Motivate staff to achieve peak performance without increasing pay ance:

Vol. 4 No. 8
August 2004
INSIDE
Leadership
Patient safety
Read these ideas for getting
your staff excited about patient
safety initiatives on p. 3.
Motivate staff to achieve peak
performance without increasing pay
Interdisciplinary care corner
Read how one hospital created
a new documentation process
to improve interdisciplinary
communication on p. 4.
Managers believe that money is a
top motivator, but it really doesn’t
encourage employees to put forth
their best efforts. Research shows
that pay will achieve two objectives: it will ensure that employees
come to work and that they stay
with your facility.
Rule #1: Tie rewards to performance: What you reward is what
you get. For example, if you want
high performance, your high performers should be rewarded differently from your low performers.
And if you want teamwork then
you must reward team players.
That’s certainly nothing to complain about, however, increased
pay is clearly not inspiring peak
performance.
Rule #2: Tie rewards to individual preferences: Because every
employee has different needs
and wants, it’s important to know
your employees and what motivates them. Ask them what their
interests are and what gets > p. 2
Management skills
Read tips and suggestions on
how to navigate through the
various groups within a
healthcare facility on p. 6.
Nursing shortage
Read how one veteran OR nurse
is working to stem the nursing
shortage on p. 7.
Training
Looking for ways to engage
resistant learners? Learn how to
get through to unmotivated staff
on p. 8.
Time management
Are you working hard but not
getting much accomplished?
Read how efficient nurse
managers “work smart” on
p. 12.
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Follow these rules to achieve peak
performance from your staff:
Communication
How to combat dangerous blanket
medication orders in your facility
Blanket orders, such as “resume
all medications,” are dangerous because physicians could forget to
include previous vital medications,
or nurses and pharmacists may
misinterpret the order.
For example, a physician could
discontinue an antiarrythmic drug
before a procedure, says Michael
Hoying, RPh, MS, pharmacy director at Fairview and Lutheran hospitals in Cleveland.
After the procedure, the physician
may issue a blanket “resume all
medications” order because he or
she intends for the patient to begin retaking the antiarrythmic. But
because the physician discontinued the order rather than holding
it, the patient may not be told to
take the antiarrythmic. This could
have harmful effects if the patient
needs the drug.
“The physician is the only one
who knows what he or she means,”
say Sarah Moake, RN, nurse
manager of the medical-surgical
unit at Henderson (TX) Memorial
> p. 2
Hospital.
www.hcpro.com
Leadership
Motivate staff
< p. 1
them excited.
Rule #3: Reward employees in public: Whenever
possible recognize team members in front of their
colleagues. You should always punish in private and
reward in public.
Rule #4: Reward staff in a timely manner: Receiving a reward or recognition six months after a
nurse has gone the extra mile loses its impact. So
do it now. And don’t worry if not all employees are
present. It’s far better to get the recognition one-onone, instead of not at all.
Rule #5: Be specific: When recognizing team
members in public, be very clear about what is
being rewarded or recognized. That level of specificity allows other team members to emulate the
right behavior and increases the probability that
similar actions will be repeated.
Rule #6: Reward at random times: You are violating this rule if employees get upset every time you
are not rewarding them. Recognizing team members
randomly causes the desired behaviors to be more
likely repeated and reduces the “WIIFM”—what’s in
it for me effect.
Rule #7: Tell stories: Get extra mileage out
of your rewards and recognitions by becoming
a storyteller. Telling stories about how a nurse
went the extra mile to ensure that the patient received the best possible care helps staff internalize
what’s important, and begins to shape behavior
and performance more effectively than policies
or statistics.
Source: Don’t Oil the Squeaky Wheel and 19 Other
Contrarian Ways to Improve Your Leadership Effectiveness. Rinke, W. J. McGraw-Hill, New York,
2004.
Communication
Medication orders
< p. 1
It’s important to train nursing staff to automatically
call the physician if they receive a vague order. Such
phone calls lead to better communication among
caregivers and can prevent potential errors from
blanket orders.
If a physician gives an order to “continue home meds,”
have staff find a list of the patient’s home medications and have that present when they call to confirm the order, says Sandra Fly, RN, Henderson
Memorial’s director of performance improvement,
quality, and JCAHO accreditation.
“It just comes down to being as professional as possible and having as much information as possible,”
Fly says.
Page 2
© 2004 HCPro, Inc.
Tips for staff to communicate efficiently
with a physician about a blanket order:
Make sure you have enough information
about the patient’s medications when you
call a physician to clarify an order.
Write a clarification in the patient’s chart
when you receive an order interpretation
from the physician so another nurse doesn’t
have to call the physician again.
Source: Hospital Pharmacy Regulation Report,
June 2004, HCPro, Inc.
Strategies for Nurse Managers—August 2004
www.hcpro.com
Patient safety
Three creative ideas to get your staff excited
and committed to patient safety initiatives
Are you stumped for ways to get staff excited about
your facility’s patient safety initiatives? The following
are three inspiring suggestions that have worked in
facilities across the country.
Notice your surroundings
Know your limits
3. Ask staff to sign a “Commitment to Patients” in
1. Design a patient safety–relatwhich they pledge to not use
“[The contract] provides a level
ed crossword puzzle and give
certain abbreviations or to
of accountability. If I sign on
prizes out to the first five or 10
pause for a time out before
that I’m going to do this, then
staffers who complete it correctsurgery. Post the contract
I’m going to work really hard
ly. (See sample puzzle on p. 5.)
prominently throughout the
to make it happen.”
Consider distributing the puzzle
unit. Nurse leaders should be
—Barbara
Organ,
RN
at staff meetings or in nurses’
some of the first in the hospimailboxes.
tal to sign the contract and
should consider posting their signed copy prominently
2. Sponsor a slogan contest. Award prizes for the
throughout each unit, says Barbara Organ, RN, direcperson who comes up with the catchiest phrase to
tor of licensure, certification, and accreditation for
promote your latest patient-safety project, suggests
Memorial Regional Hospital in Hollywood, FL.
Debra Molnar, a patient ombudsman at WadsworthRittman (OH) Hospital. Print the winning slogan on
“It provides a level of accountability,” says Organ,
pens, t-shirts, or balloons. Winning slogans at
whose hospital asks medical and nursing staff to
Wadsworth-Rittman have included, “Patient Safety:
sign such contracts. “If I sign on that I’m going to
Caring Without Compromise,” and the acronym
do this, then I’m going to work really hard to make
“THINK,” which stands for:
it happen.”
Take your time
Handle with care
Source: Briefings on Patient Safety, July 2004,
Inform others of concerns
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Strategies for Nurse Managers—August 2004
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Page 3
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Interdisciplinary care corner
Improving interdisciplinary communication:
How one hospital revamped its documentation
During the JCAHO survey at Halifax Regional Medical Center in Roanoke Rapids, NC, the surveyor
took a close look at patient records and noticed that
clinicians didn’t document how specialists from various disciplines communicated with one another
about their patients’ care plans.
However, nurses, physicians, and therapists did communicate with one other daily—they simply didn’t
document it.
“The surveyor wanted us to have one place in
the patient record where everyone could see what
each discipline’s goals were for the patient,” says
Margaret Rose, the performance improvement
director and hospital risk manager. Each discipline
needed to be able to look at the big picture of the
patient’s care.
Problem #1: Some disciplines, such as nursing,
entered their notes for patients into electronic medical records. Others, such as respiratory therapy,
wrote their notes longhand and placed them into the
patient’s hard-copy file. Surveyors wanted more consistency so that all disciplines could open a patient’s
chart and with one glance, know what each clinician’s goals were for the patient.
Problem #2: The electronic documentation system
was cumbersome. It required nurses to pass through
several screens before they reached the appropriate
screen allowing them to enter plan-of-care information. In addition, other caregivers, including physicians, were unable to access the information if
someone else was working on one of the unit’s
available computers.
Problem #3: Surveyors wanted to see that specialists communicated with physicians, nurses, discharge
planners, and case managers consistently to learn
about each patient’s care plan and any changes to it.
Page 4
© 2004 HCPro, Inc.
Those meetings occurred for patients with complicated needs or who had extended hospital stays, but
not for all patients, says Rose.
Brainstorming solutions
The hospital formed a task force that included 17
people from various disciplines. The team split into
two groups that brainstormed ways to improve the
hospital’s documentation process for communication
among disciplines. The teams gathered together at
the end of the five weeks to compare ideas and
select the best solutions.
Solution #1: The teams decided to create a simple
two-page form that nurses must insert at the front of
each hardcopy patient file. The form contains a designated section for each discipline to enter basic
information, such as the patient’s diagnosis, goals,
expected length of stay, medications, special needs,
and goals.
Providers from each discipline must fill out their corresponding section of the form. If a provider from a
particular discipline doesn’t provide care for the patient, a nurse must check off N/A, for nonapplicable,
in the space reserved for that discipline’s notes.
“We didn’t want to leave anything blank,” says Rose.
“We wanted to have some way to document that the
patient wasn't receiving certain care so that it wouldn’t
look as if it had been left blank due to an oversight.”
Solution #2: The task force also developed a 10page handbook with care-planning language to tutor
providers who don’t document patient goals regularly. The handbook explains what care planning is
and how to create and use an interdisciplinary plan
of care.
“Care planning has been an integral part of the nursing process for a long time, but not with other
Strategies for Nurse Managers—August 2004
www.hcpro.com
disciplines, such as respiratory therapy,” says Rose.
Solution #3: In 2004, the hospital plans to move to
a fully electronic documentation system that will
make it easier to enter and share patient information
within the organization. It will integrate the interdisciplinary information contained on the two-page
form.
Reaction
Some nurses didn’t like the new form and regarded it as duplicate documentation because they
already entered each patient’s goals into an electronic record. The task force emphasized that nurs-
es merely needed to write their major goal for the
patient on the form and then check a box marked,
“see documentation.”
“They didn't know that they didn’t have to put all of
their detailed documentation on there,” says Rose.
“It's just an overview.”
If you would like a copy of the two-page form that
Halifax Regional Medical Center developed contact
Rebecca Delaney at 781/639-1872, Ext. 3157 or
rdelaney@hcpro.com.
Source: Briefings on JCAHO, April 2004, HCPro, Inc.
Patient safety puzzle
Note: Find the answers on p. 11.
Across:
1. Team participation in the development
of a patient’s plan of care should be
_______.
3. You must use two of these when taking
blood samples or administering medications or blood products.
9. An infant abduction or patient suicide
would be a ______ event.
12. _______ on medical machinery should
be audible, never silenced, and attended
to promptly.
16.This is an absolute must while mixing or
preparing medications.
17.Morphine 2–5 mg IV every hour is an
example of a _____ order.
18.This should be part of your preop
verification process.
20.These are high-alert medications.
21.Do this to help identify failure points
in high-risk processes.
Source: Baylor Medical Center.
Reprinted with permission.
Down:
2. Acute Myocardial Infarction, Pneumonia, and Congestive
Heart Failure are three such measures.
3. This should have free-flow protection.
4. Number of nurses or licensed staff required to verify a
patient’s identification during blood administration.
5. Post-operative complications, wrong-site surgery, and
medication errors are a few examples of this.
6. U, IU, Q.D., Q.O.D.
7. This requires a definitive marking.
Strategies for Nurse Managers—August 2004
8. The JCAHO’s preferred mode of survey readiness.
10.Errors rarely occur in this manner.
11.This happens after a verbal or telephone order has been
written down.
13.The culprit behind medical errors.
14. MS, MSO4, and MgSO4 are often _______ with one another.
15.Passé expression for hospital-acquired infections.
19.Staff should always wash their hands before entering a
patient’s _____.
© 2004 HCPro, Inc.
Page 5
www.hcpro.com
Management skills
Managing the masses: How to navigate through
the various groups in a healthcare organization
In any organization there are different “tribes”
or groups of people who have their own culture
and their way of thinking and communicating. No
where is this more evident than in a healthcare
facility, said Peg Neuhauser, MA, in her presentation, “Orchestrating Healthcare Teams” during the
Case Management Society of America’s annual
meeting in Nashville, TN, in June. Neuhauser gave
four tips on managing various groups within a
facility to better lead staff and serve patients.
ing with staff or other nurse leaders make a habit
of asking questions that link groups. Some questions that are good to work into conversation
include the following:
1. Watch out for tribal warfare. The first step
to successful communication with various groups
is recognizing the groups that exist in your facility and what has historically has been a sticking
point between you and the people in this group.
If there’s a group with which you have a history
of bad feelings or confrontation, prepare before
you meet with them.
Also, Neuhauser advises nurse leaders to bypass
e-mail and call people or, even better, meet with
colleagues face-to-face. “The more electronic the
communication, the less personal and the harder
it gets to make connections,” she said.
Try brainstorming all of things they could say
to you that could frustrate you, so that you’re
not caught off guard during the meeting, says
Neuhauser. “If you’re prepared you can stay on
focus and on message,” she said. Also, if you use
a word or phrase that usually irritates this group
try to avoid repeating it when speaking with
them. “You have a huge vocabulary, use it,”
advises Neuhauser. “Don’t let language interfere
with your message.”
• What do you think?
• Who else might be affected by this?
• Who else needs to know about this?
4. Create the sweep effect. According to Neuhauser,
a leader only needs 25% of staff to buy into ideas
for change—after you influence this segment most
likely the rest will follow. “Identify the movers and
shakers in your organization, these are the people
who will help get the momentum going and help
you get things done,” she says.
Source: Orchestrating Healthcare Teams: The Case
Manager as Leader, Peg C. Neuhauser, MA, Case
Management Society of America annual meeting,
Nashville, TN.
Questions? Comments? Ideas?
2. Informal connections are as important as formal connections. Take a look at the different
“connectors” between groups. Neuhauser said
there is always a “go-to person” who connects
various groups through informal relationships.
You can get more accomplished by going to this
person than through formal channels. “Seek these
people out; they’re incredibly valuable people to
tap into,” she said.
3. Develop the habit of connecting. When speak-
Page 6
© 2004 HCPro, Inc.
Contact Associate Editor Rebecca Delaney
Telephone:
E-mail:
781/639-1872,
Ext. 3157
rdelaney@hcpro.com
Strategies for Nurse Managers—August 2004
www.hcpro.com
Nursing shortage
Veteran OR nurse works to stem nursing shortage
Louise DeChesser, RN, CNOR, MS, is worried. As a
54-year-old babyboomer she knows as she grows
older and her health fails the dearth of qualified
perioperative nurses will mean less quality care in
the OR.
DeChesser, who is the president of Surgical Solutions,
a healthcare consulting company, knows firsthand
how serious the current shortage of OR nurses is, and
she says it will only get worse. “There are so few OR
nurses that many facilities are using technicians to circulate through the OR and administer medications,”
she says. “The OR nurse is on the decline and we’re
using more ancillary staff as a Band AidTM, but it’s not
a permanent solution.”
Before going into ambulatory care administration
and nurse education, DeChesser worked as an OR
nurse for 35 years. Today she teaches a unique,
hands-on course to educate experienced RNs how to
work in the operating room. Most nurses today don’t
get that hands-on experience during their nursing
education, according to DeChesser.
“In the 60s and 70s students had a rotation in the
OR for three months, and you could spend more
time there for an elective,” explains DeChesser.
“Now nursing students get one day of observation
and that’s their whole experience in the OR.”
Because of that lack of education nurses are not
attracted to OR nursing, says DeChesser, and those
who are interested in working in the OR are faced
with a dilemma. “It’s a double-edged sword,” she
says. “You can’t begin working in the OR without
experience, yet how can you gain experience without working in an OR?”
The course, developed by the American Organization of Perioperative Nurses, is geared toward veteran nurses and provides hands-on, practical training.
It also provides college credit and continuing education credits if the nurse completes the semester.
For more information, visit www.aorn.org.
Stress management
Quick tips to reduce stress in your day
Unfortunately, stress is a fact of life for both nurses
and nurse leaders. Christine Dumas, DDS, and
Kevin Soden, MD, MPH, two national medical reporters, provide tips on dealing with stress to help
you handle the demands of your day:
• Put your coffee cup down. After drinking four
or five cups of coffee during the day, your body
has an elevated level of stress hormones all the
way into the evening, making you feel more
stressed out than you actually are.
• Reduce your stress on the spot. “Find a buddy
to confide in,” advises Dumas. Whether it’s a
glance at a meeting to convey your frustration or
a quick phone call to let off steam, sharing the
Strategies for Nurse Managers—August 2004
cause of your stress with a friend as soon as possible will lessen the effect it has on your work.
• Take a mini-vacation every day. “Go outside for
a few minutes and walk around. You need to get
away from work to refresh yourself,” says Soden.
• Stop working when you leave work. “The
average person thinks about work for two hours
after they leave,” says Dumas. It may be difficult,
but try to leave the problems your dealing with
on your unit when you walk out the door.
Source: Improving American Health Through Case
Management, Christine Dumas, DDS, and Kevin Soden,
MD, MPH, Case Management Society of America annual meeting, Nashville, TN. Reprinted with permission.
© 2004 HCPro, Inc.
Page 7
www.hcpro.com
Training
How to get through to change-resistant learners
The one constant in the healthcare industry is
change. Whether you have to train staff on the
JCAHO’s Patient Safety Goals, a new piece of equipment, or a new unit policy, introducing change can
be challenging—especially when staff members are
not receptive to learning about the change.
One principle of adult learning is that adults are selfdirected learners. But what happens when adults
direct themselves not to learn?
Resistant learners are restless, sometimes rebellious,
and often sullen. Their negative body language and
verbal remarks clearly communicate that they do not
want to participate, regardless of the topic or the
learning environment. Their attitudes influence other
staff, making it difficult to establish and maintain a
positive atmosphere. How can you deal with this
problem and maintain your own positive attitude?
If your staff don’t always see change as an opportunity for professional or personal growth, use this
quick exercise to show them that mastering new
concepts and skills benefits their organization and
affects their performance reviews. Discuss these
questions at an upcoming staff meeting to ease the
transition from the familiar to the unknown.
• What trends and forces of change currently affect
nursing?
• What are your strengths?
• Which of these strengths will continue to make
you successful in the future?
• What new skills do you need to learn to stay
valuable in the healthcare industry?
• What have you learned in the past six months?
• What do you expect to learn in the next six
months?
• What do you need to unlearn? Which skills are
becoming obsolete? What practices (e.g., attitudes,
behaviors, work routines, etc.) that worked for
you in the past are no longer valid?
This technique could help resistant staff adjust to
new concepts by offering a broader perspective
on change. It encourages employees to reevaluate
their individual contributions to the organization’s
culture, and to consider how their attitudes and
skills affect hospitalwide patient satisfaction and
quality improvement.
Source: Healthcare Training Weekly, HCPro, Inc.
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Strategies for Nurse Managers—August 2004
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JCAHO
Reduce risk: Steps your facility can take
to avoid patient falls during hospitalization
plugs, a warm blanket, or a brief massage. If the
Nothing is more counterproductive
patient was still awake and requesting assistance 30
and frustrating for patients, their famiminutes later, caregivers offered an over-the-counter
lies, and caregivers than an injury susmedication to relieve minor pain that might interfere
tained in a fall during hospitalization. A new study
with sleep. If another 30 minutes pass, they provided
conducted by the Washington University School of
a low dose of sleep medication that is not generally
Medicine in St. Louis found that most patient falls
associated with falls.
resulting in an injury occurred when the
patient was either in the bathroom, on
The collaborative found that 44%
the way to the bathroom, or while
of patients fell asleep after reusing a bedside commode.
Patient falls are the
ceiving warm tea or other intersecond most-frequent
vention. Another 44% fell asleep
The JCAHO targeted patient
cause of arm for patients,
after receiving a nonprescripfalls in its proposed National
topped only by
tion pain killer.
Patient Safety Goals for 2005.
medication errors.
Patient falls are the second mostAnother factor in patient
frequent cause of harm for patients,
—Amanda Borgshdorf, MHSA
falls was the confused or
topped only by medication errors, says
disoriented patient who doesn’t understand that
Amanda Borgshdorf, MHSA, coordinator of
he or she should not walk without assistance. “Pathe Madison (WI) Patient Safety Collaborative.
tients need to be reminded that they’re on a number
of medications, in an unfamiliar environment, and
The following are suggestions to help reduce patient
being put through a routine of tests, procedures, and
falls in your unit:
bed rest, all of which can make them weaker and
• Expand the use of regularly scheduled, assisted
more susceptible to falling,” says Melissa Krauss,
trips to the bathroom for patients at risk for falling.
a researcher coordinator at Washington Medical University Center.
• Ask patients whether they use a walker or cane
outside of the hospital. Ensure that canes, walkAccording to Borgshdorf, the Madison collaborative
ers, and other assistive devices are available for
also implemented a “safe-room” setup, which inpatients who need them. Many falls documented
cludes placing bedside tables on the nonexit side of
in the study occurred when patients who normalthe bed, locking bed wheels, tucking away electric
ly used a walker or a cane outside of the hospital
cords, and installing bed-exit alarms. The collaborawere not using one when they fell.
tive provided continual fall-prevention education
with a half-day inservice training program involving
• Avoid sleeping pills. Certain medications, such as
a nurse known as a “unit champion” from each
those that aid sleep, increase the risk of falls.
unit.
A group called the Madison Collaborative, composed
Source: “Hospital Falls Study Suggests Ways to Reduce
of three medical groups and four hospitals started a
Risk,” Washington University in St. Louis, School of
fall prevention program in 2001. The collaborative
Medicine and Briefings on Patient Safety, May
focused on reducing the use of sleeping aids, offering
2004, HCPro, Inc.
natural sleep inducers, such as warm herbal tea, ear
Strategies for Nurse Managers—August 2004
© 2004 HCPro, Inc.
Page 9
www.hcpro.com
Legal matters
Nurse supervision: Understand your responsibilities
Editor’s note: The following is an excerpt from Managing Documentation Risk: A Guide for Nurse Managers, written by Patricia A. Duclos-Miller, MS, RN,
CNA, and published by HCPro, Inc.
As a director, nurse manager, or supervisor,
you must ensure that patients have appropriate
care and that staff members providing care have
sufficient supervision. If a patient is injured and
suspects that your staff were not adequately supervised, he or she could allege that your supervision
was negligent.
Your liability will be based upon the following:
• Your delegation of patient care to a nurse who
was unable to perform the care
• Your failure to personally supervise the nurse
when you knew or should have known that
supervision was necessary
• Your failure to take the necessary steps to avoid
patient injury when you were present and able
to intervene
• Inadequate staffing, which can be perceived as
negligent judgment by the nurse manager
Ask yourself the following questions after an adverse
event to manage your risk:
• Did my staff follow organization policies, procedures, and practices? If not, did I adopt changes
as soon as possible after the event occurred to
prevent another adverse event?
• Was the nursing documentation reviewed for
accuracy and completeness?
• Were the necessary departments notified about
the event?
• Was an intensive investigation or root-cause analysis with staff completed as close to the event as
possible?
• Were the necessary changes adapted as soon as
possible?
• Were staff informed of the possible root causes
of the event?
• Was education provided based on any changes
to policies, procedures and practices?
Nursing in the news
Pointing the finger: Nurses blamed for most errors
Although only about 8% of physicians consider
nurses part of the decision-making team when it
comes to patient care, nurses are held accountable for the majority of medical errors, according
to a study from the University of Montana, published in the June issue of American Journal of
Nursing.
Researchers surveyed nurses, physicians, pharmacists, and hospital administrators at 29 rural hospitals for three years. Ninety percent of hospital
administrators surveyed said patient safety is primarily the responsibility of nurses.
Page 10
© 2004 HCPro, Inc.
The study’s authors tie their statistics to the
nurse recruitment and retention problem afflicting
countless hospitals, stating their findings, “make
it clear that the processes used to identify errors, assign responsibility for them, and resolve
patient safety issues may have unintended, unfavorable effects on nurse recruitment and
retention.”
Source: “An Error by Any Other Name,” Ann
Freeman Cook, PhD, Helena Hoas, PhD, Katarina Guttmannova, MA, and Jane Clare Joyner,
JD, RN, American Journal of Nursing, June 2004.
Strategies for Nurse Managers—August 2004
www.hcpro.com
Celebrating Nurses
Tune in, breaking news: The first nursefocused radio show launches on Web
The first radio program solely devoted to nurses
recently aired its inaugural broadcast in May—featuring interviews with nurses from across the country.
Nurseradio.org, operated by the New England
School of Whole Health Education and the American
Holistic Nurses Association, profiles nurses with
inspirational stories, such as a nurse who worked
with victims of the Chernobyl nuclear disaster and a
nurse who served a tour of duty in Vietnam in the
1960s in the business of nursing and public jealth
nursing.
“I think nurses are feeling somewhat unsupported
in their efforts to provide the best patient care possible,” says Mary-Anne Benedict, MSN, RN, chair
of the Nurse Radio advisory board. “This radio
program provides them an opportunity to hear from
Puzzle answers
nurse leaders and to grow professionally.”
With the seemingly permanent nursing shortage and
increased complexities and needs of patients, nurses
are at high risk for burnout. Georgianna Donadio,
PhD, producer and host of the program, says she
hopes her show provides inspiration and motivation
for nurses to continue working in their field.
“Nursing is experiencing a tremendous crisis right
now,” says Donadio. “Nurses are dissatisfied with
the work environment and they’re dropping out
of the profession. We want them to know they’re
appreciated.”
To listen to the radio program, visit www.nurseradio.
org.
AUG/SEPT
(from p. 5)
Across:
Down:
1. Multidisciplinary
2. Core
3. Patient
3. Pump
identification
Upcoming
events
Audioconferences:
4. Two
9. Sentinel
5. Sentinel event
12. Alarms
6. Do not use
16. Focus
7. Site
17. Range
8. Continuous
18. Time out
10. Isolation
20. Electrolytes
11. Read back
21. FMEA
13. Root cause
14. Confused
15. Nosocomial
19. Room
Strategies for Nurse Managers—August 2004
8/3/2004: Effective Competency Assessment:
How To Build Performance-Based Job
Descriptions That Comply With JCAHO HR
Standards
8/17/2004: Redesigning The Patient Care Work
Environment: How To Improve Patient Flow,
Staff Satisfaction And Patient Safety
8/25/2004: How To Identify And Respond
To Resident Falls
9/16/2004: Preparing Nursing/Clinical Teams
To Adopt New Technologies
For more information call our Customer Services
Department at 800/650-6787 to register.
© 2004 HCPro, Inc.
Page 11
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Time management
Working smart: How to accomplish more
in your day without working more hours
➤
What is the difference between
working hard and working smart? Many people work
lots of hours and feel they have really worked hard,
yet they may not have been working smart. With all
the demands on a nurse manager’s time, it is often
difficult to prioritize and work efficiently and effectively. When you are exhausted at the end of the
day and feel like you’ve been spinning your wheels
and didn’t accomplished much, it’s time to ask, “was
I working hard or smart?” The following are tips
from managers who work smart:
• Determine before the day begins the most important task that needs to get accomplished that day
and don’t let yourself get distracted from completing that goal.
• Don’t let staff decide priorities for you. A staff
member’s emergency doesn’t always have to
replace the first item on your “to do” list. Maybe
the nurse’s emergency can go to your #3 or #4
item.
• Ask yourself, what can I do today that will have
the most effect?
• Realize that sometimes smart work is working with staff, helping them with tasks and
procedures. You may not be getting to the
pile of paper on your desk, but you are getting more done by gaining trust and input
from staff.
Source: Adapted from the “Manager Tip of the
Month” by Shelley Cohen, RN, BS, CEN, HEalth
Resources Unlimited.
We want to hear from you
Strategies for Nurse Managers
Editorial Advisory Board
Shelley Cohen, RN, BS, CEN
President
Health Resources Unlimited
Hohenwald, TN
Bob Nelson, PhD
President
Nelson Motivation, Inc.
San Diego, CA
Sue Fitzsimons
Senior Vice President
Patient Services
Yale-New Haven Hospital
New Haven, CT
Tim Porter-O’Grady, EdD, RN, CS, CNAA, FAAN
Senior Partner
Tim Porter-O’Grady Associates, Inc.
Otto, North Carolina
David Moon
Executive Vice President
Modern Management, Inc.
Lake Bluff, IL
Dennis Sherrod, EdD, RN
Forsyth Medical Center Distinguished
Chair of Recruitment and Retention
Winston-Salem State University
Winston-Salem, North Carolina
For news and story ideas:
Contact Associate Editor Rebecca Delaney
• Phone: 781/639-1872, Ext. 3157
• Mail: 200 Hoods Lane, Marblehead, MA 01945
• E-mail: rdelaney@hcpro.com
• Fax: 781/639-2982
Publisher/Vice President: Suzanne Perney
Group publisher: Kathryn Levesque
Executive Editor: Emily Sheahan
Online resources:
• Web site: www.hcpro.com
• Visit HCPro’s Nursing site at www.hcpro.com/nursing
Subscriber services and back issues:
New subscriptions, renewals, changes of address, back
issues, billing questions, or permission to reproduce any
part of Strategies for Nurse Managers, please call our
Customer Service Department at 800/650-6787.
Strategies for Nurse Managers (ISSN 1535-847X) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $179 per year. • Postmaster: Send
address changes to Strategies for Nurse Managers, P.O. Box 1168, Marblehead, MA 01945. • Copyright 2004 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically
encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notify
us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: customerservice@hcpro.com. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to
selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. • Opinions expressed are not necessarily those
of Strategies for Nurse Managers. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific
legal, ethical, or clinical questions.
Page 12
© 2004 HCPro, Inc.
Strategies for Nurse Managers—August 2004
Verifying Nurse
Credentials:
Methods to reduce risk
and ensure patient safety
A supplement to HCPro publications
Verifying Nurse Credentials:
Methods to reduce risk and ensure
patient safety
Background
Throughout his 15-year nursing career, Charles Cullen, RN, worked
at nine hospitals and one nursing home—and murdered 13 patients.
As he moved from hospital to hospital, Cullen’s employers say they
never knew of his checkered past, which included an investigation
into his nursing care, an accusation that he had stolen drugs, and a
conviction of criminal trespassing and harassment after he broke into a
nurse’s home in 1993. In 2004, Cullen pleaded guilty to 13 murders
and two attempted murders of patients in his care.
Investigators in the case learned that when Cullen applied to various hospitals, human resources representatives called his former
employers who only disclosed the dates of his employment. This
was the case at Somerset Medical Center in Somerville, NJ, where
Cullen worked for 13 months, killed 13 patients, and tried to kill
two more. When he came under criminal investigation for patient
overdoses, Somerset Medical fired Cullen, and he applied for a new
nursing position at another New Jersey hospital. He lied on his application, stating he was fired from his previous nursing job for obtaining a nursing license under false pretenses, when in fact he was
under criminal investigation.
Cullen also lied on his New Jersey nursing license renewal form
in 1999. When asked whether any licensed healthcare facility had
taken action against him that affected his employment between 1997
and 1999, Cullen answered no. In reality, he had been fired by the
Liberty Nursing and Rehabilitation Center in Allentown, PA, for improperly administering medications in 1998.
Although less extreme, the story of Susan Ann Robertson in Louisiana
is still alarming because of the serious threat posed to patient safety.
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Verifying Nurse Credentials
Robertson applied for a nursing job at Gambro Healthcare in Gonzales,
LA, filled out an application, and told a hospital supervisor she was
a RN licensed in New York state. She said she applied for a Louisiana
license, but didn’t have it with her during the interview. Gambro
hired Robertson, and she worked at the facility for three months
until the administrators caught on, called the state boards in Louisiana
and New York, and found out she was not and had never been a
licensed nurse in either state.
“Why would you let a nurse, who underwent less scrutiny than a
physician, work in your critical care unit?” asks Hugh Greeley,
founder of The Greeley Company in Marblehead, MA, and medical
credentialing expert. Accounts of nurses and impostors such as Cullen
and Robertson send a chill through the healthcare community, not
only because of the horrific breach of trust between caregiver and
patient, but also because healthcare administrators know that they
too could have nurses who are hiding a shady past working on units
and caring for patients.
Stories of nurses faking credentials, hopping from job to job in
various states, and harming patients are a reminder that you must
be diligent in verifying nursing applicants’ licensure, criminal background, and education before hiring them to work on your units.
When hiring Cullen, Somerset Medical Center followed its own verification procedure and called his previous employers. Unfortunately
these former employers did not provide critical information that ultimately could have prevented the deaths of 13 patients. Although even
the most rigorous verification process may not expose every inconsistency in a nurse’s past, the more stringent the process, the more
capable your facility will be to find discrepancies in applicants’ backgrounds.
Unfortunately, the nurse-credentialing process in many facilities is
inadequate—allowing nurses who may have had action taken against
them by another state nursing board, a criminal history, or incomplete education onto the unit—making patients vulnerable and the
Verifying Nurse Credentials
3
facility liable. Most facilities verify nursing credentials in a process
different from physician credentialing. However, considering how
closely nurses work with patients, subjecting nursing applicants to a
less stringent credentialing process may not be in your facility’s or
patients’ best interest.
Applicants hiding their pasts
It is a sad reality that it is no longer reasonable to assume your
nursing applicants are telling the truth on their applications and in
their interviews. Raymond Jacobs, a vice president at Kroll Background America in Nashville, TN, a background-screening company,
estimates that 13% of applicants for hospital positions have a criminal past. Also, one out of every three job applications has an intentional error, according to CBSMarketwatch.com.
Human resources compliance
The “Management of Human Resources” chapter of the JCAHO’s
Comprehensive Accreditation Manual for Hospitals states that hospitals
must have a process to ensure an applicant’s qualifications are consistent with the position’s responsibilities. Under standard HR.1.20, the
hospital must verify the applicants licensure, education, experience,
competency, and criminal background according to the law, the facility’s policy, and regulations.
Verifying licensure and credentialing nurses can be a confusing process. Today, more nurses move from state-to-state throughout their
careers, and different states have different requirements for licensure.
Twenty-three state boards do not conduct criminal background checks
on applicants for nurse licensure—they rely on the applicant to disclose such information on the license application.
Unfortunately, applicants can’t always be trusted when answering
these questions, and their past could come back to haunt the institution when the truth eventually comes out. “If the nurse isn’t competent, that will be realized quickly because each nurse is under
supervision of a dedicated, highly skilled nurse manager,” says Greeley.
However, a nursing applicant’s criminal past isn’t as obvious, he says.
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Verifying Nurse Credentials
Although your facility may be compliant under JCAHO because
it follows policies and regulations when hiring nurses, current policies may not adequately spell out how to scrutinize a nurse’s background. Examine your facility’s bylaws or human resources (HR)
policy and procedures to see whether they protect your patients and
sufficiently screen applicants for dangerous nurses or impostors.
Proposed legislation
After the Cullen murders came to light, there was a groundswell of
calls for reform. New Jersey Senators Jon Corzine (D) and Frank
Lautenberg (D) proposed legislation earlier this year to expand the
National Practitioner Data Bank (NPDB) to include nurses and other
healthcare professionals.
The NPDB is a federally funded clearinghouse for information on
physicians, dentists, and other healthcare practitioners. Facilities can
find information about medical malpractice payments, adverse licensure actions, adverse clinical-privilege actions, and adverse professional society-membership actions.
If passed, Corzine’s and Lautenberg’s legislation would require hospitals to report to state nursing boards and to the NPDB when they
take any adverse action against a nurse. They would also have to
report a nurse if he or she violates a federal or state law, including
state health professional standards, such as drug diversion, falsification of documents, or repeated medication errors. When hiring nurses,
facilities would be required to first check the NPDB for information
on the applicant’s background. If a facility did not report information
to the database or did not check the NPDB before hiring a nurse,
they could be fined up to $50,000 per violation.
The senators’ legislation also provides protection to healthcare
“whistleblowers,” or employees who report activities that violate
standards of care to the NPDB.
Currently, there is no similar central repository for disciplinary information on nurses. The National Council of State Boards of Nursing
Verifying Nurse Credentials
5
maintains NURSYS, a database of nurse license and license discipline
information provided by participating state boards of nursing. Currently
27 states provide license information to the NURSYS database.
The New Jersey state assembly also reacted to the Cullen case by
drafting a bill that would allow hospitals to share more detailed
information about a former employee when contacted by another
medical facility looking to hire that individual. An amendment was
added to the bill to allow the state board of nursing to double-check
information provided by license applicants and nurses applying for
renewal.
A centralized credentialing process
Credentialing nurses usually falls to the HR department in most institutions, while the medical staff office handles physician and advancepractice RN credentialing. Because of this split, the credentialing
process is often different for nurses than it is for the medical staff.
This should not be the case, says Laura Harrington, RN, MHA,
CPHQ, practice director of external peer review, credentialing, and
national seminars at The Greeley Company. “It doesn’t matter whether
they’re an employee or part of the medical staff, facilities should use
the same procedure to verify licenses during the initial application,”
she says.
Harrington says creating a consistent credentialing process will ensure
that everyone who has contact with patients has been properly vetted.
This is common sense considering how much time nurses spend oneon-one with patients.
Current practices
In a recent HCPro survey on nurse credentialing, 98% of respondents
said their facility did have a process in place to verify nurse credentials. However, credentialing processes are laden with weaknesses
of which a fraudulent applicant could easily take advantage. For
example, when asked how they verify a nurse’s credentials, 78% of
respondents said they photocopy the nurse’s license. “It’s not good
6
Verifying Nurse Credentials
enough to photocopy a license and stick it in the file,” says Harrington.
“With today’s technology, visual verification of a license is not sufficient. Someone can easily forge a license and use it to obtain a nursing position if the facility does not verify the license with the state
board.”
Several respondents said they verify credentials merely by looking
at the nurse’s license, and only 38% of respondents said they contact nursing applicants’ previous employers during the hiring process.
Best practices
Take the following critical steps to verify nurses’ credentials and to
ensure your patients’ safety and your facility’s integrity:
Step 1: Gather applicant’s information
The application for employment should be thorough and should
obtain the information needed to ensure patient safety in your facility. “If this first step isn’t well done, then the entire decision process
is compromised,” says Greeley.
Ask for the following information on your application:
• The applicant’s name as well as other names they have used
(e.g., a maiden name)
• Education, degree obtained, and name and location of educational institution
• Professional licensure, state where the license was issued, date
issued, license number, and expiration date
• Specialty certifications
• Employment history
• Disciplinary actions on their license
Verifying Nurse Credentials
7
Also be sure to ask whether the applicant has ever been convicted
or pleaded guilty or no contest to any criminal charges (other than
speeding violations). If the answer is yes, ask the applicant to specify the charges and the dates they occurred. Also inquire whether the
applicant has ever been convicted or pleaded guilty or no contest
to a drug or alcohol-related offense and ask whether he or she has
ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program
(e.g., Medicare or Medicaid), or similar federal, state, or health agency.
Step 2: Verify applicant’s information
After asking the applicant the questions above, it’s imperative to
verify this information to the best of your ability. Document each
verification step, even if you don’t find anything, to further reduce
your institution’s liability. Some facilities hire a third party to verify
applicants’ information, but most often the HR department completes
this task. Either way, make sure there’s a specific, established process
for verification.
Primary verification is the best method to check an applicant’s qualifications, including education, licensure, and past employment.
Most state nursing boards post licensure information on their Web
sites. However, one state nursing board head recommends that
facilities call their state board for the most up-to-date information.
“Our Web site is up-to-date, but if something happened in the past
few days, although it may not be up on the site, we would still
know about it,” says Dorothy Fulton, RN, MA, executive administrator for the Alaska State Board of Nursing. Also check the state
board in every state where the nurse has worked.
Also, consider running criminal background checks on all applicants,
even if your state nursing board runs a check of its own. The nurse
may have committed a crime after receiving his or her license. In
most states, the responsibility is on nurses to notify the state board
if they are convicted of a crime—which they may or may not do,
putting your facility at risk.
8
Verifying Nurse Credentials
When checking past employment, facilities will most likely only
provide the dates the employee worked and if he or she is eligible
for reemployment. “We try to get more information than dates the
employee worked, but these days facilities are hesitant to give you
a whole lot more,” says Debra Rapert, HR director for Marion (OH)
General Hospital. Rapert says it’s a red flag if a facility tells her an
applicant is not eligible for rehire. “That should tell you what you
need to know,” she says.
Another important step in credential verification is checking federal
sanctions lists. If a nurse who has been sanctioned by the Office of
Inspector General or General Services Administration works in your
facility, you could be fined thousands of dollars. Reasons for sanctioning run from defaulting on a student loan to Medicare fraud. Remember, these sanctions do not always show up on a state board
licensing Web site.
Warning signs
Keep an eye out for the following “red flags” when gathering and
verifying an applicant’s information:
• Gaps in job history: Ask the applicant about any gaps in
his or her job history, but realize there will be interruptions
for life events such as the birth of a child or a family
emergency.
• Moving from state to state: “This could potentially be a red
flag, because so much information could be buried,” says Cecelia
Ragland, RN, MSN, from SCM Associates, a credentialing firm
in Bellflower, CA. If a nurse has worked in several states, be
sure to carefully check the status of his or her license in each
state.
• Job hopping: Any HR professional would take a second look
at any applicant who has jumped from job to job. When hiring nurses, patient safety is at stake, so carefully check the
Verifying Nurse Credentials
9
applicant’s work history by calling each employer to verify that
there were no disciplinary actions taken against the nurse.
Step 3: Continually verify employee’s license after hire date
Most facilities check their nurses’ licenses when they come up for
renewal to make sure they’re current and active. However, it is crucial that facilities institute a process to check licenses more often.
Ensure that your policy spells out that it is the nurse’s responsibility
to report any disciplinary action taken against his or her license
over the course of the year. If the nurse does not report any action
to the HR department, they could be working on the floor, interacting with patients with a suspended or inactive license. This leaves
your patients vulnerable and your facility liable. “Conduct periodic
checks with your state board to make sure there are no nurses with
revoked or suspended licenses from your facility,” says Harrington.
Transforming the credentialing process at your facility
Creating a new credential-verification process for nurses may appear
to be a daunting task. But as the Cullen case shows, it’s one that is
too important to ignore. Nurses, who often have the most direct contact with patients, should be subjected to the same scrutiny given to
members of the medical staff such as advanced practice nurses, certified nurse anesthetists, and physicians. “Make credentialing a centralized and consistent process,” advises Harrington.
Making this change will entail an evaluation of staff and resources
as well as a review of your facility’s bylaws. HR administrators should
consult the medical staff office since they most likely have an established credentialing process in place.
Strategically plan, develop, and train a department solely responsible
for the review of nurses’, physicians’, and other health professionals’ credentials during the application process, as well as throughout the year once you’ve hired them. Ensure this new process is consistent with your facility’s bylaws—if it’s not propose revisions to
the appropriate regulations.
10
Verifying Nurse Credentials
Verifying Nurse Credentials
11
08/04
SR3504
This special report is published by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. • Copyright 2004 HCPro, Inc. All rights
reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or
by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. If
you have questions, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: customerservice@hcpro.com • Opinions
expressed are not necessarily those of the editors. Mention of products and services does not constitute endorsement. Advice given
is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. HCPro, Inc., is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations.
12
Verifying Nurse Credentials