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This first objective of this training is to identify the types of errors of communication that

can increase the chances that a client may file a lawsuit.

Another objective is to enhance the quality and effectiveness of your own communication by

expanding awareness of ways to avoid malpractice incidents.

We will address communication as it relates to interactions with clients, coworkers, as well

as external communication.

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Communication is complex and affected by a variety of elements, including: setting, people

engaged in communication, and format of communication, whether it is verbal, non-verbal,

written, or electronic.

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The Joint Commission, which accredits the majority of hospitals in this country and some

nursing homes and other facilities, analyzes the root causes of sentinel or critical events.

Miscommunication is the most common cause of resident injury or death.

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Communication breakdown was the root cause of more than 60% of 2,034 medical errors, of

which 75 % resulted in a resident’s death. In other words, 915 people died as a result of a

communication error. In 2005, communication continued to lead as the root cause of sentinel

events in all categories.

Data from The Joint Commission found that between 1995 and 2004 communication problems

were the leading root causes of the following:

Sentinel events (75%)

Delays in treatment (85%)

Medication errors (nearly 65%)

Perinatal deaths and injuries (more than 80%)

Ventilator events (65%)

Wrong-site surgery (nearly 80%)

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Clear- Does the receiver understand what I am saying?

Concise - Have I confused the message or receiver by giving too much unnecessary

information?

Correct- Is the message I am providing accurate and in accordance with the situation, policy,

procedure?

Complete- Does the receiver have all the information necessary to complete the task or

make an informed decision?

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There are four main points to nonverbal communication: - If your verbal and nonverbal messages don’t match, people believe your nonverbal

messages. Picture this. You’re furious, with a scrunched up forehead and sharply bitter tone, and you say, “I am NOT angry!” There will be no doubt in people’s minds that you are angry, despite you saying you are not.

- Pay attention to the nonverbal signals of your residents, if not you may miss really important information and respond in ways that appear insensitive or uncaring. Also, pay attention and be present when with a resident. If you aren’t present to the person you’re with, you’re going to miss their signals entirely, be unable to meet their real needs, and miss the chance to show you’re caring.

-Residents’ nonverbal signals are often not about you. It is often the situation, not the person, which triggers negative nonverbal signals. Anxiety, stress, nervousness, fear, newness, pain-all of these cause residents and families to feel distress and show it in their nonverbal behavior. So, when your residents scowl, groan, harrumph, raise their eyebrows, use snapping tones, shake their heads, and clench their teeth, consider first that these are signs of their distress over their situation, not about you. Instead of taking it personally, remain objective and resident and use these as triggers for responding with empathy.

- Strive to be culturally sensitive to nonverbal communication differences. While communication research has shown that some nonverbal behaviors are universally understood (e.g., expressions of happiness, sadness, fear, disgust, surprise, and anger), the meaning of most other nonverbal behaviors depends on one’s culture. In some cultures, shaking the head sideways means you agree and the thumbs-up gesture is considered rude.

Remember: Nonverbal communication has an enormous impact. Your posture, tone, pace, and face all give away your real meaning.

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Nonverbal dynamics between staff and residents have an enormous impact on rapport, trust,

and mutual respect.

It is important to be aware that sometimes people say one thing, but their nonverbal

behavior does not support what they have said.

Some staff respond to the content of what their residents are saying, even when the

nonverbal behaviors communicate a completely different message, so try to focus on the

nonverbal behaviors of residents as well as what they have said.

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Employees may frequently deal with difficult communication situations, and there are a

variety of ways that these issues can come about. Some key points to remember when

dealing with clients and their families include:

Deal with clients and their families honestly and treat all participants with respect.

Utilize appropriate listening skills, which we will talk about shortly.

Establish a rapport – this can go a long way towards mitigating potentially difficult situations.

Avoid medical jargon – speak plainly in ways that your clients and their families can

understand. Encourage questions and understanding.

Provide a private neutral place that’s free of conflict.

Use interpreter services when needed to avoid language barriers.

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Phone and e-mail communication are often a necessary tool in providing good care to

residents. Both means of communication facilitate contact and when used properly can be an

excellent way of supplementing care. However, client communication by telephone and e-

mail may also jeopardize privacy.

It is very important to follow the written policies of your facility addressing appropriate and

secure use to safeguard resident’s protected health information.

Contact your supervisor or the facility’s risk manager if you have any questions regarding

what information is protected.

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There are two key risk management principles you should always be aware of when utilizing

phone and e-mail communication:

Ensure security of transmitted information

Ensure privacy of content

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Some tips to help reduce telephone risk:

Designate a telephone conversation area to ensure privacy.

Use landlines when possible. Inform residents that cellular telephone messages may be intercepted.

Never leave sensitive information on an answering machine, in a voicemail message or with an answering service. This includes test results or medical advice.

Update resident telephone numbers on a regular basis. You should do this for e-mail addresses as well.

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Electronic communication has the same documentation and retention requirements as other

media. E-mails can easily be attached to an electronic medical record. If your facility relies

upon paper records, print out e-mails and file them in the record with progress notes.

Unlike self-documented e-mails, telephone messages must be written down after the

discussion and placed in the progress notes section of the resident care record.

Preprinted telephone logs should be used to document - date and time of correspondence

resident’s name and age

identity of the caller/sender when different from the resident’s

chief complaint or concern

brief history and assessment

advice protocol used

name and signature of responding nurse

necessary follow-up, such as a required return call

Follow your facility’s documentation format for telephone responses to e-mails and e-mail

responses to telephone discussions.

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Be aware and know the protocol for these special situations. 1. Prescription requests. Must be approved by a physician or other provider with prescriptive authority, be in accordance with practice protocols, and documented in the resident’s healthcare record. Document: Chronic conditions, recent surgeries, medications, allergies and pregnancy status. All fax or telephone contacts with retail pharmacies Amount of medication ordered and dispensed Whether a physical examination is required before additional refills are approved. 2. Laboratory results. Many states prohibit use of e-mail to convey certain laboratory results: Sexually transmitted diseases Presence of a malignancy Mental health and drug abuse issues. If e-mail notification is appropriate, thoroughly document all transmissions, noting whether the resident was advised to seek medical attention or take specific action. 3. Urgent and non-urgent requests. Set realistic expectations among residents regarding response times Emergency situations are always highest priority. Non-urgent inquiries can be treated flexibly, e.g., by returning calls at the end of the day and responding to e-mails within one or more business days. 4. Out-of-office communication. If it applies to your practice setting, Always alert residents to current and anticipated absences by utilizing your e-mail system’s out-of office function. When using an automatic call distribution system, state the hours of operation and advise residents to call 911 for any emergency. Provide an after-hours contact number.

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Although it may seem obvious, it is important to be aware of how others perceive your behaviors. Engage in these behaviors to show respect: Listen and be fully attentive. Truly hear. Be engaged in the conversation. Make eye contact. Don’t talk over others in the conversation. Don’t walk away when someone is talking to you. Acknowledge and express appreciation Greet colleagues when you enter a room. Acknowledge colleagues and let them know they are appreciated. Congratulate colleagues on accomplishments and a job well done. Exhibit empathy and understanding Be considerate of others feelings. Consider the thoughts and feelings behind actions. Be inclusive rather than exclusive. Display courtesy and consideration Look at colleagues when they are speaking to you. Address people by their names. Say “please” and “thank you”. Be available to offer help and assistance. Be accountable and professional Arrive at work on time. Be truthful. Fulfill your commitments. Don’t gossip.

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As we mentioned previously, intimidation negatively impacts service to clients. Let’s take a

look at an ISMP survey that shows just how serious this can be.

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For example, 88% of respondents encountered condescending language or voice intonation,

87% encountered impatience with questions and 79% encountered a reluctance or refusal to

answer questions or phone calls. When it came to explicit forms of intimidation, almost half

of the respondents reported experiencing strong verbal abuse (48%) or threatening body

language (43%).

Intimidation altered the way 49% of all respondents handled order clarifications or questions

about medication orders. At least once during the past year, about 40% of respondents who

had concerns about a medication order assumed that it was correct, rather than interact

with the intimidating prescriber. 34% reported that the prescriber's reputation alone was

intimidating enough for them not to question the order, even if they had concerns. The

unfortunate result was that 7% reported that they had been involved in a medication error

during the past year in which intimidation played a role.

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Another important aspect of communication is teamwork and collaboration.

There are many barriers to communicating effectively in a team:

Gender –doctors are predominately men, while the remaining healthcare service

professionals are mainly composed of women.

Education- differences in varied levels of training and educational background results in

perceived status differences that influence nature and frequency of communication across

disciplines .

Generational differences - 4 different generations work closely together. This can result in

frequent misunderstandings and misconceptions; it is important to recognize and value the

variation in generational perspective.

Large team size

Instability of the workforce and assignments

Absence of a common purpose

Nurse-Physician relationship

In the next slide, we will look more closely the nurse-physician relationship and ways to

overcome communication barriers.

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When discussing a resident with a healthcare prescriber, an inexperienced or fatigued nurse may omit specific important information. The goal of SBAR (pronounced S-BAR) is to provide a specific structure for this nurse-physician communication in order to avoid omissions or errors.

Situation: When calling a healthcare provider to report a change in the resident’s condition, the nurse identifies his or her name and unit, the name and room number of the resident, and the problem. The nurse describes what is happening at the present time that has warranted the SBAR communication.

Situation: “Dr. Little, this is Maria Sanchez of 3 North. I am calling you to notify you that your resident, Liam Kelly, in Room 319-2, fell on the floor today while being transferred out of bed.”

Background: The nurse includes relevant background information specific to the situation. For example, this could include the resident’s diagnosis, his mental status, current vital signs, complaints, pain level, and physical assessment findings.

Background: “As you know, Mr. Kelly had a discectomy and bone fusion on January 17. His legs have been weak since surgery. He fell when our aide was helping him get up with a walker. His current vital signs are 145/90, pulse of 88 and respirations of 20. He is able to move all of his extremities, although he is complaining of pain in his incisional site of 7 on a scale from 1-10.”

Assessment: This step of the communication provides the nurse with the opportunity to offer an analysis of the problem. If the situation is unclear, the nurse tries to isolate the problem to the body system that might be involved and describes the seriousness of the problem. This may be challenging for some nurses because many have been conditioned to hold back the results of their critical thinking skills. Some facilities use the assessment step to convey more extensive data about the resident, such as changes from prior assessments.

Assessment: “I see no changes in his neurological status since he fell; neither of his legs is shortened and externally rotated. He is quite anxious now and also worried something his neck has been injured.”

Recommendation: The nurse states what he or she thinks would help resolve the situation or what is the desired response. This might be phrased in the form of a question: “Do you think we should give him a medication, perform lab work, do an xray, perform cardiac monitoring, or transfer to another unit? Will you come to evaluate him?”

Recommendation: “I believe it would reassure Mr. Kelly if you would examine him. When can we expect you to come?”

Recommendations may include asking the physician to come in or requesting orders for something specific, perhaps a diagnostic test. New nurses typically have more trouble voicing their recommendation than experienced nurses.

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•Ask for what you want in a direct, honest, and respectful manner

•Remain cool, calm, and collected and appropriately set limits

•If a conflict cannot be resolved one-to-one, document the offense and seek third-party

assistance

•Do not take things personally

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In 1996, HIPAA or the Health Insurance Portability and Accountability Act was enacted into

law. This was the first national legislation to assure every resident across the nation

protection of their health insurance information. HIPAA protects a resident's rights to the

confidentiality of his/her medical information and, for the first time, creates federal civil

and criminal penalties for improper use or disclosure of protected health information. The

privacy portion of the law limits those who may have access to a resident's health

information and how it may be used.

Hospitals and providers may use this information only for:

Treatment,

Obtaining payment for care, and

For specified operational purposes like improving quality of care

Must inform residents in writing of how their health data will be used; establish systems to

track disclosure; and allow residents to review, obtain copies, and amend their own health

information.

Nurses, through the Nightingale Pledge and all subsequent nursing codes, have identified the

need for confidentiality; long before national legislation was ever contemplated!

The Code for Nurses, published by the American Nurses Association Ethics Committees “is the

standard by which ethical conduct is guided and evaluated by the profession” (ANA, 1994,

p.1). Provision 3 of the Code of Ethics for Nurses states: “The nurse promotes, advocates for,

and strives to protect the health, safety and rights of the patient” (ANA, 2001). The

statements 3.1 and 3.2 are explicit in their language regarding privacy and confidentiality.

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Let’s focus on the specific sections of HIPAA that are of particular importance to nurses.

First, is Protected Health Information or PHI.

PHI is defined as all individually identifiable health information held or transmitted by or to

the covered entity in any form or media, whether electronic, paper, or verbal. Covered

entity refers to healthcare providers, plans, and clearinghouses that engage in specific,

standard electronic transactions.

Examples of PHI include:

Name

Date of birth

Social security number

Device identifiers/serial numbers

Full-face photos

According to HIPAA guidelines, disclosure of PHI is limited to:

The individual residents and their legally authorized representative,

The Department of Health and Human Services, and legal entities as defined by state law

There are, however, exceptions to the Privacy Rule, which include, but aren't limited to,

reporting of victims of abuse, neglect, or domestic violence.

Residents must be provided with a written copy of the organization's Notice of Privacy (in its

entirety), which specifies their individual right to restrict the use or disclosure of this

information.

Nurses are prohibited from discussing PHI in the presence of unauthorized individuals,

including other residents, family members, and visitors, in common or public areas where

you may be overheard or when using telecommunication devices that aren't secure.

Law enforcement isn't a covered entity. PHI may be disclosed without authorization when

deemed necessary for public safety. There should be institutional policies in place to guide

nurses regarding unauthorized disclosures to law enforcement.

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The second section of HIPAA that is of particular importance to nurses is the standards for

electronic transactions security section.

Standards for electronic transactions security

Be smart when communicating resident information, be it by fax, telephone, e-mail, or other

technologies When communicating with another clinician, remember this:

Others besides the addressee may process messages during addressee's usual business hours

or during addressee's vacation or illness

Electronic messages can occasionally go to the wrong party

Electronic communication can be accessed from various locations

Information written by one clinician may be sent electronically to other care providers

The Internet does not typically provide a secure media for transporting confidential

information unless both parties are using encryption technologies.

Fax machines are perhaps the least secure technology when it comes to transmitting resident

information. Certain types of information are prohibited by law from being faxed outside of

an institution without appropriate written authorization, e.g., genetic test results, HIV

information, and sexual assault counseling.

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Nurses see and hear confidential information every day. Occasionally, we become so

comfortable with resident information that it can be easy to forget how important it is to

keep information private.

Here are ways nurses can keep compliant with HIPAA policies:

Keep confidential all resident information including (but not limited to): resident's name,

physical or psychological condition, emotional status, financial situation, and demographic

information.

Share resident information on a "need- to-know" basis according to medical necessity.

Be mindful of your surroundings when discussing resident information. Avoid discussing

residents in public places such as elevators, hallways, shuttle buses, public transportation, or

social events.

Keep confidential papers, reports, computer disks, and data in a secure place.

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It's the responsibility of each nurse to know his or her organization's privacy policies and how

to follow established HIPAA policies.

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A nurse is participating in a research project and needs access to PHI to make clinical

comparisons of response to treatment. Is this okay?

Nurses may participate in research. It's important to distinguish the areas of your

responsibilities that are resident centered and those that are research centered because the

Privacy Rule makes a clear distinction.

If you're rendering clinical care, you're allowed to have access to PHI to properly carry out

your job. However, if you want access to PHI to make clinical comparisons of response to

treatment or answer another research question, the hospital admission authorization

wouldn't apply.

In that circumstance, the nurse researcher would be required to request either authorization

from the residents or a waiver of authorization because the information will be used for a

purpose other than the purpose indicated on the hospital admission consent.

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Here are some websites that can guide a nurse in maintaining resident privacy and

confidentiality. These are resources for keeping up to date on the latest policies and

amendments as well as access to frequently asked questions.

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