote Client Safety
A nurse notices that a team member did not properly wash their hands during client care. Feedback is provided immediately in a private area after the team member left the client room: “I noticed you didn’t wash your hands when you entered the client’s room. Can you help me understand why that didn’t occur?” (Wait for an answer.) “Performing hand hygiene is essential for protecting our clients from infection. It is also hospital policy, and we are audited for compliance to this policy. Let me know if you have any questions and I will check back with you later in the shift.” (Monitor the team member for appropriate hand hygiene for the remainder of the shift.)
Two-Challenge Rule
When an assertive statement is ignored by the decision-maker, the team member should assertively voice their concern at least two times to ensure that it has been heard by the decision-maker. This strategy is referred to as the two-challenge rule. When this rule is adopted as a policy by a health care organization, it empowers all team members to pause care if they sense or discover an essential safety breach. The decision-maker being challenged is expected to acknowledge the concern has been heard.[60]
CUS Assertive Statements
During emergent situations, when stress levels are high or when situations are charged with emotion, the decision-maker may not “hear” the message being communicated, even when the two-challenge rule is implemented. It is helpful for agencies to establish assertive statements that are well-recognized by all staff as implementation of the two-challenge rule. These assertive statements are referred to as the CUS mnemonic: “I am Concerned - I am Uncomfortable - This is a Safety issue!”[61] See Figure 7.8[62] for an illustration of CUS assertive statements.
Using these scripted messages may effectively catch the attention of the decision-maker. However, if the safety issue still isn’t addressed after the second statement or the use of “CUS” assertive statements, the team member should take a stronger course of action and utilize the agency’s chain of command. For the two-challenge rule and CUS assertive statements to be effective within an agency, administrators must support a culture of safety and emphasize the importance of these initiatives to promote client safety.
Read an example of a nurse using assertive statements in the following box.
Assertive Statement Example
A nurse observes a new physician resident preparing to insert a central line at a client’s bedside. The nurse notes the resident has inadvertently contaminated the right sterile glove prior to insertion.
Nurse: “Dr. Smith, I noticed that you contaminated your sterile gloves when preparing the sterile field for central line insertion. I will get a new set of sterile gloves for you.”
Dr. Smith: (Ignores nurse and continues procedure.)
Nurse: “Dr. Smith, please pause the procedure. I noticed that you contaminated your right sterile glove by touching outside the sterile field. I will get a new set of sterile gloves for you.”
Dr. Smith: “My gloves are fine.” (Prepares to initiate insertion.)
Nurse: “Dr. Smith - I am concerned! I am uncomfortable! This is a safety issue!”
Dr. Smith: (Stops procedure, looks up, and listens to the nurse.) “I’ll wait for that second pair of gloves.”
Managing Conflict
Conflict is not uncommon on interprofessional teams, especially when there are diverse perspectives from multiple staff regarding client care. Nurse leaders must be prepared to manage conflict to support the needs of their team members.
When conflict occurs, the DESC tool can be used to help resolve conflict by using “I statements.” DESC is a mnemonic that stands for the following[63]:
- D: Describe the specific situation or behavior; provide concrete data.
- E: Express how the situation makes you feel/what your concerns are using “I” statements.
- S: Suggest other alternatives and seek agreement.
- C: Consequences stated in terms of impact on established team goals while striving for consensus.
The DESC tool should be implemented in a private area with a focus on WHAT is right, not WHO is right. Read an example of a nurse using the DESC tool in the following box.
Example of Using the DESC Tool[64]
Situation: A physician became angry at a nurse who was inserting a client’s Foley catheter and yelled at the nurse in front of the client and other team members. The nurse later addressed the physician in a private area outside the client’s room using the DESC tool and “I statements”:
D: “I noticed you got angry at me when I inserted the client’s Foley catheter.”
E: “I’m concerned how you addressed that issue in front of the client and three other staff members. It made me feel bad in front of the client and my colleagues.”
S: “In the future, if you have an issue with how I do things, please pull me aside privately to discuss your concern.”
C: “Our organization has a policy for managing communication challenges among team members if we can’t agree on this alternative.”
Managing interpersonal conflict resolution is described further in the “Conflict Resolution” section.
View a supplementary detailed video webinar from AHRQ describing the TeamSTEPPS® principles at youtu.be/fxlRtpzsUug.[65]
Team Qualitities Case Application (Answers can be found at the end of book)
Mary is recovering from a stroke and requires comprehensive care involving multiple disciplines. Her care team has scheduled interdisciplinary team meetings twice a week to discussion Mary's progress, adjust her care plan, and address any concerns. Dr. Patel is Mary's primary physician and consults with Chris (physical therapist) and Emily (speech therapist) before making any changes to Mary's medication that might affect her therapy sessions. Chris and Emily coordinate their therapy schedules to help maximize Mary's participation and avoid conflicting sessions and fatigue. Laura is Mary's social worker and has a large roster of clients. Laura struggles to include Mary's family in the discharge planning discussions but feels that she has identified an appropriate facility that Mary and her family will be receptive to for discharge. She moves forward with the client placement paperwork. Lisa is Mary's dietician, and she has identified a dietary plan that will best contribute to Mary's nutritional needs and healing. She acknowledges that Mary's dietary preferences are much different than what she has selected in her dietary plan, but Lisa knows that she has identified the best dietary plan to meet Mary's energy needs.
Identify which team members are demonstrating team success strategies and how they are demonstrated?
Which team members are not demonstrating team success strategies? How could these team members modify their approach?
Conflicts are inevitable when working on a team composed of members with different personalities, roles, and responsibilities. It is essential for all nurses to develop conflict resolution skills.
Common Sources of Interpersonal Conflict
Common sources of interpersonal conflict in health care settings are passive-aggressiveness, horizontal aggression, defensiveness, peer informer behavior, and victimization behaviors.[66]
Passive-Aggressiveness
Passive-aggressiveness is a behavior that shows disconnection between what a person says and does. Many times, a passive-aggressive person will agree with another person’s request, but later express feelings of frustration or anger to others and not comply with the request.
As an example, a charge nurse informs the team of RNs in a team meeting that a new policy requires bedside rounding. A nurse responds enthusiastically during the meeting but then complains to others about the policy and refuses to do it. The best method of managing passive-aggressive behavior is to confront it calmly and directly. For this example, it would be helpful for the charge nurse to say, “I was disappointed to hear you are upset about the new bedside rounding policy because you didn’t express any concerns directly to me. It would be helpful for you to directly communicate concerns to me so we can discuss them and make a plan for going forward.”[67]
Horizontal Aggression
The nursing literature describes diffuse incivility, lateral/horizontal violence, and bullying among nurses in the workplace.[68] Horizontal aggression refers to hostile behavior among one’s peers. It is not acceptable and should be directly confronted in a constructive manner or it will get worse. A suggested approach to a peer displaying horizontal aggression is to respond calmly and sincerely, “I value your expertise and experience and am looking for your help and support.” If the negative behavior continues after an attempt to address the individual directly, the nurse supervisor should be notified according to the agency’s chain of command.[69]
Defensiveness
It can be difficult to receive negative feedback. Some people respond by becoming defensive. Defensiveness puts the blame for one’s shortcomings on another person to make oneself appear better.
As an example, a charge nurse addresses a nurse about not turning on the bed alarm after repositioning a client and leaving the room. The nurse responds defensively by inaccurately blaming others, stating, “The nursing assistants are always sloppy with their responsibilities.” It is helpful to confront defensiveness by restating the facts in a calm manner and redirecting the conversation to the problem, its resolution, and the risk of jeopardizing client safety. For example, the charge nurse could reply, “In this situation, I saw you leave the room after repositioning the client, and when I went into the room to answer the client’s call light, the bed alarm was off.”[70]
Peer Informer Behavior
Peer informer behavior is similar to gossip. Peer informers relay information about fellow team members to the nurse leader, and this information often lacks objective evidence. It is often best to respond to the informer by asking them to speak to their team member directly about their concerns unless it is an urgent matter that must be dealt with immediately. However, keep in mind that if concerns are shared about a staff member by more than one team member, it may be a pattern of behavior, and the nurse leader should follow up with that staff member.[71]
As an example, a nurse approaches the charge nurse and says, “Everyone is concerned about how much time Nancy is spending in the room with her clients. She gets behind in her work and the rest of us have to make up for it.” The charge nurse could reply, “Have you addressed your concerns directly with Nancy?” If the nurse replies, “No,” then the charge nurse could state, “Please talk to Nancy directly with your concerns first.” However, if another nurse shares a similar concern with the charge nurse, then the charge nurse should address this pattern of behavior with Nancy and obtain her perspective.
Victimization
Victimization occurs when a team member feels they are being singled out unfairly or held to higher expectations than their peers. Comments may include, “Why am I getting called out on this when other people are doing this and aren’t getting in trouble?” or “I was never told this; why am I always the last to know?” Team members who feel victimized should be reminded by the nurse leader they are held to the same standards as the other members. However, keep in mind that sharing information about other staff members’ performance breaches confidentiality, so do not include another employees’ performance information in conversations but instead focus on policies and procedures that apply to everyone.[72]
Types of Conflict
There are various sources of conflict that nurses may encounter in their work environment.
Role Conflict: Role conflict arises when individuals have multiple, often conflicting, expectations associated with their roles. In professional settings, an employee may face role conflict when their job responsibilities are unclear or when there are conflicting demands from different supervisors. For example, a project manager might experience tension if their role requires them to enforce strict deadlines while also being expected to accommodate frequent changes in project scope. This type of conflict can lead to stress, decreased job satisfaction, and reduced productivity. Role conflict can be mitigated by clear communication, well-defined job descriptions, and regular feedback to ensure alignment of expectations.[73]
Communication Conflict: Communication conflict occurs when there is a failure in the exchange of information. Misunderstandings, misinterpretations, and lack of effective communication can lead to disputes and frustrations. For instance, in a team setting, if one member interprets a directive differently from others, it can result in duplicated efforts or missed tasks. Communication conflict is often exacerbated by differences in communication styles, cultural backgrounds, or language barriers. Addressing this type of conflict involves fostering an environment of open and clear communication, utilizing active listening techniques, and ensuring that all parties have a mutual understanding of the messages being conveyed.[74]
Goal Conflict: Goal conflict happens when the objectives of individuals or groups are incompatible. In organizations, different departments might pursue goals that are in opposition, such as a sales team aiming for maximum customer satisfaction while a production team focuses on minimizing costs. These conflicting goals can hinder overall progress and lead to tension among team members. To resolve goal conflicts, it is crucial to align individual and departmental goals with the broader objectives of the organization. This can be achieved through strategic planning, cross-functional collaboration, and regular goal-setting meetings that ensure all efforts are directed towards a common purpose.[75]
Personality Conflict: Personality conflict arises from differences in individual temperaments, attitudes, and behaviors. Such conflicts are common in any setting where diverse personalities interact, such as workplaces, schools, or social groups. For example, a highly extroverted person might clash with a reserved colleague, leading to friction in their interactions. Personality conflicts can negatively impact team cohesion and productivity. Managing these conflicts involves fostering a culture of respect and understanding, providing training in emotional intelligence and conflict resolution, and encouraging individuals to appreciate and leverage the strengths of diverse personalities.[76]
Ethical/Values Conflict: Ethical or values conflict occurs when individuals or groups have fundamentally different beliefs and values. These conflicts are often deeply rooted and can be particularly challenging to resolve. In a corporate environment, an ethical conflict might arise if one employee believes in strict adherence to company policies while another prioritizes flexibility and personal judgment. Values conflicts can also occur over issues such as diversity, environmental responsibility, and corporate social responsibility. Addressing ethical or values conflicts requires creating an environment of mutual respect, where different perspectives are valued. Organizations can benefit from having clear ethical guidelines and fostering an inclusive culture that encourages open dialogue and ethical decision-making.[77]
Conflict Management
Individuals manage conflict differently. During conflict, a person’s behavior is typically driven by their commitment to their goals or their commitment to relationships[78]:
- Commitment to goals: The extent to which an individual attempts to satisfy their personal concerns or goals.
- Commitment to relationships: The extent to which an individual attempts to satisfy the concerns of another party or maintain the relationship with the other party.
Most people use different methods to resolve conflict depending on the situation and what strategy best applies. One approach is not necessarily better than another, and all approaches can be learned and used effectively with practice. However, to effectively manage conflict, it is important to first analyze the situation and then respond accordingly.
A long-standing conflict resolution model created by Thomas and Killmann describes five approaches to dealing with conflict: avoiding, competing, accommodating, compromising, and collaborating. Each of these steps is further described in the following subsections.[79]
Avoidance Approach
An avoidance approach to conflict resolution demonstrates a low commitment to both goals and relationships. This is the most common method of dealing with conflict, especially by people who view conflict negatively. See Table 7.7a for types of avoidance, potential results, and situations when this strategy may be appropriate.[80]
Table 7.7a. Avoidance Approach[81]
| Types of Avoidance Approaches | Potential Results | Appropriate Use |
|---|---|---|
|
|
|
Application to Nursing
In a clinical setting, there may be times when it is appropriate to avoid confrontation. For example, on a particularly busy day in the emergency department, a client in a life-threatening condition was recently received. The attending physician shouts orders to the nurse in a disrespectful manner. The nurse avoids addressing the conflict until after the client has been stabilized and then shares their concerns. However, if the physician continues to bark orders to nursing staff in nonemergency situations, avoidance is no longer appropriate, and the conflict must be addressed to establish a positive and respectful working environment.[82]
Competitive Approach
A competitive approach to conflict management demonstrates a high commitment to goals and a low commitment to relationships. Individuals who use the competitive approach pursue their goals at other individuals’ expense and will use whatever power is necessary to win. A competitive approach may be displayed when an individual defends an action, belief, interest, or value they believe to be correct. Competitive approaches may also be supported by infrastructure (agency promotion procedures, courts of law, legislature, etc.).[83] See Table 7.7b for types of competitive approaches, potential results, and appropriate uses.
Table 7.7b. Competitive Approach[84]
| Types of Competitive Approaches | Potential Results | Appropriate Use |
|---|---|---|
|
|
|
Application to Nursing
A competitive approach to conflict resolution may be appropriate in a clinical setting if a nurse leader realizes a nurse has made an error while preparing to administer IV medication to a client. The nurse leader may stop the nurse from inaccurately administering the medication and take over completing the procedure. In this case, the goal of client safety outweighs the commitment to the relationship with that nurse. However, after client safety is maintained, it would be inappropriate to continue the competitive approach when debriefing the nurse about a simple human error. Debriefing should focus on educating the nurse about policy and procedures to improve their performance. However, if it is determined the nurse was acting recklessly and disciplinary measures must be instituted by a manager, then the competitive approach may be appropriate.[85] This approach to responding to errors is often referred to as “Just Culture.”
Read more about Just Culture in the “Legal Implications” chapter.
Accommodating Approach
An accommodating approach to conflict management demonstrates a low commitment to goals and high commitment to relationships. This approach is the opposite of the competitive approach. It occurs when a person ignores or overrides their own concerns to satisfy the concerns of the other party. An accommodating approach is often used to establish reciprocal adaptations or adjustments, but when the other party does not reciprocate, conflict can result. Accommodators typically do not ask for anything in return but can become resentful when a reciprocal relationship isn’t established. If resentment grows, individuals relying on the accommodating approach may shift to a competitive approach from a feeling of “being used” that can lead to conflict.[86] See Table 7.7c for types of the accommodating approach, potential results, and appropriate uses.
Table 7.7c. Accommodating Approach[87]
| Types of Accommodating Approaches |
Potential Results | Appropriate Use |
|---|---|---|
|
|
|
Application to Nursing
It may be appropriate to use an accommodating approach when one of the nurses on your team has a challenging client who is taking up a lot of time and effort. By being situationally aware and noticing the nurse has been involved in that client’s room for a long period of time, you offer to provide task assistance in an effort to provide mutual support. You are aware this will increase your workload for a short period of time, but it will assist your colleague and promote a strong team. However, the accommodating approach is no longer appropriate if the nurse continues to expect you to cover their tasks after the situation has been resolved.[88]
Compromising Approach
A compromising approach to conflict resolution strikes a balance between commitment to goals and commitment to relationships. The objective of a compromising approach is a quick solution that will work for both parties. It typically involves both parties giving up something in return for something, thereby “meeting in the middle."[89] See Table 7.7d for types of compromising approaches, potential results, and appropriate uses.
Table 7.7d. Compromising Approach
| Types of Compromising Approaches |
Potential Results | Appropriate Use |
|---|---|---|
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|
|
Application to Nursing
Compromise is an appropriate approach to conflict in many clinical settings. For example, you are working with another nurse who rarely assists other team members. The nurse asks you for assistance with a blood draw for a client. You hesitate because you are searching for a lunch tray that has not yet been delivered for a client with diabetes. You ask your colleague to obtain the client’s lunch tray while you complete their request for assistance with a blood draw. It would be inappropriate to refuse to assist the nurse based on their reputation because this could impact safe, effective care for the client.[90]
Collaborative Approach
The collaborative approach to conflict resolution demonstrates a high commitment to goals, as well as a high commitment to relationships. The collaborative approach attempts to meet the concerns and priorities of all parties, but trust and willingness for risk are required for this approach to be effective.[91] See Table 7.7e for types of collaborative approaches, potential results, and appropriate uses.
Table 7.7e. Collaborative Approach[92]
| Type of Collaborative Approaches |
Potential Results | Appropriate Use |
|---|---|---|
|
|
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Application to Nursing
An example of appropriately using the collaborative approach in conflict management in a clinical setting is when discussing vacation time off with team members. During a team meeting, time is available to discuss and focus on what is important and a priority for each member of the team. However, the collaborative approach to conflict management would be inappropriate when discussing the implementation of a new agency policy if the team has little influence in making adjustments.[93]
All approaches to conflict can be appropriate for specific situations, but they can also be inappropriate or overused. When conflict occurs, take time to consider which approach is most beneficial for the situation. Keep in mind that using wrong approaches can escalate conflict, damage relationships, and reduce your ability to effectively meet team goals. Correct conflict management approaches build trust in relationships, accomplish goals, and de-escalate conflict.[94]
Everyone has the capacity to use any of these approaches for managing conflict and can shift from their natural style as needed. We tend to react with our most dominant natural style when under stress, but other approaches can be learned and applied with practice and self-awareness. When dealing with others who have not developed their capacity to shift from their natural style of conflict management, it is important to consider their underlying needs. By understanding individuals’ needs existing beneath the surface of the conflict, you can work with the other person toward achieving a common goal.[95]
Addressing Individual Needs and Approaches
There are times when other individuals take an approach that is not helpful to resolving the conflict. It is important to remember the only person you can control during a conflict is yourself. Be flexible with your approach according to the situation and the team members with whom you are working. If someone is taking an approach that is not beneficial to resolving conflict, it can be helpful to try to understand the needs that underlie their decision to take that approach.[96]
Here are some examples of needs underlying their approaches to conflict and suggested ways to address them[97]:
- People using the avoidance approach may need to feel physically and emotionally safe. Take the time to reassure them that their needs will be heard.
- People taking the competitive approach often feel the need for something to be accomplished to meet their goals. It may be helpful to say, “We will work out a solution, but it may take some time to get there.”
- People using the accommodating approach may need to know that no matter what happens during the conversation, your relationship will remain intact. It may be helpful to say, “This decision will not affect our relationship or how we work together.”
- People using the compromising approach may need to know that they will get something in return. It may be helpful to say, “We will do Action A first, and then we will do Action B for you.” However, be sure to be true to your word.
- People using the collaborative approach may need to know what you want before they are comfortable sharing their needs. It may be helpful to say, “I need this, this, and this...What do you need?”
Take free online Conflict Quizzes and Assessments to identify your preferred conflict management styles.
Escalating and De-Escalating Conflict
An approach taken to manage conflict can escalate (increase) or de-escalate (decrease) the conflict. Conflict on a team can take a life of its own and escalate beyond reason if not managed appropriately by nurse leaders. When conflict is not managed appropriately, negative consequences within the team often occur, and client safety can be compromised. Increased rates of absenteeism and turnover may also occur.[98]
Conflict tends to escalate under the following conditions[99]:
- There is an increase in emotions like anger, frustration, etc.
- An individual feels that they are being threatened (i.e., the fight-or-flight response is triggered).
- Other people get involved and choose sides.
- The individuals were not friendly prior to the conflict.
- The individuals desire to engage in conflict.
However, conflict can be de-escalated under the following conditions[100]:
- Attention is focused on solving the problem.
- There is a decrease in emotion and perceived threat.
- The individuals were friendly prior to the conflict.
- The individuals desire to reduce conflict.
Read an example of escalating conflict in the following box.
Example of Escalating Conflict[101]
A conflict begins between two team members who became short-tempered with each other while caring for a client experiencing a medical emergency.
- The parties become aware of the conflict but attempt to deal with it sensibly. Often, they will attribute the problem to “a misunderstanding” and indicate “we can work it out.”
- If an appropriate conflict management approach is not used, the parties begin to move from cooperation to competition. (“I’ll bend - but only if they bend first.”) They begin to view the conflict as resulting from deliberate action on the part of the other. (“Didn’t they know this was going to happen?”) Positions begin to harden and defensiveness sets in, creating adversarial encounters. Parties begin to strengthen their positions and look to others on the team for support. (“Don’t you feel I’m being reasonable?” or “Did you know what that idiot did to me?”)
- As communication deteriorates, parties rely on assumptions about the other individual and attribute negative motives to them. (“I bet they did that on purpose.”) Groupthink can take over the subgroups as each individual seeks others to take on their side. (“We have to appear strong and make a united front.”)
- Parties believe that cooperation cannot resolve the problem because of the assumed negative actions of the other. (“I’ve tried everything to get them to see reason,” “It’s time to get tough,” or “I’m going to put a stop to this.”)
- Parties begin to feel righteous and blame the other for the entire problem. Generalizing and stereotyping begin. (“I know what those kinds of people are like. . . We can’t let them get away with this.”) Parties begin to be judgmental and moralistic and believe they are defending what is “right.” (“It’s the principle of the matter” or “What will others say if we give in to this?”)
- Severe confrontation is anticipated and planned, thus making it inevitable. The parties view this confrontation as acceptable. The objective of the conflict becomes to hurt the other more than being hurt, and the dispute is beyond rational analysis. (“I’m going to make you pay even if we both go down over this,” “There is no turning back now,” or “They won’t make a fool out of me.”)
There are positive steps to take to de-escalate conflict with another individual before it gets out of control. See Figure 7.9[102] for steps to de-escalate conflict and implement change.
Conflict Management Tips
Nurses must develop their own tool kit to manage conflict in a productive, positive way. Due to rapid turnover in the health care environment at this time, new nurses may find themselves in a "charge nurse" position within their first year of practice. See Table 7.7f for tips on managing conflict constructively.[103]
Table 7.7f. Conflict Management Tips[104]
| Tip | Description |
|---|---|
| Be Consistent | Convey to the team that expectations are consistent and implemented fairly across the team. Set expectations and make sure the team knows those expectations via department meetings and visual reminders. Follow up to ensure expectations are met. This sets a clear picture of what is required. |
| Be Team-Focused | Be aware of team members' strengths and weaknesses. Address poor performance and negative attitudes. Teamwork and team dynamics impact client safety and staff retention. Ask team members what they need from you as a leader. Coach team members and staff on a regular basis. |
| Convey Trust and Integrity | Trustworthiness and integrity are powerful when managing conflict. Team members are more likely to handle difficult situations constructively if they know they are supported by an approachable and supportive team leader. Stay focused on the individual and remind them that you value them and want them to feel heard. It may be helpful to include a statement such as, “As health care members, we are held accountable for positive behaviors with team members.” |
| Lead with Truth | If you need to have a difficult conversation, lead with the tough message and be clear. For example, try saying, “There's something difficult I need to talk with you about. I'm concerned about the feedback I've been receiving from clients.” Even in conveying a tough message, you can build trust by showing the employee that you'll be honest with them and share feedback openly.
Don't leave the team member guessing about the problem or what they need to do to improve. Clearly state the performance gap, your expectations, the reason it matters, and the timeline for improvement, including a future meeting to review feedback and give a progress update. Provide support and available resources to help them make the needed change. |
| Anticipate Reactions | Knowing how a team member will respond when conflicts arise can be a challenge. Common negative reactions to conflicts are defensiveness, deflection, and denial. Defensive comments may include, “No one's ever brought this to me before.” You can reply, “I'm invested in you and want to see you succeed. I owe it to you and our department to be transparent with you and share these concerns.”
Deflection can take the form of an employee asking you why a coworker didn't directly bring up the concern. Often, it's because others are too intimidated by the individual or situation to speak up. Your reply can be, “Accountability between colleagues is always encouraged, but as your leader, I owe it to you to share this feedback. Do you feel your colleagues perceive you as approachable and open to feedback?” Denial may include the employee refuting that the incident of concern ever happened. You can calmly remind the employee that we own others' perceptions of our behaviors and you want to help them understand where some actions may be giving people the wrong impression. |
| Use Available Resources | Engage in professional development for managing conflicts when they arise. Share knowledge and experiences with other nurse leaders to build networks, partner with other teams within the organization, and use the human resources department when needed. |
Previous sections of this chapter discussed IPEC competencies required for effective interprofessional collaboration and methods for managing conflict. In addition to demonstrating these competencies, nurses also have many other responsibilities related to interprofessional collaborative practice. Nurses plan and participate in interdisciplinary care conferences; assign, delegate, and supervise nursing team members; educate clients and staff; act as client advocates; make client referrals; ensure continuity of care; and contribute to the evaluation of client outcomes. These responsibilities of the nurse are further described in the following subsections.
Planning and Participating in Interdisciplinary Care Conferences
The nurse identifies clients who would benefit from interdisciplinary care conferences. Interdisciplinary care conferences are meetings where interprofessional team members professionally collaborate, share their expertise, and plan collaborative interventions to meet client needs. As the interprofessional team member likely to spend the most time at the client’s bedside, nurses are key members for advocating for client needs during interdisciplinary care conferences. The nurse utilizes effective communication techniques by expressing and advocating for client needs, listening attentively to suggestions of other team members, formulating a collaborative plan of care, and documenting it in the client’s nursing care plan.
Reflective Activity
View the following YouTube video illustrating an interdisciplinary care conference as a client’s plan of care is designed and implemented.[105]
Interprofessional Professionalism Collaborative
Reflective Questions[106]:
- As you watch the video, notice how the professionals from different health disciplines communicate and interact with each other to formulate the plan of care for a client and how the care is continued through multidisciplinary involvement.
- Assess interprofessional collaborative practice of the health care team using the following PDF:
Assigning, Delegating, and Supervising
Nurses assign, delegate, and supervise care of other members of the nursing team, such as licensed practical/vocational nurses (LPN/VN) and unlicensed assistive personnel (UAP). Appropriately assigning and delegating care with appropriate supervision are strategies that ensure quality client care is completed efficiently.
Read more about assigning and delegating in the “Delegation and Supervision” chapter.
Educating Clients and Staff
Nurses provide client education, train staff, and serve as a staff resource. For example, an RN serves as a resource to unlicensed assistive personnel (UAP) floating to their unit. The RN provides a general orientation of the unit, explains the pertinent needs of the clients as they pertain to the UAP’s assigned tasks, and shares how the staff interact and communicate within the unit. The RN ensures the UAP understands the orientation information, is competent in their assigned/delegated tasks, and utilizes the RN as a resource throughout the shift.
Acting As a Client Advocate
Nurses advocate for client needs with family members, interprofessional team members, health care administrators, and, in some cases, health insurance companies and policy makers. Nurses protect and defend the rights and interests of their clients and ensure their safety, especially if the client is unable to advocate for themselves. For example, clients who are unconscious, developmentally disabled, illiterate, or experiencing confusion often require assertive advocacy with the interprofessional team to effectively meet their needs and preferences.[107]
Read more about nurse advocacy in the “Advocacy” chapter.
Making Client Referrals
Nurses assess clients, determine their needs, and make referrals based on potential or actual problem(s). If the assessed needs of the client cannot be met by the collaborative nursing interventions, the nurse seeks out other resources to fulfill the client’s needs. For example, nurses often advocate for referrals to community resources such as home health care, support groups, social services, respite care, emergency shelters, transportation, elder day care, and parenting groups. After needed referrals are identified, the nurse obtains necessary provider orders and completes applicable referral forms. This information is shared confidentially with the client and the referral resource.
Ensuring Continuity of Care
Nurses serve a vital role for maintaining continuity of care and making any client transition of care smooth and unfragmented. Continuity of care is defined as “the use of information on past events and personal circumstances to make current care appropriate for each individual.”[108] Transitions of care include admission to a facility, transfer from one unit to another within the same facility, transfer from one facility to another, or discharge to their home or a long-term care facility. For example, a transfer occurs when a client is moved from a medical unit bed to the intensive care unit.
There is high risk for medical errors during transitions of care. Nurses help make transitions seamless with good handoff reports and documentation while effectively collaborating with the interprofessional team. Read about preventing medication errors during transitions of care in the following box.
Preventing Medication Errors During Transitions[109]
Key strategies for improving medication safety during transitions of care include the following:
- Implementing formal structured processes for medication reconciliation at all transition points of care. Steps of effective medication reconciliation are to build the best possible medication history by interviewing the client and verifying with at least one reliable information source, reconciling and updating the medication list, and communicating with the client and future health care providers about changes in their medications.
- Partnering with clients, families, caregivers, and health care professionals to agree on treatment plans, ensuring clients are equipped to manage their medications safely, and ensuring clients have an up-to-date medication list.
- Where necessary, prioritize clients at high risk of medication-related harm for enhanced support such as post-discharge contact by a nurse.
Safely Admitting and Discharging Clients
Admission refers to an initial visit or contact with a client. Discharge refers to the completion of care and services in a health care facility and the client is sent home (or to another health care facility).
Admissions and discharges are more than just the physical movement of an individual. They require a great deal of confidential information sharing to maintain continuity of care. During an admission, nurses use the nursing process to thoroughly assess the client, diagnose nursing problems, establish expected outcomes, and create a nursing care plan. Referrals for other inpatient services, such as a dietician, wound care nurse, chaplain, social worker, or other interprofessional team members, may be initiated. Additionally, the client and their family members are oriented to the setting, and information is provided regarding HIPAA and client rights and responsibilities; medications are reconciled; and other admission tasks are completed based on agency policy.
During discharge, there is also a great deal of information shared with clients regarding follow-up appointments with interprofessional team members, medication reconciliation, and client education.
Reporting New Information and Changing Conditions
The nurse is often responsible for reporting new information to the interprofessional team regarding inpatients, such as newly reported laboratory or diagnostic results or changes in a client’s condition. Here are some examples of a nurse reporting and following up on issues:
- A client receiving BiPAP therapy has worsening oxygen saturation levels and respiratory status. The nurse reports these changes to the respiratory therapist, who reassesses and adjusts the positive pressure settings as needed.
- An inpatient receiving furosemide has new abnormal potassium levels. The nurse reports the newly reported lab results to the provider.
- A client receiving an antibiotic for the first time develops a rash and shortness of breath. The nurse reports the client’s adverse reaction to the prescribing provider and the pharmacist and ensures the allergy is noted in the client’s chart.
- A family member shares a recent change in a client’s living arrangements that is concerning. The nurse reports updates to the social worker to assist in making alternative living arrangements.
Contributing to the Evaluation of Client Outcomes
In today’s complex health care system, data regarding client outcomes is constantly documented and analyzed. This data drives management decisions and is also reported to insurance companies as a component of “pay for performance” reimbursement processes. The nurse is directly involved in this data by establishing expected outcomes customized to the client, evaluating these outcomes, and documenting data supporting outcomes related to collaborative nursing interventions.
Learning Objectives
- Compare theories of ethical decision making
- Examine resources to resolve ethical dilemmas
- Examine competent practice within the ethical framework of health care
- Apply the ANA Code of Ethics to diverse situations in health care
- Analyze the impact of cultural diversity in ethical decision making
- Explain advocacy as part of the nursing role when responding to ethical dilemmas
The nursing profession is guided by a code of ethics. As you practice nursing, how will you determine “right” from “wrong” actions? What is the difference between morality, values, and ethical principles? What additional considerations impact your ethical decision-making? What are ethical dilemmas and how should nurses participate in resolving them? This chapter answers these questions by reviewing concepts related to ethical nursing practice and describing how nurses can resolve ethical dilemmas. By the end of this chapter, you will be able to describe how to make ethical decisions using the Code of Ethics established by the American Nurses Association.
The American Nurses Association (ANA) defines morality as “personal values, character, or conduct of individuals or groups within communities and societies,” whereas ethics is the formal study of morality from a wide range of perspectives.[110] Ethical behavior is considered to be such an important aspect of nursing the ANA has designated Ethics as the first Standard of Professional Performance. The ANA Standards of Professional Performance are "authoritative statements of the actions and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently." See the following box for the competencies associated with the ANA Ethics Standard of Professional Performance[111]:
Competencies of ANA's Ethics Standard of Professional Performance[112]
- Uses the Code of Ethics for Nurses With Interpretive Statements as a moral foundation to guide nursing practice and decision-making.
- Demonstrates that every person is worthy of nursing care through the provision of respectful, person-centered, compassionate care, regardless of personal history or characteristics (Beneficence).
- Advocates for health care consumer perspectives, preferences, and rights to informed decision-making and self-determination (Respect for autonomy).
- Demonstrates a primary commitment to the recipients of nursing and health care services in all settings and situations (Fidelity).
- Maintains therapeutic relationships and professional boundaries.
- Safeguards sensitive information within ethical, legal, and regulatory parameters (Nonmaleficence).
- Identifies ethics resources within the practice setting to assist and collaborate in addressing ethical issues.
- Integrates principles of social justice in all aspects of nursing practice (Justice).
- Refines ethical competence through continued professional education and personal self-development activities.
- Depicts one's professional nursing identity through demonstrated values and ethics, knowledge, leadership, and professional comportment.
- Engages in self-care and self-reflection practices to support and preserve personal health, well-being, and integrity.
- Contributes to the establishment and maintenance of an ethical environment that is conducive to safe, quality health care.
- Collaborates with other health professionals and the public to protect human rights, promote health diplomacy, enhance cultural sensitivity and congruence, and reduce health disparities.
- Represents the nursing perspective in clinic, institutional, community, or professional association ethics discussions.
Reflective Questions
- What Ethics competencies have you already demonstrated during your nursing education?
- What Ethics competencies are you most interested in mastering?
- What questions do you have about the ANA’s Ethics competencies?
The ANA's Code of Ethics for Nurses With Interpretive Statements is an ethical standard that guides nursing practice and ethical decision-making.[113] This section will review several basic ethical concepts related to the ANA's Ethics Standard of Professional Performance, such as values, morals, ethical theories, ethical principles, and the ANA Code of Ethics for Nurses.
Values
Values are individual beliefs that motivate people to act one way or another and serve as guides for behavior considered “right” and “wrong.” People tend to adopt the values with which they were raised and believe those values are “right” because they are the values of their culture. Some personal values are considered sacred and moral imperatives based on an individual’s religious beliefs.[114] See Figure 6.1[115] for an image depicting choosing right from wrong actions.
In addition to personal values, organizations also establish values. The American Nurses Association (ANA) Professional Nursing Model states that nursing is based on values such as caring, compassion, presence, trustworthiness, diversity, acceptance, and accountability. These values emerge from nursing practice beliefs, such as the importance of relationships, service, respect, willingness to bear witness, self-determination, and the pursuit of health.[116] As a result of these traditional values and beliefs by nurses, Americans have ranked nursing as the most ethical and honest profession in Gallup polls since 1999, with the exception of 2001, when firefighters earned the honor after the attacks on September 11.[117]
The National League of Nursing (NLN) has also established four core values for nursing education: caring, integrity, diversity, and excellence[118]:
- Caring: Promoting health, healing, and hope in response to the human condition.
- Integrity: Respecting the dignity and moral wholeness of every person without conditions or limitations.
- Diversity: Affirming the uniqueness of and differences among persons, ideas, values, and ethnicities.
- Excellence: Cocreating and implementing transformative strategies with daring ingenuity.
Morals
Morals are the prevailing standards of behavior of a society that enable people to live cooperatively in groups. “Moral” refers to what societies sanction as right and acceptable. Most people tend to act morally and follow societal guidelines, and most laws are based on the morals of a society. Morality often requires that people sacrifice their own short-term interests for the benefit of society. People or entities that are indifferent to right and wrong are considered “amoral,” while those who do evil acts are considered “immoral.”[120]
Ethical Theories
There are two major types of ethical theories that guide values and moral behavior referred to as deontology and consequentialism.
Deontology is an ethical theory based on rules that distinguish right from wrong. See Figure 6.2[121] for a word cloud illustration of deontology. Deontology is based on the word deon that refers to “duty.” It is associated with philosopher Immanuel Kant. Kant believed that ethical actions follow universal moral laws, such as, “Don’t lie. Don’t steal. Don’t cheat.”[122] Deontology is simple to apply because it just requires people to follow the rules and do their duty. It doesn’t require weighing the costs and benefits of a situation, thus avoiding subjectivity and uncertainty.[123],[124],[125]
The nurse-client relationship is deontological in nature because it is based on the ethical principles of beneficence and maleficence that drive clinicians to “do good” and “avoid harm.”[126] Ethical principles will be discussed further in this chapter.
Consequentialism is an ethical theory used to determine whether or not an action is right by the consequences of the action. See Figure 6.3[128] for an illustration of weighing the consequences of an action in consequentialism. For example, most people agree that lying is wrong, but if telling a lie would help save a person’s life, consequentialism says it’s the right thing to do. One type of consequentialism is utilitarianism. Utilitarianism determines whether or not actions are right based on their consequences with the standard being achieving the greatest good for the greatest number of people.[129],[130],[131] For this reason, utilitarianism tends to be society-centered. When applying utilitarian ethics to health care resources, money, time, and clinician energy are considered finite resources that should be appropriately allocated to achieve the best health care for society.[132]
Utilitarianism can be complicated when accounting for values such as justice and individual rights. For example, assume a hospital has four clients whose lives depend upon receiving four organ transplant surgeries for a heart, lung, kidney, and liver. If a healthy person without health insurance or family support experiences a life-threatening accident and is considered brain dead but is kept alive on life-sustaining equipment in the ICU, the utilitarian framework might suggest the organs be harvested to save four lives at the expense of one life.[133] This action could arguably produce the greatest good for the greatest number of people, but the deontological approach could argue this action would be unethical because it does not follow the rule of “do no harm.”
Read more about Decision making on organ donation: The dilemmas of relatives of potential brain dead donors.
Interestingly, deontological and utilitarian approaches to ethical issues may result in the same outcome, but the rationale for the outcome or decision is different because it is focused on duty (deontologic) versus consequences (utilitarian).
Societies and cultures have unique ethical frameworks that may be based upon either deontological or consequentialist ethical theory. Culturally derived deontological rules may apply to ethical issues in health care. For example, a traditional Chinese philosophy based on Confucianism results in a culturally acceptable practice of family members (rather than the client) receiving information from health care providers about life-threatening medical conditions and making treatment decisions. As a result, cancer diagnoses and end-of-life treatment options may not be disclosed to the client in an effort to alleviate the suffering that may arise from knowledge of their diagnosis. In this manner, a client’s family and the health care provider may ethically prioritize a client’s psychological well-being over their autonomy and self-determination.[135] However, in the United States, this ethical decision may conflict with HIPAA Privacy Rules and the ethical principle of client autonomy. As a result, a nurse providing client care in this type of situation may experience an ethical dilemma. Ethical dilemmas are further discussed in the "Ethical Dilemmas" section of this chapter.
See Table 6.2 comparing common ethical issues in health care viewed through the lens of deontological and consequential ethical frameworks.
Table 6.2. Ethical Issues Through the Lens of Deontological or Consequential Ethical Frameworks
| Ethical Issue | Deontological View | Consequential View |
|---|---|---|
| Abortion | Abortion is unacceptable based on the rule of preserving life. | Abortion may be acceptable in cases of an unwanted pregnancy, rape, incest, or risk to the mother. |
| Bombing an area with known civilians | Killing civilians is not acceptable due to the loss of innocent lives. | The loss of innocent lives may be acceptable if the bombing stops a war that could result in significantly more deaths than the civilian casualties. |
| Stealing | Taking something that is not yours is wrong. | Taking something to redistribute resources to others in need may be acceptable. |
| Killing | It is never acceptable to take another human being’s life. | It may be acceptable to take another human life in self-defense or to prevent additional harm they could cause others. |
| Euthanasia/physician- assisted suicide | It is never acceptable to assist another human to end their life prematurely. | End-of-life care can be expensive and emotionally upsetting for family members. If a competent, capable adult wishes to end their life, medically supported options should be available. |
| Vaccines | Vaccination is a personal choice based on religious practices or other beliefs. | Recommended vaccines should be mandatory for everyone (without a medical contraindication) because of its greater good for all of society. |
Ethical Principles and Obligations
Ethical principles are used to define nurses’ moral duties and aid in ethical analysis and decision-making.[136] Although there are many ethical principles that guide nursing practice, foundational ethical principles include autonomy (self-determination), beneficence (do good), nonmaleficence (do no harm), justice (fairness), fidelity (keep promises), and veracity (tell the truth).
Autonomy
The ethical principle of autonomy recognizes each individual’s right to self-determination and decision-making based on their unique values, beliefs, and preferences. See Figure 6.4[137] for an illustration of autonomy. The American Nurses Association (ANA) defines autonomy as the “capacity to determine one’s own actions through independent choice, including demonstration of competence.”[138] The nurse’s primary ethical obligation is client autonomy.[139] Based on autonomy, clients have the right to refuse nursing care and medical treatment. An example of autonomy in health care is advance directives. Advance directives allow clients to specify health care decisions if they become incapacitated and unable to do so.
Read more about advance directives and determining capacity and competency in the “Legal Implications” chapter.
Nurses as Advocates: Supporting Autonomy
Nurses have a responsibility to act in the interest of those under their care, referred to as advocacy. The American Nurses Association (ANA) defines advocacy as “the act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for persons (whether an individual, group, population, or society) or for an issue, such as potable water or global health.”[140] See Figure 6.5[141] for an illustration of advocacy.
Advocacy includes providing education regarding client rights, supporting autonomy and self-determination, and advocating for client preferences to health care team members and family members. Nurses do not make decisions for clients, but instead support them in making their own informed choices. At the core of making informed decisions is knowledge. Nurses serve an integral role in client education. Clarifying unclear information, translating medical terminology, and making referrals to other health care team members (within their scope of practice) ensures that clients have the information needed to make treatment decisions aligned with their personal values.
At times, nurses may find themselves in a position of supporting a client’s decision they do not agree with and would not make for themselves or for the people they love. However, self-determination is a human right that honors the dignity and well-being of individuals. The nursing profession, rooted in caring relationships, demands that nurses have nonjudgmental attitudes and reflect “unconditional positive regard” for every client. Nurses must suspend personal judgement and beliefs when advocating for their clients’ preferences and decision-making.[142]
Beneficence
Beneficence is defined by the ANA as “the bioethical principle of benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law.”[143] See Figure 6.6[144] for an illustration of beneficence. Put simply, beneficence is acting for the good and welfare of others, guided by compassion. An example of beneficence in daily nursing care is when a nurse sits with a dying client and holds their hand to provide presence.
Nursing advocacy extends beyond direct client care to advocating for beneficence in communities. Vulnerable populations such as children, older adults, cultural minorities, and the homeless often benefit from nurse advocacy in promoting health equity. Cultural humility is a humble and respectful attitude towards individuals of other cultures and an approach to learning about other cultures as a lifelong goal and process.[145] Nurses, the largest segment of the health care community, have a powerful voice when addressing community beneficence issues, such as health disparities and social determinants of health, and can serve as the conduit for advocating for change.
Nonmaleficence
Nonmaleficence is defined by the ANA as “the bioethical principle that specifies a duty to do no harm and balances avoidable harm with benefits of good achieved.”[146] An example of doing no harm in nursing practice is reflected by nurses checking medication rights three times before administering medications. In this manner, medication errors can be avoided, and the duty to do no harm is met. Another example of nonmaleficence is when a nurse assists a client with a serious, life-threatening condition to participate in decision-making regarding their treatment plan. By balancing the potential harm with potential benefits of various treatment options, while also considering quality of life and comfort, the client can effectively make decisions based on their values and preferences.
Justice
Justice is defined by the ANA as “a moral obligation to act on the basis of equality and equity and a standard linked to fairness for all in society.”[147] The principle of justice requires health care to be provided in a fair and equitable way. Nurses provide quality care for all individuals with the same level of fairness despite many characteristics, such as the individual's financial status, culture, religion, gender, or sexual orientation. Nurses have a social contract to “provide compassionate care that addresses the individual’s needs for protection, advocacy, empowerment, optimization of health, prevention of illness and injury, alleviation of suffering, comfort, and well-being.”[148] An example of a nurse using the principle of justice in daily nursing practice is effective prioritization based on client needs.
Read more about prioritization models in the “Prioritization” chapter.
Other Ethical Principles
Additional ethical principles commonly applied to health care include fidelity (keeping promises) and veracity (telling the truth). An example of fidelity in daily nursing practice is when a nurse tells a client, “I will be back in an hour to check on your pain level.” This promise is kept. An example of veracity in nursing practice is when a nurse honestly explains potentially uncomfortable side effects of prescribed medications. Determining how truthfulness will benefit the client and support their autonomy is dependent on a nurse’s clinical judgment, self-reflection, knowledge of the client and their cultural beliefs, and other factors.[149]
A principle historically associated with health care is paternalism. Paternalism is defined as the interference by the state or an individual with another person, defended by the claim that the person interfered with will be better off or protected from harm.[150] Paternalism is the basis for legislation related to drug enforcement and compulsory wearing of seatbelts.
In health care, paternalism has been used as rationale for performing treatment based on what the provider believes is in the client’s best interest. In some situations, paternalism may be appropriate for individuals who are unable to comprehend information in a way that supports their informed decision-making, but it must be used cautiously to ensure vulnerable individuals are not misused and their autonomy is not violated.
Nurses may find themselves acting paternalistically when performing nursing care to ensure client health and safety. For example, repositioning clients to prevent skin breakdown is a preventative intervention commonly declined by clients when they prefer a specific position for comfort. In this situation, the nurse should explain the benefits of the preventative intervention and the risks if the intervention is not completed. If the client continues to decline the intervention despite receiving this information, the nurse should document the education provided and the client’s decision to decline the intervention. The process of reeducating the client and reminding them of the importance of the preventative intervention should be continued at regular intervals and documented.
Care-Based Ethics
Nurses use a client-centered, care-based ethical approach to client care that focuses on the specific circumstances of each situation. This approach aligns with nursing concepts such as caring, holism, and a nurse-client relationship rooted in dignity and respect through virtues such as kindness and compassion.[151],[152] This care-based approach to ethics uses a holistic, individualized analysis of situations rather than the prescriptive application of ethical principles to define ethical nursing practice. This care-based approach asserts that ethical issues cannot be handled deductively by applying concrete and prefabricated rules, but instead require social processes that respect the multidimensionality of problems.[153] Frameworks for resolving ethical situations are discussed in the “Ethical Dilemmas” section of this chapter.
Nursing Code of Ethics
Many professions and institutions have their own set of ethical principles, referred to as a code of ethics, designed to govern decision-making and assist individuals to distinguish right from wrong. The American Nurses Association (ANA) provides a framework for ethical nursing care and guides nurses during decision-making in its formal document titled Code of Ethics for Nurses With Interpretive Statements (Nursing Code of Ethics). The Nursing Code of Ethics serves the following purposes[154]:
- It is a succinct statement of the ethical values, obligations, duties, and professional ideals of nurses individually and collectively.
- It is the profession’s nonnegotiable ethical standard.
- It is an expression of nursing’s own understanding of its commitment to society.
The preface of the ANA’s Nursing Code of Ethics states, “Individuals who become nurses are expected to adhere to the ideals and moral norms of the profession and also to embrace them as a part of what it means to be a nurse. The ethical tradition of nursing is self-reflective, enduring, and distinctive. A code of ethics makes explicit the primary goals, values, and obligations of the profession.”[155]
The Nursing Code of Ethics contains nine provisions. Each provision contains several clarifying or “interpretive” statements. Read a summary of the nine provisions in the following box.
Nine Provisions of the ANA Nursing Code of Ethics
- Provision 1: The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.
- Provision 2: The nurse’s primary commitment is to the client, whether an individual, family, group, community, or population.
- Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the client.
- Provision 4: The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.
- Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.
- Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.
- Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.
- Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.
- Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.
Read the free, online full version of the ANA's Code of Ethics for Nurses With Interpretive Statements.
In addition to the Nursing Code of Ethics, the ANA established the Center for Ethics and Human Rights to help nurses navigate ethical conflicts and life-and-death decisions common to everyday nursing practice.
Read more about the ANA Center for Ethics and Human Rights.
Specialty Organization Code of Ethics
Many specialty nursing organizations have additional codes of ethics to guide nurses practicing in settings such as the emergency department, home care, or hospice care. These documents are unique to the specialty discipline but mirror the statements from the ANA’s Nursing Code of Ethics. View examples of ethical statements of specialty nursing organizations using the information in the following box.
Sample Ethical Statements of Selected Specialty Nursing Organizations
Nurses frequently find themselves involved in conflicts during client care related to opposing values and ethical principles. These conflicts are referred to as ethical dilemmas. An ethical dilemma results from conflict of competing values and requires a decision to be made from equally desirable or undesirable options.
An ethical dilemma can involve conflicting client’s values, nurse values, health care provider’s values, organizational values, and societal values associated with unique facts of a specific situation. For this reason, it can be challenging to arrive at a clearly superior solution for all stakeholders involved in an ethical dilemma. Nurses may also encounter moral dilemmas where the right course of action is known but the nurse is limited by forces outside their control. See Table 6.3a for an example of ethical dilemmas a nurse may experience in their nursing practice.
Table 6.3a. Examples of Ethical Issues Involving Nurses
| Workplace | Organizational Processes | Client Care |
|---|---|---|
|
|
|
Read more about Ethics Topics and Articles on the ANA website.
According to the American Nurses Association (ANA), a nurse’s ethical competence depends on several factors[156]:
- Continuous appraisal of personal and professional values and how they may impact interpretation of an issue and decision-making
- An awareness of ethical obligations as mandated in the Code of Ethics for Nurses With Interpretive Statements[157]
- Knowledge of ethical principles and their application to ethical decision-making
- Motivation and skills to implement an ethical decision
Nurses and nursing students must have moral courage to address the conflicts involved in ethical dilemmas with “the willingness to speak out and do what is right in the face of forces that would lead us to act in some other way.”[158] See Figure 6.7[159] for an illustration of nurses’ moral courage.
Nurse leaders and organizations can support moral courage by creating environments where nurses feel safe and supported to speak up.[160] Nurses may experience moral conflict when they are uncertain about what values or principles should be applied to an ethical issue that arises during client care. Moral conflict can progress to moral distress when the nurse identifies the correct ethical action but feels constrained by competing values of an organization or other individuals. Nurses may also feel moral outrage when witnessing immoral acts or practices they feel powerless to change. For this reason, it is essential for nurses and nursing students to be aware of frameworks for solving ethical dilemmas that consider ethical theories, ethical principles, personal values, societal values, and professionally sanctioned guidelines such as the ANA Nursing Code of Ethics.
Moral injury felt by nurses and other health care workers in response to the COVID-19 pandemic has gained recent public attention. Moral injury refers to the distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.[161] Health care workers may not have the time or resources to process their feelings of moral injury caused by the pandemic, which can result in burnout. Organizations can assist employees in processing these feelings of moral injury with expanded employee assistance programs or other structured support programs.[162] Read more about self-care strategies to address feelings of burnout in the "Burnout and Self-Care" chapter.
Frameworks for Solving Ethical Dilemmas
Systematically working through an ethical dilemma is key to identifying a solution. Many frameworks exist for solving an ethical dilemma, including the nursing process, four-quadrant approach, the MORAL model, and the organization-focused PLUS Ethical Decision-Making model.[163] When nurses use a structured, systematic approach to resolving ethical dilemmas with appropriate data collection, identification and analysis of options, and inclusion of stakeholders, they have met their legal, ethical, and moral responsibilities, even if the outcome is less than ideal.
Nursing Process Model
The nursing process is a structured problem-solving approach that nurses may apply in ethical decision-making to guide data collection and analysis. See Table 6.3b for suggestions on how to use the nursing process model during an ethical dilemma.[164]
Table 6.3b. Using the Nursing Process in Ethical Situations[165]
| Nursing Process Stage | Considerations |
|---|---|
| Assessment/Data Collection |
|
| Assessment/Analysis |
|
| Diagnosis |
|
| Outcome Identification |
|
| Planning |
|
| Implementation |
|
| Evaluation |
|
Four-Quadrant Approach
The four-quadrant approach integrates ethical principles (e.g., beneficence, nonmaleficence, autonomy, and justice) in conjunction with health care indications, individual and family preferences, quality of life, and contextual features.[166] See Table 6.3c for sample questions used during the four-quadrant approach.
Table 6.3c. Four-Quadrant Approach[167]
| Health Care Indications
(Beneficence and Nonmaleficence)
|
Individual and Family Preferences
(Respect for Autonomy)
|
| Quality of Life
(Beneficence, Nonmaleficence, and Respect for Autonomy)
|
Contextual Features
(Justice and Fairness)
|
MORAL Model
The MORAL model is a nurse-generated, decision-making model originating from research on nursing-specific moral dilemmas involving client autonomy, quality of life, distributing resources, and maintaining professional standards. The model provides guidance for nurses to systematically analyze and address real-life ethical dilemmas. The steps in the process may be remembered by using the mnemonic MORAL. See Table 6.3d for a description of each step of the MORAL model.[168],[169]
Table 6.3d. MORAL Model
| M: Massage the dilemma | Collect data by identifying the interests and perceptions of those involved, defining the dilemma, and describing conflicts. Establish a goal. |
|---|---|
| O: Outline options | Generate several effective alternatives to reach the goal. |
| R: Review criteria and resolve | Identify moral criteria and select the course of action. |
| A: Affirm position and act | Implement action based on knowledge from the previous steps (M-O-R). |
| L: Look back | Evaluate each step and the decision made. |
PLUS Ethical Decision-Making Model
The PLUS Ethical Decision-Making model was created by the Ethics and Compliance Initiative to help organizations empower employees to make ethical decisions in the workplace. This model uses four filters throughout the ethical decision-making process, referred to by the mnemonic PLUS:
- P: Policies, procedures, and guidelines of an organization
- L: Laws and regulations
- U: Universal values and principles of an organization
- S: Self-identification of what is good, right, fair, and equitable[170]
The seven steps of the PLUS Ethical Decision-Making model are as follows[171]:
- Define the problem using PLUS filters
- Seek relevant assistance, guidance, and support
- Identify available alternatives
- Evaluate the alternatives using PLUS to identify their impact
- Make the decision
- Implement the decision
- Evaluate the decision using PLUS filters
In addition to using established frameworks to resolve ethical dilemmas, nurses can also consult their organization’s ethics committee for ethical guidance in the workplace. Ethics committees are typically composed of interdisciplinary team members such as physicians, nurses, allied health professionals, administrators, social workers, and clergy to problem-solve ethical dilemmas. See Figure 6.8[172] for an illustration of an ethics committee. Hospital ethics committees were created in response to legal controversies regarding the refusal of life-sustaining treatment, such as the Karen Quinlan case.[173] Read more about the Karen Quinlan case and controversies surrounding life-sustaining treatment in the “Legal Implications” chapter.
After the passage of the Patient Self-Determination Act in 1991, all health care institutions receiving Medicare or Medicaid funding are required to form ethics committees. The Joint Commission (TJC) also requires organizations to have a formalized mechanism of dealing with ethical issues. Nurses should be aware of the process for requesting guidance and support from ethics committees at their workplace for ethical issues affecting clients or staff.[174]
Institutional Review Boards and Ethical Research
Other types of ethics committees have been formed to address the ethics of medical research on clients. Historically, there are examples of medical research causing harm to clients. For example, an infamous research study called the “Tuskegee Study” raised concern regarding ethical issues in research such as informed consent, paternalism, maleficence, truth-telling, and justice.
In 1932 the Tuskegee Study began a 40-year study looking at the long-term progression of syphilis. Over 600 Black men were told they were receiving free medical care, but researchers only treated men diagnosed with syphilis with aspirin, even after it was discovered that penicillin was a highly effective treatment for the disease. The institute allowed the study to go on, even when men developed long-stage neurological symptoms of the disease and some wives and children became infected with syphilis. In 1972 these consequences of the Tuskegee Study were leaked to the media and public outrage caused the study to shut down.[175]
Potential harm to clients participating in research studies like the Tuskegee Study was rationalized based on the utilitarian view that potential harm to individuals was outweighed by the benefit of new scientific knowledge resulting in greater good for society. As a result of public outrage over ethical concerns related to medical research, Congress recognized that an independent mechanism was needed to protect research subjects. In 1974 regulations were established requiring research with human subjects to undergo review by an institutional review board (IRB) to ensure it meets ethical criteria. An IRB is group that has been formally designated to review and monitor biomedical research involving human subjects.[176] The IRB review ensures the following criteria are met when research is performed:
- The benefits of the research study outweigh the potential risks.
- Individuals’ participation in the research is voluntary.
- Informed consent is obtained from research participants who have the ability to decline participation.
- Participants are aware of the potential risks of participating in the research.[177]
Nursing students may encounter ethical dilemmas when in clinical practice settings. Read more about research regarding ethical dilemmas experienced by students as described in the box.
Nursing Students and Ethical Dilemmas[179]
An integrative literature review performed by Albert, Younas, and Sana in 2020 identified ethical dilemmas encountered by nursing students in clinical practice settings. Three themes were identified:
1. Applying learned ethical values vs. accepting unethical practice
Students observed unethical practices of nurses and physicians, such as breach of client privacy, confidentiality, respect, rights, duty to provide information, and physical and psychological mistreatment, that opposed the ethical values learned in nursing school. Students experienced ethical conflict due to their sense of powerlessness, low status as students, dependence on staff nurses for learning experiences, and fear of offending health care providers.
2. Desiring to provide ethical care but lacking autonomous decision-making
Students reported a lack of moral courage in questioning unethical practices. The hierarchy of health care environments left students feeling disregarded, humiliated, and intimidated by professional nurses and managers. Students also reported a sense of loss of identity in feeling forced to conform their personal identity to that of the clinical environment.
3. Whistleblowing vs. silence regarding client care and neglect
Students observed nurses performing unethical nursing practices, such as ignoring client needs, disregarding pain, being verbally abusive, talking inappropriately about clients, and not providing a safe or competent level of care. Most students reported remaining silent regarding these observations due to a lack of confidence, feeling it was not their place to report, or the fear of negative consequences. Organizational power dynamics influenced student confidence in reporting unethical practices to faculty or nurse managers.
The researchers concluded that nursing students feel moral distress when experiencing these kinds of conflicts:
- Providing ethical care as learned in their program of study or accepting unethical practices
- Staying silent about client care neglect or confronting it and reporting it
- Providing quality, ethical care or adapting to organizational culture due to lack of autonomous decision-making
These ethical conflicts can be detrimental to students' professional learning and mental health. Researchers recommended that nurse educators should develop educational programs to support students as they develop ethical competence and moral courage to confront ethical dilemmas.[180]
Read more about ethics education in nursing in the ANA’s Online Journal of Issues in Nursing article.
COVID-19 and the Nursing Profession
The COVID-19 pandemic has highlighted the importance of nurses’ foundational knowledge of ethical principles and the Nursing Code of Ethics. Scarce resources in an overwhelmed health care system resulted in ethical dilemmas and moral injury for nurses involved in balancing conflicting values, rights, and ethical principles. Many nurses were forced to weigh their duty to clients and society against their duty to themselves and their families. Challenging ethical issues occurred related to the ethical principle of justice, such as fair distribution of limited ICU beds and ventilators, and ethical dilemmas related to end-of-life issues such as withdrawing or withholding life-prolonging treatment became common.[181]
Regardless of their practice setting or personal contact with clients affected by COVID-19, nurses have been forced to reflect on the essence of ethical professional nursing practice through the lens of personal values and morals. Nursing students must be knowledgeable about ethical theories, ethical principles, and strategies for resolving ethical dilemmas as they enter the nursing profession that will continue to experience long-term consequences as a result of COVID-19.[182]
Sara is a new graduate nurse orienting on the medical floor at a large teaching hospital. She has been working on the floor for two weeks and notices that many of the nurses provide shift handoff reports to one another outside of the client rooms. Sara asks her preceptor why the nurses stand and report client care information in the hallway. Her preceptor responds that this is the standard way staff can meet the agency guidelines for beside handoff reporting without "disturbing" clients while they are resting. Sara has concerns about this action on many levels. What legal repercussions might this "hallway reporting" have?
Sara is smart to identify that discussing client care information in a hallway outside of client rooms may jeopardize client HIPAA protections and confidentiality. Sensitive client information should never be discussed freely where others may overhear care information and details. Additionally, the act of bedside handoff reporting is meant to provide an inclusive environment for clients to participate with care staff in the report and information exchange. Discussing report details outside of the client room does not actively include the client in the bedside reporting procedure.
Sara is a new graduate nurse orienting on the medical floor at a large teaching hospital. She has been working on the floor for two weeks and notices that many of the nurses provide shift handoff reports to one another outside of the client rooms. Sara asks her preceptor why the nurses stand and report client care information in the hallway. Her preceptor responds that this is the standard way staff can meet the agency guidelines for beside handoff reporting without "disturbing" clients while they are resting. Sara has concerns about this action on many levels. What legal repercussions might this "hallway reporting" have?
Sara is smart to identify that discussing client care information in a hallway outside of client rooms may jeopardize client HIPAA protections and confidentiality. Sensitive client information should never be discussed freely where others may overhear care information and details. Additionally, the act of bedside handoff reporting is meant to provide an inclusive environment for clients to participate with care staff in the report and information exchange. Discussing report details outside of the client room does not actively include the client in the bedside reporting procedure.
The impact of inadequate stress management for health care personnel can greatly impact health care organizations. When harmful stress is not adequately addressed, burnout can rapidly become a burgeoning problem resulting in absenteeism, decreased productivity, decline in care quality, staff dissatisfaction, and employee turnover. Work environment and lack of workplace support often contribute to feelings of burnout and job attrition.[183] Organizations must recognize the significance of stress in regard to the cyclical nature it plays in the retention of employees. For example, if one employee experiences harmful stress resulting in depression and anxiety, this may influence their timeliness and attendance at work. If the employee begins to struggle, they may be more inclined to phone in as “sick time” for shifts or even be a “no show” for a scheduled shift. When this occurs, the burden of their absence is passed on to other employees on the unit. Calls for overtime, mandated stay, or increased client care assignments quickly increase the burden on the other members of the health care team. As a result, the team members experiencing increased workload feel an impact on their own job-related stress. The compounded stress can quickly overtax an individual who has been managing normal work-related stress. Many individuals who were previously self-managing stress may struggle under these increased role demands. When there is a decrease in an individual’s “downtime,” there is even less reprieve from the stressful work environment. As a result, the organization and health care system become even more overtaxed, and the cycle perpetuates itself among other staff.[184] Managers and directors often struggle with rehiring and orienting staff at a rate that is suitable to offset the stress cycle and decreased retention within the organization.
Promoting Nurse Retention
Nurse leaders must be proactive in finding solutions to address clinical nurse and nursing faculty shortages and high nurse turnover rates. The 2018 National Healthcare Retention and RN Staffing Report states the following data[185]:
- The U.S. Bureau of Labor Statistics reports that 233,000 new RN jobs will be created annually.
- Forty-five percent of hospitals anticipate increasing their RN staff.
- Hospital turnover is at 18.2%, an increase from previous years.
- RNs working in emergency care, step-down, and medical-surgical units experience high turnover rates, with the highest rate of turnover for certified nursing assistants.
- The average cost of each RN turnover is $49,500, resulting in an average hospital losing an estimated $4.4 to $7 million due to turnover.
- Each percent change in RN turnover will cost or save the average hospital $337,500.
- It takes approximately 2.5 months to recruit an experienced RN.
- More than half of hospitals would like to decrease reliance on supplemental staffing.
- For every 20 travel RNs eliminated, a hospital can save an average of $1,435,000.
Unfortunately, many nurse leaders struggle to receive organizational support for recruitment and hiring in a timely fashion. Demonstrating the need for staff replacement often cannot be established until a staff vacancy exists. As a result, the retention cycle is further compromised when workload is impacted due to staff vacancies during the recruitment and orientation process. Many frontline nursing staff may not be aware of the rigorous challenges that nurse leaders face when requesting administrative support for additional staff positions. Most organizations require executive-level approval for hiring, and unit productivity is examined for rationale that additional staff are needed. The time required for this investigation and executive-level approval can be very challenging for staff nurses who experience the workload burden during the vacancies. During this time frame, nurse leaders may struggle to maintain team morale while also acknowledging the organization’s need to be financially responsible in staff hiring.
It is important for all parties to remain engaged in their current work roles during the recruitment, hiring, and orientation periods of new nurses. Trust in one another during this time is critical, and all parties must remember the needs of clients receive top priority. Providing optimal care to the best of one’s ability is of the utmost importance even when experiencing staffing challenges. Additionally, staff, nursing leaders, and administrators within the organization must unite to find actionable solutions that acknowledge the impact of stress and reduce the impact of harmful stress contributing to the burnout of colleagues. There is no simple solution. All individuals must be united in exploring strategies to reduce the occurrence of burnout and seek to make change to enhance the health and well-being of all involved.
In addition to recognizing stress manifestations in oneself, health care professionals must identify signs of stress in others. All members of the health care team experience stress, and effective coping can quickly turn into ineffective coping when manageable, normal stress shifts to harmful stress. Nurses should understand how stress may manifest in a colleague and how one can help and intervene if signs of harmful stress occur.
The signs of harmful stress in a colleague often manifest in a similar manner to what is seen in oneself, but certain signs may be more readily identified by an external source. It is not unusual to identify the mental or behavioral signs of harmful stress in a colleague more rapidly than the physical manifestations. Individuals should be mindful of signs of harmful stress in others, such as changes in mood, irritability, signs of fatigue, increased errors, and absenteeism.[186] Individuals exhibiting these signs may be signaling they are struggling to manage harmful stress. It is important to promptly address these signs with the individual. The tendency to assume one can self-manage or will “get over it” can lead to feelings of isolation that will only perpetuate the stress.
When observing potential signs of harmful stress in a colleague, providing an opportunity to discuss the stressors can be a valuable avenue for promoting effective coping. It is important to remember that the individual exhibiting signs of harmful stress may not recognize they are impacted by stress, but having a colleague acknowledge one’s change in mood or attitude can open the opportunity for self-reflection. Although acknowledging signs of harmful stress in a colleague may feel awkward, asking if someone is okay and addressing signs of potential harmful stress can be a significant step in helping them cope. Acknowledgement can occur with statements such as, “I noticed that you seem more frustrated at work lately. Is everything okay?” or “You seem to be more quiet in the breakroom after our shifts. How are you feeling? I know the busy days can really add up.” Simple statements and questions open opportunities to share feelings and frustrations and also demonstrate caring for team members.[187] This approach creates dialogue about stressful experiences and provides support needed to positively address harmful stress.
In addition to demonstrating care for one’s colleague by inviting conversation about harmful stress, sharing resources is also helpful. It is important for nurses to know they are not alone in experiencing feelings of stress, and attention to these feelings can help one develop strategies to positively address them. Planning discussions with a trusted mentor or friend can be very helpful when exploring feelings related to stress. These discussions also provide an opportunity to share information regarding coping strategies such as mindfulness interventions, resiliency programs, or other formalized resources like employee assistance programs.[188] There are also routine workplace measures that significantly impact stress reduction. For example, many nurses do not take the time to ensure they are taking breaks, eating healthy meals, or simply removing themselves from the care environment for brief periods of time. Simple strategies that can dramatically reduce workplace stress include taking a brief walk outside during one’s lunch break or taking a few deep breaths prior to the beginning of a work shift. Other simple measures such as daily exercise and meditation can reduce stress and increase confidence to address the tasks at hand.[189] Although experienced nurses may already be incorporating these strategies, it is important for novice nurses to understand the value of these strategies.
