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myocardial infarction (MI), a proposed course of problems within the system that extend the length
events leading to a successful patient outcome of stay or drive up costs because of overutilization
within the 4-day DRG-defined time frame or repetition of services. For example:
might be as follows (Doenges, Moorhouse, &
Mr. J. was admitted to the telemetry unit with a
Geissler, 1997): (1) Patient states that chest pain
diagnosis of MI. He had no previous history of heart
is relieved; (2) ST- and T-wave changes resolve
disease and no other complicating factors such as
and pulse oximeter reading is greater than
diabetes, hypertension, or elevated cholesterol levels.
90%; patient has clear breath sounds; (3) Patient
His DRG-prescribed length of stay was 4 days. He
ambulates in hall without experiencing extreme
had an uneventful hospitalization for the first
fatigue or chest pain; (4) Patient verbalizes
2 days. On the third day, he complained of pain in
feelings about having an MI and future fears;
the left calf. The calf was slightly reddened and
(5) Patient identifies effective coping strategies;
warm to the touch. This condition was diagnosed as
(6) Ventricular dysfunction, dysrhythmia, or
thrombophlebitis, which increased his length of hos-
crackles resolved
pitalization. The case manager’s review of the
SCMs may be used alone or together. A patient events leading up to the complaints of calf pain
who is admitted for an MI may have care planned indicated that, although the physician had ordered
using a critical pathway for an acute MI, a heparin compression stockings for Mr. J., the stockings never
protocol, and a dysrhythmia algorithm. In addition, arrived, and no one followed through on the order.
the nurses may refer to the standards of care in The variances related to his proposed length of stay
developing a traditional nursing care plan. were discussed with the team providing care, and
SCMs can improve physiological, psychological, measures were instituted to make sure that this
and financial outcomes. Services and interventions oversight would not occur again.
are sequenced to provide safe and effective out- Critical pathways provide a framework for com-
comes in a designated time and with most effective munication and documentation of care. They are
use of resources.They also give an interdisciplinary also excellent teaching tools for staff members
perspective that is not found in the traditional from various disciplines. Institutions can use criti-
nursing care plan. Computer programs allow cal pathways to evaluate the cost of care for differ-
health-care personnel to track variances (differ- ent patient populations (Capuano, 1995; Crummer
ences from the identified standard) and use these & Carter, 1993; Flarey, 1995; Lynam, 1994).
variances in planning QI activities. Most institutions have adopted a chronological,
The use of SCMs does not take the place of the diagrammatic format for presenting a critical pathway.
expert nursing judgment. The fundamental pur- Time frames may range from daily (day 1,
pose of the SCM is to assist health-care providers day 2, day 3) to hourly, depending on patient needs.
in implementing practices identified with good Key elements of the critical pathway include discharge
clinical judgment, research-based interventions, planning, patient education, consultations, activities,
and improved patient outcomes. Data from SCMs nutrition, medications, diagnostic tests, and treat-
allow comparisons of outcomes, development of ment (Crummer & Carter, 1993). Table 10-2
research-based decisions, identification of high- is an example of a critical pathway. Although orig-
risk patients, and identification of issues and prob- inally developed for use in acute care institutions,
lems before they escalate into disasters. Do not be critical pathways can be developed for home care
afraid to learn and understand the different SCMs. and long-term care. The patient’s nurse is usually
responsible for monitoring and recording any devi-
Critical Pathways ations from the critical pathway. When deviations
Critical pathways are clinical protocols involving all occur, the reasons are discussed with all members
disciplines. They are designed for tracking a of the health-care team, and the appropriate
planned clinical course for patients based on aver- changes in care are made. The nurse must identify
age and expected lengths of stay. Financial out- general trends in patient outcomes and develop
comes can be evaluated from critical pathways by plans to improve the quality of care to reduce the
assessing any variances from the proposed length of number of deviations.Through this close monitor-
stay. The health-care agency can then focus on ing, the health-care team can avoid last-minute

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surprises that may delay patient discharge and can ■ Preparing the patient for discharge
predict lengths of stay more effectively. ■ Telephoning the patient post discharge
Each of these processes can be evaluated in terms
Aspects of Health Care to Evaluate
of timeliness, appropriateness, accuracy, and com-
A CQI program can evaluate three aspects of
pleteness (Irvine, 1998). Process variables include
health care: the structure within which the care is
psychosocial interventions, such as teaching and
given, the process of giving care, and the outcome
counseling, and physical care measures. Process also
of that care. A comprehensive evaluation should
includes leadership activities, such as interdiscipli-
include all three aspects (Brook, Davis, &
nary team conferences. When process data are col-
Kamberg, 1980; Donabedian, 1969, 1977, 1987).
lected, a set of objectives, procedures, or guidelines
When evaluation focuses on nursing care, the inde-
is needed to serve as a standard or gauge against
pendent, dependent, and interdependent functions
which to compare the activities. This set can be
of nurses may be added to the model (Irvine,1998).
highly specific, such as listing all the steps in a
Each of these dimensions is described here, and
catheterization procedure, or it can be a list of
their interrelationship is illustrated in Table 10-3.
objectives, such as offering information on breast-
feeding to all expectant parents or conducting
Structure
weekly staff meetings.
Structure refers to the setting in which the care is The American Nurses Association (ANA)
given and to the resources (human, financial, Standards of Care are process standards that
and material) that are available. The following answer the question: What should the nurse be
structural aspects of a health-care organization can doing, and what process should the nurse follow to
be evaluated: ensure quality care?
■ Facilities. Comfort, convenience of layout, acces-
Outcome
sibility of support services, and safety
■ Equipment. Adequate supplies, state-of-the-art An outcome is the result of all the health-care
equipment, and staff ability to use equipment providers’ activities. Outcome measures evaluate
■ Staff. Credentials, experience, absenteeism, the effectiveness of nursing activities by answering
turnover rate, staff-patient ratios such questions as: Did the patient recover? Is the
■ Finances. Salaries, adequacy, sources family more independent now? Has team function-
ing improved? Outcome standards address indica-
Although none of these structural factors alone
tors such as physical and mental health; social and
can guarantee quality care, they make good care
physical function; health attitudes, knowledge,
more likely. A higher level of nurses each shift and
and behavior; utilization of services; and customer
a higher proportion of RNs are associated with
satisfaction (Huber, 2000).
shorter lengths of stay; higher proportions of RNs
The outcome questions asked during an evalua-
are also related to fewer adverse patient outcomes
tion should measure observable behavior, such as
(Lichtig, Knauf, & Milholland, 1999; Rogers
the following:
et al., 2004).
■ Patient: Wound healed; blood pressure within
Process normal limits; infection absent
Process refers to the activities carried out by the ■ Family: Increased time between visits to the
health-care providers and all the decisions made emergency department; applied for food stamps
while a patient is interacting with the organization ■ Team: Decisions reached by consensus; atten-
(Irvine, 1998). Examples include: dance at meetings by all team members
■ Setting an appointment Some of these outcomes, such as blood pressure or
■ Conducting a physical assessment time between emergency department visits, are eas-
■ Ordering a radiograph and magnetic resonance ier to measure than other, equally important out-
imaging scan comes, such as increased satisfaction or changes in
■ Administering a blood transfusion attitude. Although the latter cannot be measured as
■ Completing a home environment assessment precisely,it is important to include the full spectrum

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table 10-2
Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days
Cardiology or Medical Unit
ND and Categories
of Care Day 1 _____ Day 2 _____ Day 3 _____ Day 4 _____
Decreased cardiac Goals: Display VS within → →
output R/T: Participate in actions acceptable limits; Dysrhythmias →
Decreased myocardial to reduce cardiac dysrhythmias controlled or absent
contractility, altered workload controlled; pulse Free of signs of →
electrical conduction, oximetry within respiratory distress
structural changes acceptable range
Meet own self-care Demonstrate
needs with measurable
assistance as increase in activity
necessary tolerance
Fluid volume excess Verbalize Verbalize Plan for lifestyle/ Plan in place to meet
R/T compromised understanding of understanding of behavior changes postdischarge needs
regulatory fluid/food restrictions general condition
mechanisms: and health-care
hypertension, needs
sodium/water Breathing sounds Breath sounds clear
retention clearing
Urinary output Balanced I&O
adequate
Weight loss (reflecting Edema resolving Weight stable or
fluid loss) continued loss if
edema present
Referrals Cardiology Cardiac rehabilitation Community resources
Dietitian Occupational therapist
(for ADLs)
Social services
Home care
Diagnostic studies ECG, echo, Doppler Echo-Doppler (if not
ultrasound, stress done day 1) or other
test, cardiac scan cardiac scans
CXR CXR
ABGs/pulse oximeter
Cardiac enzymes Cardiac enzymes (if ↑)
ANP, BNP
BUN/Cr BUN/Cr BUN/Cr
CBC/electrolytes, Electrolytes Electrolytes
MG++
PT/aPTT PT/aPTT (if taking anti- PT/aPTT (as indicated)
Liver function studies coagulants)
Serum glucose
Albumin/total protein
Thyroid studies
Digoxin level (as Repeat digoxin level (if
indicated) indicated)
UA

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table 10-2 CikguOnline
Sample Critical Pathway: Heart Failure, Hospital; ELOS 4 Days
Cardiology or Medical Unit—cont’d
ND and Categories
of Care Day 1 _____ Day 2 _____ Day 3 _____ Day 4 _____
Additional Apical pulse, → → bid →
assessments heart/breath sounds
q8h
Cardiac rhythm → → D/C
(telemetry) q4h
BP, P, R q2h until → q8h → →
stable, q4h
Temp q8h → → →
I&O q8h → → → D/C
Weight qAM → → →
Peripheral edema q8h → → bid → qd
Peripheral pulses q8h → → bid → D/C
Sensorium q8h → → bid → D/C
DVT check qd → → →
Response to activity → → →
Response to → → →
therapeutic
interventions
Medication allergies: IV diuretic → PO → →
ACEI, ARB, vasodialtors, → → →
beta blocker
IV/PO potassium → → D/C
Digoxin → → →
PO/cutaneous nitrates → → →
Morphine sulfate → → D/C
Daytime/hs sedation → → → D/C
PO/low-dose → → PO or D/C →
anticoagulant
Stool softener/laxative → → →
Patient education Orient to unit/room Cardiac education per Signs/symptoms to Provide written
protocol report to health-care instructions for
Review advance Review medications: provider home care
directives Dose, times, route, Plan for home-care Schedule for follow-up
purpose, side effects needs appointments
Discuss expected Progressive activity
outcomes, program
diagnostic
tests/results
Fluid/nutritional Skin care
restrictions/needs
Additional nursing Bed/chair rest → BPR/ambulate as → Up ad lib/graded →
actions tolerated, cardiac program
program
Assist with physical → → →
care
Pressure-relieving → → → (send home)
mattress
Dysrhythmia/angina → → →
care per protocol
Supplemental O → → D/C if able →
2
Cardiac diet → →
CP = critical path; ELOS = estimated length of stay; ND = nursing diagnosis.
Doenges, M.E., Moorhouse, M.F., and Geissler, A.C. (2010). Nursing Care Plans: Guidelines for Individualizing Patient Care,ed. 8. Philadelphia: FA Davis, with permission.

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table 10-3
Dimensions of QI in Nursing: Examples
Independent Function Dependent Function Interdependent Function
Structure Pressure ulcer risk assessment High-speed automatic dial-up system Nursing case management
form available puts nurses in touch with physicians model of care adopted on
rapidly rehabilitation unit
Process Assesses risk for development Order to increase dosage of pain Communicates with therapists
of pressure ulcer and medication obtained and about need for customized
implements preventive measures processedwithin 1 hour wheelchair
Outcome Skin intact at discharge Relief from pain Able to enter narrow doorway
to bathroom unassisted
Adapted from Irvine, D. (1998). Finding value in nursing care: A framework for quality improvement and clinical evaluation. Nursing Economics, 16(3),
110–118.


of biological, psychological, and social aspects real or potential exposures that might threaten it.
(Strickland, 1997). For this reason, considerable As a nurse, it is your responsibility to report adverse
effort has been put into identifying the patient out- incidents to the risk manager, according to your
comes that are affected by the quality of nursing organization’s policies and procedures. In many
care. For example, the ANA identified 10 quality states, this is a legal requirement.
indicators in acute care that are likely to relate to the Risk events are categorized according to severity.
availability and quality of professional nursing serv- Although all untoward events are important,
ices in hospitals. Across the United States, data are not all carry the same severity of outcomes
being collected from nursing units using these qual- (Benson-Flynn, 2001).
ity indicators.
A major problem in using and interpreting out- 1. Service occurrence. A service occurrence is an
come measures is that outcomes are influenced by unexpected occurrence that does not result in
many factors. For example, the outcome of patient a clinically significant interruption of services
teaching done by a nurse on a home visit is affected and that is without apparent patient or employee
by the patient’s interest and ability to learn, the injury. Examples include minor property or
quality of the teaching materials, the presence or equipment damage, unsatisfactory provision
absence of family support, information (which may of service at any level, or inconsequential inter-
conflict) from other caregivers, and the environ- ruption of service. Most occurrences in this
ment in which the teaching is done. If the teaching category are addressed within the patient
is successful, can the nurse be given full credit for complaint process.
the success? If it is not successful, who has failed? 2. Serious incident. A serious incident results in a
It is necessary to evaluate the process as well as clinically significant interruption of therapy or
the outcome to determine why an intervention service, minor injury to a patient or employee,
such as patient teaching succeeds or fails. A com- or significant loss or damage of equipment or
prehensive evaluation includes all three aspects: property. Minor injuries are usually defined as
structure, process, and outcome. However, it is needing medical intervention outside of hospital
much more difficult to gather and monitor out- admission or physical or psychological damage.
come data than to measure structure or process. 3. Sentinel events. A sentinel event is an unex-
pected occurrence involving death or serious/
Risk Management permanent physical or psychological injury, or
An important part of CQI is risk management, a the risk thereof. The phrase, “or the risk there-
process of identifying, analyzing, treating, and eval- of” includes any process variation for which a
uating real and potential hazards. The Joint recurrence would carry a significant chance of a
Commission (JC) recommends the integration of serious adverse outcome. Such events are called
a quality control/risk management program to sentinel because they signal the need for imme-
maintain continuous feedback and communication. diate investigation and response. When a sen-
To plan proactively, an organization must identify tinel event occurs, appropriate individuals

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within the organization must be made aware of imperative.The main goal is patient safety.Reporting
the event; they must investigate and understand and remediation must occur quickly (Huber, 2000).
the causes of the event; and they must make Once an incident has occurred, you must com-
changes in the organization’s systems and plete an incident report immediately. The incident
processes to reduce the probability of such an report is used to collect and analyze data for future
event in the future (jcaho.org/ptsafety_frm.html). determination of risk. The report should be accu-
rate, objective, complete, and factual. If there is
The subset of sentinel events that is subject to
future litigation, the plaintiff’s attorney can sub-
review by JC includes any occurrence that meets
poena the report. The report should be prepared in
any of the following criteria:
only a single copy and never placed in the medical
■ The event has resulted in an unanticipated death record (Swansburg & Swansburg, 2002). It is kept
or major permanent loss of function, not related with internal hospital correspondence.
to the natural course of the patient’s illness or Nurses have a responsibility to remain educated
underlying condition. and informed and to become active participants in
■ The event is one of the following (even if the out- understanding and identifying potential risks to
come was not death or major permanent loss of their patients and to themselves. Ignorance of the
function): suicide of a patient in a setting where law is no excuse. Maintaining a knowledgeable,
the patient receives around-the-clock care (e.g., professional, and caring nurse-patient relationship
hospital, residential treatment center, crisis is the first step in decreasing your own risk.
stabilization center), infant abduction or discharge
to the wrong family, rape, hemolytic transfusion The Economic Climate
reaction involving administration of blood or in the Health-Care System
blood products having major blood group incom-
patibilities, surgery on the wrong patient or
For many years, decisions about care were based
wrong body part (jcaho.org/ptsafety_frm.html)
primarily on providing the best quality care, what-
ever the cost. As the economic support for health
Adhering to nursing standards of care as well as the
care is challenged, however, health-care providers
policies and procedures of the institution greatly
are pressured to seek methods of care delivery that
decreases the nurse’s risk. Common areas of risk for
achieve quality outcomes at lower cost.
nursing include:
■ Medication errors Economic Perspective
■ Documentation errors and/or omissions The economic perspective is rooted in three funda-
■ Failure to perform nursing care or treatments mental observations:
correctly
1. Resources are scarce. Due to scarce resources,
■ Errors in patient safety that result in falls
three choices result:
■ Failure to communicate significant data to
patients and other providers (Swansburg & ■ The amount to be spent on health-care services
Swansburg, 2002) and the composition of those services
■ The methods for producing those services
Risk management programs also include attention
■ The method of distribution of health care,
to areas of employee wellness and prevention of
which influences the equity with which these
injury. Latex allergies, repetitive stress injuries,
services are distributed
carpal tunnel syndrome, barrier protection for
tuberculosis, back injuries, and the rise of antibiotic- 2. Resources have alternative uses. As a result of
resistant organisms all fall under the area of risk this scarcity, the choice to expend resources in
management (Huber, 2000). one area eliminates the use of those same
Adhering to standards of care and exercising the resources in another area. If more nursing
amount of care that a reasonable nurse would homes are going to be built, for example, then
demonstrate under the same or similar circumstances there will be fewer hospitals, less housing, less
can protect the nurse from litigation. Understanding education, or other uses of those same
what actions to take when something goes wrong is resources.

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3. Individuals want different services or have
different preferences. Some people choose Factors Increasing Costs
alternative treatment modalities such as
acupuncture, herbal therapy, or massage therapy • Expansion of national economy
rather than traditional health care. Health-care • General inflation
services are marketed extensively. • Aging population
• Growth of third-party payments
• Employer-provided health insurance
Regulation and Competition
• Tax deduction for medical expenses
During the past three decades, federal and state
• Increased costs of labor and equipment
governments have attempted to restrain the cost of
• Expansion of medical technology
health care by focusing. Regulation attempts to and products
control cost through government actions; competi- • Malpractice insurance and litigation
tion uses market forces. Competition can drive
aspects of health care through consumers,
providers, and suppliers. Among the attempts to
control cost were: Factors Containing Costs
1. Medicare Prospective Payment System (PPS). • Federal economic stabilization program
In 1983 the federal government changed its • Voluntary effort hospital regulation program
method of paying hospitals for treating • State-level health-care payment programs
Medicare patients. Instead of paying for actual • Medicare prospective payment system (PPS)
costs, the PPS pays hospitals a fixed, predeter- with payments of fixed amount per admission
mined sum for a particular admission. If a hos- • Diagnostic-related groups (DRGs) for
pital can provide the service at a cost below the hospital payments
fixed amount, it pockets the difference. If more • Resource-based relative value scale (RBRVS)
resources and money are used than the prede- for physician payments
termined amount, the hospital incurs a loss. • Managed care plans
2. DRGs. Tied to the PPS, DRGs are the patient
classification systems by which the Medicare Figure 10.2 Factors affecting the cost of health care.
PPS determines payment. Each of the (From Chang, C.F., Price, S.A., & Pfoutz, S.K. [2001].
495 DRGs represents a particular case type. Economics and Nursing: Critical Professional Issues.
Philadelphia: FA Davis, p. 79.)
3. Managed care. Managed care is a system of
health care that combines the financing and
delivery of health services into a single entity. 5. Medical savings accounts (MSA). As a regula-
Currently, more than 75% of people with pri- tory tool, MSAs are a cost-sharing method for
vate health insurance are enrolled in managed incentivizing consumers to plan and share in
care plans. Managed care plans are seen as cost- the cost of their own health-care expenditures.
saving alternatives to traditional fee-for-service Money that would normally be spent on
delivery systems. Through provider networks health-care premiums by the employer-
and selective provider contracting, they attempt consumer is deposited into an MSA. Accounts
to control resource use and health-care costs created under the Medicare Modernization
(Chang, Price, & Pfoutz, 2001). Figure 10.2 Act of 2003 are the property of the employee-
depicts the current factors increasing and consumer, giving more choice into how and
containing health-care costs. where the money is spent. The account is tax-
4. Cost sharing. With rising health-care costs, deferred until it is used for allowable health-
employers purchasing health plans have begun related spending as in high-deductable health
to shift some of the increase cost in premiums, plans and tax-deferred plans. Other types of
prescriptions, and specialty services to employ- consumer-directed plans exist, such as the
ees. Higher cost for consumers and shifting flexible spending account, health reimburse-
financial burdens have left more Americans ment account, and medical saving accounts, all
without health-care coverage. of which have stipulations for use.

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6. Single-Payer/National Health Coverage. demand from employers, and the new graduate
A single-payer system aims to decrease the cost pipeline for RNs.
of care by eliminating third-party insurers,
costly overhead, and bureaucracy while provid- ■ Supply of existing RNs. The total supply of
ing coverage for all. Plans may offer choices to U.S. RNs is estimated at 2.9 million and is pro-
consumers regarding providers, hospitals, and jected to remain the same though 2020. The
specialty services, and physicians and hospitals supply of active RNs, including those who are
are paid through negotiates, fee-for-service, or licensed, working, or seeking employment as an
salary. Costs are controlled through budgeting, RN, is projected be 2.1–2.3 million from 2000
bulk purchasing, and negotiation (Physicians to 2020 (U.S. Department of Health and
for a National Health Plan, 2008). Human Services [HRSA], 2006).
■ New graduate supply pipeline. Nursing program
Proponents of a single-payer system cite lower costs graduation and NCLEX-RN pass rates affect
per capita while ensuring access to care for all supply. The American Association of Colleges of
Americans. Opponents cite that the possible trade- Nursing (AACN) reported an increase in bac-
off for decreased cost and improved access leads to calaureate level–entry enrollments, up by 5.4% in
increased mortality, poorer outcomes of care, limited 2006 (AACN, 2008). According to the National
to no-cost savings, and loss of control by consumers Council of State Boards of Nursing (2008), first-
(National Center for Policy Analysis, 2008). time candidates for nursing licensure in 2007
The intended effects of regulation and competi- numbered 200,209, with a pass rate of 69.4%.
tion are to decrease cost. Despite the variety of However, HRSA (2006) projected that U.S.
attempts over the years to drive down costs, they nursing programs must graduate 90% more nurs-
continue to go up, imposing a heavy burden on es to meet the U.S. demands for nurses (p. 2).
consumers or employers (Center for Studying ■ Demand from employers. The Bureau of Labor
Health System Change, 2008). However, improved Statistics predicts the RN job to be among the
quality and safety prevent unnecessary deaths and top 10 in growth rate (U.S. Department of
errors that contribute to the high cost of care Labor, 2008). Total job openings for RNs will
(IOM, 2000; IOM 2003a). The U.S. government, exceed 1.1.million, including new job growth
consumers, providers, and organizations have a and replacement of retiring nurses.
vested interest in controlling health-care expendi-
tures and in preventing waste while maintaining In a survey of over 5000 community hospitals, the
quality care. American Hospital Association (2007) reported
116,000 RN vacancies as of December 2006. The
Nursing Labor Market effects of these vacancies contribute to decreased
employee and patient satisfaction and increased hiring
RNs comprise 77% of the nurse workforce, and of foreign-educated nurses. The majority of urban
almost 60% of RNs are employed by hospitals.The hospital emergency departments reported capacity
nationwide unemployment rate for RNs is only 1%. issues and spend time on by-pass or diversion due to
Vacancy rates nationwide are reported at anywhere a lack of properly staffed critical care beds.
from 13% to 20% and are rising. A serious nursing In 2002 more than 100,000 new RNs were
shortage is here, and it will continue until at least hired; the majority were foreign-born nurses and
2020. The demand for nurses is expected to nurses over age 50 returning to the workforce in
increase even more dramatically as the baby tough economic times. Although the new hires and
boomers reach their 60s, 70s, and beyond. From a sharp increase in RN salaries are positive, the cur-
now until 2030, the population age 65 years and rent nursing shortage is far from over.
older will double.
Factors Contributing to the Nursing Shortage
Defining and Identifying the Nursing Shortage
Many complex factors have led to and continue to
The nursing shortage is defined simply as a supply- contribute to the current critical nursing shortage:
demand issue. Unfortunately, the current nursing
shortage is more complex and severe than previous ■ High acuity, increasing age of patients in
shortages in terms of the available supply, the hospitals. Medically complex patients require

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skilled nursing care. The number of aging baby staffing, the model of care, and professional
boomers will significantly increase the demands nursing practice (Ritter-Teitel, 2002).
on the health-care systems and increase the
needs for RNs. Safety in the U.S. Health-Care
■ Increased demand for nurses. As health care System
moves to a variety of community settings, only
the most acute patients remain in the hospital. Patient safety is the prevention of harm caused by
The transfer of less acute patients to nursing errors. The IOM defines errors as “the failure of a
homes and community settings creates addition- planned action to be completed as intended (e.g.,
al job opportunities. Research supporting error of execution) or the use of a wrong plan to
improved patient outcomes when patient care is achieve an aim (e.g., error of planning) (IOM,
provided by RNs as opposed to unlicensed per- 2000, p. 57). It is important to note that errors are
sonnel will also increase demand for RNs. unintentional and that not all errors lead to an
■ Aging nursing workforce. In 2000, fewer than adverse event causing harm or death.
one in three RNs was younger than 40 years of
age. The percentage of nurses age 40–49 years is Types of Errors
currently more than 35%. To Err is Human (2000) relied on the work of
Leape et al. (1993) to categorize types of errors
In March 2004 the average age of the RN popula-
(Box 10-7). After categorizing types of errors,
tion was 46.8 years of age, up from 45.2 in 2000.
Leape and colleagues found that 70% of all errors
The RN population under the age of 30 dropped
were preventable.
from 9% of the nursing population in 2000 to 8%
Human errors can occur for many reasons. Skill-
in 2004 (AACN, 2008).
based errors can be slips or lapses when the actions
■ Job dissatisfaction. Staffing levels, heavy taken by the provider were not what was intended
workloads, increased use of overtime, lack of (Duke University Medical Center, 2005). An
sufficient support staff, and salary discrepancies example of rule-based error is an experienced nurse
between nurses and other health-care profes- administering the wrong medication by picking up
sionals have contributed to growing dissatisfac- the wrong syringe.
tion and lower retention of nurses. Many
facilities are now using workplace issues and
incentives as a retention strategy. box 10-7
■ Reduction in and shortage of nursing faculty. As Types of Errors (IOM, 2000, p. 36)
retirements for faculty continue, the shortage
Diagnostic
of faculty continues to affect the number of Error or delay in diagnosis
students admitted to nursing programs. In Failure to employ indicated tests
2007 nursing programs reported more than Use of outmoded tests or therapy
750 open nursing faculty positions (AACN, Failure to act on results of monitoring or testing
2008). In addition, nursing programs turned Treatment
Error in the performance of an operation, procedure, or test
away over 40,000 qualified nursing applicants,
Error in administering the treatment
in part, due to the shortage of nursing faculty Error in the dose or method of using a drug
(AACN, 2008). Avoidable delay in treatment or in responding to an abnor-
■ The need to control spiraling health-care costs, mal test
along with the issues of supply and demand for Inappropriate (not indicated) care
nursing services will continue. According to the Preventive
ANA, more than 40% of nurses graduate initially Failure to provide prophylactic treatment
from associate-degree nursing programs. You, Inadequate monitoring or follow-up of treatment
personally, will be affected by trends in health- Other
Failure of communication
care delivery, but you can also be a major voice
Equipment failure
in decision making (Nelson, 2002). As in the Other system failure
past, cost control and demand for nursing
Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing medical
services will most likely involve changing nurse injury. Qual Rev Bull. 19(5):144–149, 1993.

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Not all errors lead to patient harm or to an systems (Rosenthal & Booth, 2005). In addition,
adverse event. Each type of event can be studied to the Food and Drug Administration (FDA) man-
glean data used to improve safety. dates reporting of serious harm or death (adverse
events) related to drugs and medical devices. Failure
■ Near miss. A near miss is an error that results in
to report mandatory requirements may lead to fines,
no harm or very minimal patient harm (IOM,
withdrawal of participation in clinical trials, or loss
2000, p. 87). Near misses are useful in identify-
of licensure to operate.
ing and remedying vulnerabilities in a system
The Joint Commission relied on root cause
before harm can occur.
analysis from each sentinel event. Root cause analy-
■ Adverse event. An adverse event is injury to a
sis is the process of learning from consequences.
patient caused by medical management rather
The consequences can be desirable, but most root
than an underlying condition of the patient
cause analysis deals with adverse consequences. An
(IOM, 2000). The IOM reports have highlight-
example of a root cause analysis is a review of a
ed the prevalence of errors, especially preventa-
medication error, especially one resulting in a death
ble adverse events. Adverse events have been
or severe complications. Principles of root cause
classified into four types (see Box 10-7).
analysis include:
■ Accident. An accident is an event that involves
damage to a defined system that disrupts the 1. Determine what influenced the consequences,
ongoing or future output of that system. i.e., determine the necessary and sufficient
Accidents occur when multiple systems fail and influences that explain the nature and the mag-
tend to be unplanned or unforeseen. Accidents nitude of the consequences.
provide information about systems. 2. Establish tightly linked chains of influence.
3. At every level of analysis, determine the neces-
Error Identification and Reporting sary and sufficient influences.
4. Whenever feasible, drill down to root causes.
Nurses are on the front line in identifying and
5. Know that there are always multiple root causes.
reporting errors. However, many errors are not
reported or go undetected. Providers and organiza- The Joint Commission also developed the
tions may fear blame or punishment for mistakes International Center for Patient Safety, which
or errors. establishes National Patient Safety Goals each year
and publishes Sentinel Event Strategies. Box 10-8
Developing a Culture of Safety
To achieve safe patient care, a culture of safety must
exist. Organizations and senior leadership must
box 10-8
drive change to develop a culture of safety—a
blame-free environment in which reporting of Joint Commission International Center
errors is promoted and rewarded. A culture of for Patient Safety
safety promotes trust, honesty, openness, and trans- 1. Sets patient safety standards
parency. Teamwork and involvement of the patient 2. Implements and oversees sentinel event policy and
advisory group
contribute to promoting a culture of safety. When
3. Publishes Sentinel Event Alert newsletter and quality
a culture of safety exists, individual providers do check reports
not fear reprisal and are not blamed for identifying 4. Sets yearly national patient safety goals
or reporting errors. Reported errors provide data 5. Developed the universal protocol related to surgical
and information necessary to understand why or procedures
6. Evaluates organizations’monitoring of quality of care
how the error occurred, thus improving care and
issues
preventing harm. 7. Conducts patient safety research
Event-reporting systems hold organizations 8. Provides patient safety resources
accountable and lead to improved safety.Mandatory 9. Supports the Speak Up program
reporting systems are operated by regulatory agen- 10. Involved with patient safety coalitions and legislative
efforts
cies and have a strong focus on errors associated
Adapted from Joint Commission on Accreditation of Healthcare
with serious harm or death. As of 2005, 24 states
Organizations (JCAHO), accessed November 26, 2005, from
had either mandatory or voluntary reporting jcpatientsafety.org

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describes the work of the International Center for box 10-9
Patient Safety. These tools developed by the Joint
Organizations and Agencies Supporting
Commission offer health-care organizations goals Quality and Safety
and strategies to prevent harm and death based on
Government Agencies
what has been learned from sentinel events.
• U.S. Department of Health and Human Services
http://www.hhs.gov/
Organizations, Agencies, and Initiatives • Food and Drug Administratoin (FDA) http://www.fda.gov/
Supporting Quality and Safety in the • Initiatives: Medwatch and Sentinel Initiative
Health-Care System • Health Resources and Services Administration (HRSA)
http://www.hrsa.gov/
The ongoing movement to improve quality and • Initiatives: Health Information Technology and National
safety has led to the development of governmental Practitioner Database
and private organizations (see Box 10-9) in addition • Center for Medicare and Medicaid Services (CMS) http://
to those mentioned in the historical perspective www.cms.hhs.gov/
• Initiatives: Hospital Quality Initiative, MedQIC, American
at the beginning of this chapter. These organiza-
Health Quality Association (AHQA),
tions and agencies currently monitor, evaluate, • Agency for Healthcare Research and Quality (AHRQ)
accredit, influence, research, finance, and advocate http://www.ahrq.gov/
for quality within the health delivery system. Each • Initiatives: Health IT, Improving Health Care Quality,
organization works inside and outside the system Medical Errors and Patient Safety, Measuring Quality
• VA National Center for Patient Safety http://www.
to drive change leading to improved health out-
va.gov/ncps/
comes and improved system quality. Each organi-
Health-Care Provider Professional Organizations
zation works within its mission to address various • American Nurses Association http://nursingworld.org/
characteristics of the health-care system or to • Initiative: National Database of Nursing Quality
address patient needs. Some organizations serve Indicators (NDNQI)
multiple roles beyond their primary mission. • Association of Perioperative Registered Nurses (AORN)
https://www.aorn.org/
• Initiative: Patient Safety First and AORN Toolkits
Government Agencies
• American Hospital Association (AHA)
Federal and state-level government agencies pro- http://www.aha.org/
vide tools and resources for improving quality and • Initiative: AHA Quality Center
• Association of Academic Health Centers
safety within the U.S. health-care system.
http://www.aahcdc.org/index.php
Government agencies also oversee regulation, • Priorities: Health Profession Workforce and Health Care
licensure, and mandatory and voluntary reporting Reform
programs. Non-Profit Organizations, Foundations, and Research
Within the U.S. Department of Health and • The Leapfrog Group http://www.leapfroggroup.org/
Human Services (HHS) reside multiple agencies • Kaiser Family Foundation http://www.kff.org/
that support quality and safety. HHS is the U. S. • Markel Foundation-Connecting for Health http://www.
connectingforhealth.org/aboutus/index.html#
government’s principal agency for protecting the
• Robert Wood Johnson Foundation-Quality Equality in
health of all Americans and providing essential Healthcare http://www.rwjf.org/qualityequality/
human services,including health care (HHS,2008). index.jsp
HHS works closely with state and local govern- • National Patient Safety Foundation http://www.
ments to meet the nation’s health and human needs. npsf.org/
• The Commonwealth Fund http://www.commonwealthfund.
In addition to administering Medicare and
org/aboutus/
Medicaid, the Center for Medicare and Medicaid
Quality Organizations
(CMS) administers quality initiatives intended “to • Institute for Healthcare Improvement (IHI) http://
assure quality health care for all Americans through www.ihi.org/ihi
accountability and public exposure” (CMS, 2008). • The Joint Commission http://www.jointcommission.org/
Initiatives include: • National Committee for Quality Assurance (NCQA) http://
web.ncqa.org/
■ MedQIC. This initiative aims to ensure each • National Quality Forum http://www.qualityforum.org/
Medicare recipient receives the appropriate level
of care. MedQIC is a community-based QI
program that provides tools and resources to

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encourage changes in processes, structures, and ■ AHRQ Quality Indicators. Set of quality indi-
behaviors within the health-care community. cators used by organizations to highlight
■ Post–Acute Care Reform Plan. CMS is exam- potential quality concerns, identify areas that
ining post-acute transfers with the aim of reduc- need further study and investigation, and track
ing care fragmentation and unsafe transitions. changes over time
■ Hospital Quality Initiative. This is a major ini-
The U. S. Department of Defense (DoD) and the
tiative aimed at improving quality of care at the
Veterans Health Administration (VHA) have
provider and organization level. Organizations
taken leadership positions in developing tools,
provide data through public reporting of quality
resources, and programs aimed at improving safety,
measures that translate information to assist
promoting change, and promoting a culture of safety
consumers in health decisions. This initiative cre-
within the DoD and VHA. The VHA National
ates a uniform set of quality measurement by
Center for Patient Safety developed a toolkit for
which consumers can compare organizations and
fall prevention and management, tools for escape
by which organizations can benchmark progress
and elopement management, and cognitive aids for
toward achieving goals in specified areas of care,
root cause analysis and health failure mode and
such as acute myocardial infarct, congestive heart
effect analysis.
failure, pneumonia, and postsurgical infections.
These data feed the Hospital Compare Web site
Health-Care Provider Professional
(www.hospitalcompare.hhs.gov). Organizations
Organizations
are incentivized to participate with an offering of
increased reimbursement. Professional organizations directly address the mis-
sions and concerns regarding quality and safety of
Also under the HHS is the Agency for Healthcare the professionals they represent. Each organization
Research and Quality (AHRQ), which is the lead offers programs, access to evidence-based practices,
federal agency charged with improving the quality, toolkits, and newsletters to aid their members in
safety, efficiency, and effectiveness of health care for driving quality within their own practice and
all Americans (HHS, 2008).Through multiple ini- organization.
tiatives, the support of research, and evidence- The vital quality and safety initiative of the
based decision-making, the AHRQ aims to fulfill ANA is the National Database of Nursing Quality
its mission: Indicators (NDNQI), a database of unit-specific
■ Health IT. A multifaceted initiative that includes nurse-sensitive information collected at hospitals.
(a) research support of $260 million in grants and Data are collected and evaluated to improve quality.
contracts to support and stimulate investment The indicators reflect the structure, process, and
in health information technology (IT); (b) the outcomes of nursing care and lead to improved
newly created AHRQ National Resource Center, quality and safety at the bedside. The ANA also
which provides technical assistance and research has a strong focus on safe nurse staffing levels to
funding to aid technology implementation within promote safe, quality patient care.
communities; and (c) learning laboratories at
more than 100 hospitals nationwide to develop Nonprofit Organizations and Foundations
and test health IT applications With few exceptions, nonprofit organizations and
■ National Quality Measures Clearinghouse foundations are generally focused on consumer
(NQMC). Web-accessible database provides education, policy development, and research to
access to evidence-based quality measures and improve quality and safety within the health-care
measure sets; NQMC provides access for system. Many organizations serve multiple mis-
obtaining detailed information on quality sions. The Kaiser Family Foundation (2005) has a
measures and to further their dissemination, strong emphasis on U.S. and international nonpar-
implementation, and use in order to inform tisan health policy and health policy research. Self-
health-care decisions funded research and public opinion polling on
■ Medical Errors and Patient Safety. Web site topics related to quality and safety in the health-
providing access to evidence-based tools and care system contribute to policy and legislation
resources for consumers and providers development.

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Also having a multifaceted mission, the physical plant, number of patient beds per nurse,
renowned Robert Wood Johnson Foundation credentialing of service providers, and other
(RWJF) serves multiple missions and seeks to standards for each department. This system of
improve health and health care for all Americans. evaluation has given way to a more process- and
RWJF’s success comes from leveraging partner- outcome-focused model: CQI. Today, the JC
ships and its endowment to “building evidence and accredits more than 19,000 health-care organiza-
producing, synthesizing and distributing knowl- tions. Evaluation of nursing services is an impor-
edge, new ideas and expertise” (RWJF, 2008) in tant part of the accreditation. JC–accredited
eight program areas. RWJF is responsible for agencies are measured against national standards
sucessfully funded projects and research that set by health-care professionals. Hospitals,
improve quality and safety for all Americans. health-care networks, long-term care facilities,
The Leapfrog Group is a nonprofit organiza- ambulatory care centers, home health agencies,
tion interested in improving safety, quality, and behavioral health-care facilities, and clinical
affordability of health care through incentives and laboratories are among the organizations seeking
rewards to those who use and pay for health care JC accreditation. Although accreditation by the
(Leapfrog Group, 2007). With a focus on reducing JC is voluntary, Medicare and Medicaid reim-
preventable medical mistakes, the Leapfrog Group bursement cannot be sought by organizations not
touted their benefits to improve safety and quality accredited by JCAHO.
to consumers and business owners with three leaps:
(a) improve transparency by reporting hospital Integrating Initiatives and
survey results addressing quality and safety indica- Evidenced-Based
tors; (b) incentivize better quality and safety Practices Into Patient Care
performance; and (c) collaborate with other orga- As you familiarize yourself with each of these
nizations to improve quality and safety. To date, organizations and their respective initiatives, con-
there is limited evidence that the Leapfrog Group sider how they will affect the management of
has effectively improved quality or safety. patient care. Your responsibility as a professional
Limitations to success may be in part because too RN is to acknowledge their presence, understand
few hospitals have participated in the surveys and and value their importance, and participate in your
too few consumers have used the available infor- facility-adopted initiatives and evidence-based
mation to make health decisions; however, there is practices.Additionally,as a leader and manager,you
an indication that, with time, participation could will be expected to drive changes based upon
improve with adjustments in strategy by the endeavors of many of these organizations, agencies,
Leapfrog Group (Galvin, Delbanco, Milstein, & and initiatives ensuring that quality and safety con-
Belden, 2005). tinue to improve.

Quality Organizations Health-Care System Reform
Each of the quality organizations strives to improve Eighty-two percent of Americans believe the U.S.
system-wide quality for Americans through a vari- health-care system is in need of either fundamental
ety of programs and methods. change or complete rebuilding (How, Shih, Lau,
The National Committee for Quality Assurance & Shoen, 2008). Americans want leadership to
(NCQA) was established in 1990 to accredit health address quality, cost, coverage, and access. The
plans and certify organizations. Its success in sup- debate rests on how best to achieve necessary
porting quality and safety resides in its Health reform.
Effectiveness Data and Information Set (HEDIS). The IOM report proposed five core compe-
Over 90% of U.S. health plans use HEDIS to tencies (Box 10-10) in which all health-care
measure performance. HEDIS allows for con- professionals will need to be effective as providers
sumers and employers to evaluate health plans and leaders in the 21st-century health-care
using data from HEDIS as a report card of the system.
plan’s success. By integrating these competencies into
JC was established in 1951 with a focus on 21st-century health profession education, you can
structural measures of quality, assessment of the begin to support health-care reform while managing

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box 10-10
Core Competencies for Health Professionals (IOM, 2003a, p. 4)
Provide patient-centered care. Identify, respect, and care about patients; differences, values, preferences, and expressed
needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate
patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion
of healthy lifestyles, including a focus on population health.
Work in interdisciplinary teams. Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is
continuous and reliable.
Employ evidence-based practice. Integrate best research with clinical expertise and patient values for optimum care, and
participate in learning and research activities to the extent feasible.
Apply quality improvement. Identify errors and hazards in care; understand and implement basic safety design principles,
such as standardization and simplification; continually understand and measure quality of care in terms of structure, process,
and outcomes in relation to patient and community needs; and design and test interventions to change processes and
systems of care with the objective of improving quality.
Utilize informatics. Communicate, manage knowledge, mitigate error, and support decision making using information
technology.


patient care.As a practicing professional,you can use 4. The ANA supports a single-payer health-care
the competencies to guide future professional devel- system (ANA, 2005, p. 2).
opment and ensure positive impact on health-care Although updated in 2008, the ANA’s policy still
reform while improving quality and safety. maintains the same four principles.
Role of Nursing in System Reform Influence of Nursing
The ANA’s Agenda Nurses are empowered through self-determination,
In 1989, taking a leadership position regarding meaning, competence, and impact (Whitehead,
health-care reform, the ANA began to address Weiss, & Tappen, 2007, p. 71). Additionally, nurses
concerns regarding quality, safety, and cost of care play vital roles in collective bargaining and decision
as well as the potential health-care reform within making within their organizations, empowered
the United States Working with more than 60 through professional organization such as the
nursing and health-care organizations, the ANA ANA (see Chapter 5).
published Nursing’s Agenda for Health Care Reform Nurses are respected and trusted health-care
(ANA, 1991). This document was positioned as its professionals. To influence change in the health-
blueprint for reform. care system, professional nurses must first acknowl-
Building on the ANA’s report from 1991, the edge power within the profession and recognize
ANA’s Health Care Agenda (ANA, 2005) describes their central role in health care. To be effective,
the organization’s policy on health system reform. nurses must leverage their professional expertise
This policy includes four basic principles: and the trust and respect they have garnered. It is
critical that nurses speak up and seek an active role
1. Health care is a basic human right. A restruc-
in shaping health-care reform:
tured health-care system should include univer-
sal access to essential services. ■ Become informed. Research topics of interest
2. The development of health policies that incor- to you and your practice. Rely on the Internet
porate the IOM’s six aims of health care will and your professional organizations as resources
save money. for current policy and legislative topics.
3. The health-care system must be reshaped and ■ Plan. After selecting a topic, prepare your plan:
redirected away from the overuse of expensive, gather facts and figures that will support your
technology-driven, acute, hospital-based ideas and position. Outline them, and address
services in the model we now have to one your audience in person, on paper, or via the
in which a balance is struck between high- Web. The most influential people are prepared
technology treatment and community-based and believe in their topic.
and preventive services, with emphasis on ■ Take action. Shape public opinion by the
the latter. method of your choice. Start small, and build

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your impact. (1) Write a letter to your represen- selected, focus attention on the following in patient
tative (local, state, federal), ANA leadership or care delivery (Hansten & Washburn, 2001, p. 24D):
state-level delegate, the editor of your local
1. Think critically. Use your creative, intuitive,
newspaper, or to the editor of your favorite
logical, and analytical processes continually in
nursing journal/magazine. (2) Attend a meeting
working with patients.
where your topic will be addressed in a public
2. Plan and report outcomes. Emphasizing results
forum or at a professional gathering. Meet the
is a necessary part of managing resources in
people who are influential, and share your ideas
today’s cost-conscious environment. Focusing
or learn from others. (3) Vote for candidates and
on the outcomes moves the nurse out of the
officers in your professional organizations and
mindset of focusing just on tasks.
within the government. (4) Visit your represen-
3. Make introductory rounds. Begin each shift
tative (local, state, federal) or ANA leadership
with the health-care team members introduc-
or state-level delegate to share your ideas.
ing themselves, describing their roles, and pro-
(5) Volunteer. Ask what you can do to help.
viding patients updates.
(6) Testify before decision-making bodies.
4. Plan in partnership with the patient. In conjunc-
tion with the introductory rounds, spend a few
Conclusion minutes early in the shift with each patient,
discussing shift objectives and long-term goals.
Pressure from quality organizations, consumers,
This event becomes the center of the nursing
payers, and providers has caused the focus in the
process for the shift and ensures that the patient
health-care system to shift from patient care to
and nurse are working toward the same outcomes.
issues of cost and quality. Experts indicate that
5. Communicate the plan. Avoid confusion
quality promotes decreased costs and increased sat-
among members of the team by communicat-
isfaction. This is an opportunity for nurses to
ing the intended outcomes and the important
become more professional and empowered to
role that each member plays in the plan.
organize and manage patient care so that it is safe,
6. Evaluate progress. Schedule time during the
efficient, and of the highest quality. Begin early in
shift quickly to evaluate outcomes and the
your career to participate actively in QI initiatives.
progress of the plan and to make revisions as
Regardless of the care model used or the indicators
necessary.
Study Questions
1. How have historical, social, political, and economic trends affected your practice? Give specific
examples and their implications.
2. What problems have you identified during your clinical experiences that could be considered issues
to be addressed using CQI?
3. What SCMs have you seen implemented in practice? Which ones might you use to assist you in
planning care? If you have not seen any, ask the nurse manager what is used on the unit.
4. Review the section in this chapter on risk management. In what areas of risk do you feel you are
the most vulnerable? How will you work on correcting your risk?
5. Discuss the role of the nurse in CQI and risk management.
6. Based on patient safety goals for the current year, what will you do to ensure adherence to these goals?
7. What are evidence-based practices that promote quality and safety within the health-care system?
8. Describe how regulatory agencies and accrediting agencies affect patient care and outcomes at the
bedside.

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9. Review the nonprofit organizations and government agencies that influence and advocate for
quality and safety in the health-care system. What do the organizations or agencies do that
supports the hallmarks of quality? What have been the results of their efforts for patients, facilities,
the health-care delivery system, and the nursing profession? How have the organizations or
agencies affected your facility and professional practice?
10. Explain how technology enhances and promotes safe patient care, educates patients and
consumers, evaluates health-care delivery, and enhances the nurse’s knowledge base in your
practice and at your organization.
11. How would you begin discussion on quality and safety issues with the nurse manager or
colleague?

12. What issues may arise when the care delivery system is changed? What does the RN need to
consider when implementing these changes?



Case Study to Promote Critical Reasoning

The director of CQI has called a meeting of all the staff members on your floor. Based on last
quarter’s statistics, the length of stay of patients with uncontrolled diabetes is 2.6 days longer than
that of patients for the first half of the year. She has requested that the staff identify members who
wish to be CQI team members looking at this problem. You, the staff nurse, have volunteered to be
a member of the team. The team will consist of the diabetes educator, a patient-focused care
assistant, a pharmacist, and you.

1. Why were these people selected for the team?
2. What data need to be collected to evaluate this situation?
3. What are the potential outcomes for patients with uncontrolled diabetes?

4. Develop a flowchart of a typical hospital stay for a patient with uncontrolled diabetes.



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Time Management





OBJECTIVES OUTLINE
After reading this chapter, the student should be able to: The Tyranny of Time
■ Describe personal perceptions of time. How Do Nurses Spend Their Time?
■ Discuss the rationale for good time management skills. Organizing Your Work
■ Set short- and long-term personal career goals. Setting Your Own Goals
■ Analyze activities at work using a time log. Lists
■ Incorporate time management techniques into clinical Long-Term Planning Systems
practice. Schedules and Blocks of Time
■ Organize work to make more effective use of available time. Filing Systems
■ Set limits on the demands made on one’s time.
Setting Limits
■ Create a personal calendar using a computerized calendar
system. Saying No
Eliminating Unnecessary Work
Streamlining Your Work
Avoiding Crisis Management
Keeping a Time Log
Reducing Interruptions
Categorizing Activities
Finding the Fastest Way
Automating Repetitive Tasks
The Rhythm Model for Time Management
Conclusion


































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Coming onto the unit, Celia, the evening charge people measure it (Smith, 1994). It really does not
nurse, already knew that a hectic day was in matter which theory is correct because, for nurses,
progress. Scattered throughout the unit were clues their professional and personal lives are guided
from the past 12 hours. Two patients on emergency by time.
department stretchers had been placed outside obser- How often do you look at your watch during the
vation rooms already occupied by patients who were day? Do you divide your day into blocks of time?
admitted the previous day in critical condition. Do you steal a quick glance at the clock when you
Stationed in the middle of the hall was the code cart, come home after putting in a full day’s work? Do
with its drawers opened and electrocardiograph you mentally calculate the amount of time left to
paper cascading down the sides. Approaching the complete the day’s tasks of grocery shopping, driv-
nurses’ station, Celia found Guillermo buried deep in ing in a car pool, making dinner, and leaving again
paperwork. He glanced at her with a face that had to take a class or attend a meeting? Calendars,
exhaustion written all over it. His first words were, clocks, watches, newspapers, television, and radio
“Three of your RNs called in sick. I called staffing for remind people of their position in time. Perception
additional help, but only one is available. Good of time is important because it affects people’s use
luck!” Celia surveyed the unit, looked at the number of time and their response to time (Box 11-1).
of staff members available, and reviewed the patient Computers complete operations in a fraction of
acuity level of the unit. She decided not to let the sit- a second, and speeds can be measured to the
uation upset her. She would take charge of her own nanosecond. Time clocks that record the minute
time and reallocate the time of her staff. She began to employees enter and leave work are commonplace,
reorganize her staff mentally according to their and few excuses for being late are really considered
capabilities and alter the responsibilities of each acceptable. Timesheets and schedules are part of
member. Having taken steps to handle the problem, most health-caregivers’ lives. Staff members are
Celia felt ready to begin the shift.
Business executives, managers, students, and nurses
know that time is a valuable resource.Time cannot box 11-1
be saved and used later, so it must be used now and Time Perception
wisely. As a new nurse, you may at times find your- Webber (1980) collected a number of interesting tests of
self sinking in the “quicksand”of a time trap, know- people’s perception of time. You may want to try several
ing what needs to be done but just not having the of these:
necessary time to do it (Ferrett, 1996). In today’s • Do you think of time more as a galloping horseman or a
fast-paced health-care environment, time manage- vast motionless ocean?
• Which of these words best describes time to you: sharp,
ment skills are critical to a nurse’s success. Learning
active, empty, soothing, tense, cold, deep, clear, young,
to take charge of your time and to use it effectively or sad?
and efficiently is the key to time management • Is your watch fast or slow? (You can check it with the
(Gonzalez, 1996). Many nurses believe they never radio.)
have enough time to accomplish their tasks. Like • Ask a friend to help you with this test. Go into a quiet
room without any work, reading material, radio, food,
the White Rabbit in Alice in Wonderland, they are
or other distractions. Have your friend call you after
constantly in a rush against time. Time manage- 10–20 minutes have elapsed. Try to guess how long
ment, simply, is organizing and monitoring time so you were in that room.
that patient care tasks can be scheduled and imple- Webber test results interpreted. A person who has a circular
mented in a timely and organized fashion (Bos & concept of time would compare time with a vast ocean.
Vaughn, 1998). A galloping horseman would be characteristic of a linear
conception of time, emphasizing speed and forward
motion. A person oriented to a fast tempo and achievement
The Tyranny of Time would describe time as clear, young, sharp, active,
or tense rather than empty, soothing, sad, cold, or deep.
These same fast-tempo people are likely to have fast
Newton stated that time was absolute and that it
watches and to overestimate the amount of time that they
occurred whether the universe was there or not. sat in a quiet room.
Einstein theorized that time has no independent
Adapted from Webber, R.A. (1980). Time Is Money! Tested Tactics That
existence apart from the order of events by which Conserve Time for Top Executives. New York: Free Press.

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expected to follow precisely set schedules and meet institutions need to change their thinking on how to
deadlines for almost everything, from distributing manage work. Most are looking toward technology
medications to completing reports on time. Many to help cope with staffing shortages (Baldwin,2002).
agencies produce vast quantities of computer- For example:
generated data that can be analyzed to determine
A new graduate worked in a medical intensive care
the amount of time spent on various activities.
unit from 7 a.m. to 3 p.m. and rotated every third
Several fallacies exist regarding time manage-
week to 11 p.m. to 7 a.m., working 7 days straight
ment. One of the foremost is that time can be man-
before getting 2 days off. It was not difficult to
aged like other resources. Time is finite. There are
remain awake during the entire shift the first night
only 24 hours in a day, so the amount of time avail-
on duty, but each night thereafter staying awake
able cannot be controlled, only how it is used
became increasingly difficult. After taking and
(Brumm, 2004). Individual personality, culture,
recording the 2 a.m. vital signs, the new graduate
and environment interact to influence human
inevitably fell asleep at the nurses’ station. He was so
perceptions of time (Matejka & Dunsing, 1988).
tired that he had to check and recheck patient med-
Everybody has an internal tempo (Chappel, 1970).
ications and other procedures for fear of making a
Some internal tempos are quicker than others.
fatal error. He became so anxious over the possibility
Environment also affects the way people respond to
of injuring someone that sleep during the day became
time.A fast-paced environment influences most peo-
impossible. Because of his obsession with rechecking
ple to work at a faster pace, despite their internal
his work, he had difficulty completing tasks and
tempo. For individuals with a slower tempo, this
was always behind at the end of the shift (of course,
pace can cause discomfort. If you are high-
napping did not help his time management).
achievement–oriented, you are likely to have already
set some career goals for yourself and to have a men- A number of studies have examined how nurses use
tal schedule of deadlines for reaching these goals (“go their time, especially nurses in acute care. For exam-
on to complete my bachelor of science in nursing in ple, a study by Arthur Andersen found that only
4 years; a master of science in nursing in 6 years”). 35% of nursing time is spent in direct patient care
Many health-care professionals are linear, fast- (including care planning, assessment teaching, and
tempo, achievement-oriented people. Simply technical activities). Lundgren and Segesten (2001)
working at a fast pace, however, is not necessarily found that this increases to 50% when an all-RN
equivalent to achieving a great deal. Much energy staff is involved in patient care delivery, as the nurses
can be wasted in rushing around and stirring things spent less time supervising non-nursing personnel.
up but actually accomplishing very little. This Documentation accounts for another 20% of
chapter looks at ways in which you can use your nursing time. The remainder of time is spent on
time and energy wisely to accomplish your goals. transporting patients, processing transactions,
performing administrative responsibilities, and
How Do Nurses Spend Their Time? undertaking hotel services (Brider, 1992).
Categories may change from study to study, but
Nurses are the largest group of health-care profes- the amount of time spent on direct patient care is
sionals. Because of the number of nurses needed and usually less than half the workday. As hospitals
the shift variations, attention concerning the effi- continue to reevaluate the way they deliver health
ciency and effectiveness of their time management is care, nurses are finding themselves more involved
needed. Efficient nurses deliver care in an organized with tasks that are not directly patient-related,
manner that makes best use of time, resources, and such as determining quality improvement, devel-
effort. Effective care improves a situation. oping critical pathways, and so forth. These are
Today’s labor market for skilled health-care pro- added to their already existing patient care func-
fessionals remains tight. Institutions face new chal- tions. The critical nursing shortage compounds
lenges, not of “trimming the fat, but compensate this problem. The result is that, in some cases,
[sic] for loss of muscle” (Baldwin, 2002, p. 1). nurses are able to meet only the highest-priority
Current shortages of nurses, radiology technicians, patient needs, particularly in certain clinical set-
pharmacists, and other health-care specialists show tings such as short-stay units or ambulatory care
all the signs of a long-term problem. Health-care centers (Curry, 2002).

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Any change in the distribution of time spent on your personal and career goals. This can help you
various activities can have a considerable impact on make decisions about the future.
patient care and on the organization’s bottom line. This concept can be applied to daily activities as
Prescott (1991) offered the following example: well as help in career decisions. Ask yourself ques-
tions about what you want to accomplish over a
If more unit management responsibilities could be
particular period. Personal development skills
shifted from nurses to non-nursing personnel, about
include discipline, goal setting, time management
48 minutes per nurse shift could be redirected to
and organizational skills, self monitoring, and a
patient care. In a large hospital with 600 full-time
positive attitude toward the job (Bos & Vaughn,
nurses, the result would be an additional 307 hours
1998). Many of the personal management and
of direct patient care per day. Calculating the results
organizational skills related to the workplace focus
of this time-saving strategy in another way shows
on time management and scheduling. Most new
an even greater impact: the changes would con-
nurses have the skills required to perform the job
tribute the equivalent of the work of 48 additional
but lack the personal management skills necessary
full-time nurses to direct patient care.
to get the job done, specifically when it comes to
Many health-care institutions are considering inte- time management.
grating units with similar patient populations and To help organize your time, set both short- and
having them managed by a non-nurse manager, long-term goals. Short-term goals are those that
someone with business and management expertise, you wish to accomplish within the near future.
not necessarily nursing skills. However, as a group, Setting up your day in an organized fashion is a
nurses respect managers who have nursing expertise short-term goal, as is scheduling a required medical
and who are able to perform as nurses.They believe errors or domestic violence course.
that a nurse-manager has a greater understanding of Long-term goals are those you wish to complete
both patient and professional staff needs.To address over a long time. Advanced education and career
these service concerns, many educational institu- goals are examples. A good question to ask yourself
tions have developed dual graduate degrees com- is,“What do I see myself doing 5 years from now?”
bining nursing and management. Every choice you make requires a different alloca-
tion of time (Moshovitz, 1993).
Organizing Your Work
Alinore, a licensed practical nurse returning to
Setting Your Own Goals school to obtain her associate’s degree in nursing,
It is difficult to decide how to spend your time faced a multitude of responsibilities. A wife, a
because there are so many tasks that need time. A mother of two toddlers, and a full-time staff mem-
good first step is to take a look at the situation, ber at a local hospital, Alinore suddenly found
and get an overview.Then ask yourself, “What are herself in a situation in which there just were not
my goals?” Goals help clarify what you want and enough hours in a day. She became convinced that
give you energy, direction, and focus. Once you becoming a registered nurse was an unobtainable
know where you want to go, set priorities. This is goal. When asked where she wanted to be in 5 years,
not an easy task. Remember Alice’s conversation she answered,“At this moment, I think, on an island
with the Cheshire Cat in Lewis Carroll’s Alice in in Tahiti!” Several instructors helped Alinore devel-
Wonderland: op a time plan. First, she was asked to list what she
did each day and how much time each task required.
“Would you tell me please, which way I ought to go
This list included basic child care, driving children
from here?” asked Alice.
to and from day care, shopping, cooking meals,
“That depends a good deal on where you want to
cleaning, hours spent in the classroom, study hours,
go to,” said the Cat.
work hours, and time devoted to leisure. Once this
“I don’t care where,” said Alice.
was established, she was asked which tasks could be
“Then it doesn’t matter which way you go,” said
allocated to someone else (e.g., her husband), which
the Cat (Carroll, 1907).
tasks could be clustered (e.g., cooking for several days
How can you get somewhere if you do not know at a time), and which tasks could be shared. Alinore’s
where you want to go? It is important to explore husband was willing to assist with car pools, grocery

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shopping, and cleaning. Previously, Alinore never box 11-2
asked him for help. Cooking meals was clustered:
Ten Frequent Activities That Infringe
Alinore made all the meals in 1 day and then froze on Time
and labeled them to be used later. This left time for
• Managing by crisis
other activities. Alinore graduated at the top of her • Telephone calls
class and subsequently completed her BSN. She • Poor planning
became a clinical preceptor for other associate degree • Taking on too much
nursing students on a pediatric unit in a county • Unexpected visitors
• Improper delegation
hospital. She never did get to Tahiti, though.
• Disorganization
• Inability to say no
Employers pay nurses for their time. Does that • Procrastinating
mean that nurses “sell” their time? If so, then nurs- • Meetings
es “own” their time. Looking at time from this per- Adapted from the ABA Career Resource Center, http://www.abanet.org/
spective changes the point of view about time, as careercounsel/prelaw/5timeprelawtips.pdf
nurses then manage their own time to accomplish
patient care tasks.
Time management means handling time with a beginning of the next day. Do not include routine
measure of proficiency. Therefore, time manage- tasks because they will make the list too long and
ment means meeting patient care needs skillfully you will do them without the extra reminder.
during a nursing shift (Navuluri, 2001). Organizing If you are a team leader, place the unique tasks
work eliminates extra steps or serious delays in of the day on the list: team conference, telephone
completing it. Organizing also reduces the amount calls to families, discussion of a new project, or in-
of time spent in activities that are neither produc- service demonstration of a new piece of equip-
tive nor satisfying. ment. You may also want to arrange these tasks in
Working on the most difficult tasks when you order of their priority, starting with those that
have the most energy decreases frustration later in must be done that day. Ask yourself the following
the day when you may be more tired and less effi- questions regarding the tasks on the list
cient. To begin managing your time, develop a (Moshovitz, 1993):
clear understanding of how you use your time.
■ What is the relative importance of each of these
Creating a personal time inventory helps you
tasks?
estimate how much time you spend on typical
■ How much time will each task require?
activities. Keeping the inventory for a week gives
■ When must each task be completed?
a fairly accurate estimate of how you spend your
■ How much time and energy have to be devoted
time. The inventory also helps identify “time
to these tasks?
wasters” (Gahar, 2000).
MacKenzie (1990) identified 20 of the biggest If you find yourself postponing an item for several
time wasters. Some of these come directly from the days, decide whether to give it top priority the next
work environment,whereas others are personal char- day or drop it from the list as an unnecessary task.
acteristics. To avoid time wasters, take control. It is The list should be in a user-friendly form: on
important to prevent endless activities and other your electronic organizer, in your pocket, or on a
people controlling you (American Bar Association clipboard. Checking the list several times a day
Career Resource Center, n.d.). Every day, set priori- quickly becomes a good habit. Computerized
ties to help you meet your goals.Ten frequent activ- calendar-creator programs help in setting priori-
ities that infringe on time are in Box 11-2. ties and guiding daily activities. Many of these
are found on the Internet or intranet of an insti-
Lists tution. These programs can be set to appear on
One of the most useful organizers is the “to do”list. the desktop when you turn on your computer to
You can make this list either at the end of every day give an overview of the day, week, or month. This
or at the beginning of each day before you do any- calendar acts as an automated to-do list. Your
thing else. Some people say they do it at the end of daily list may become your most important time
the day because something always interferes at the manager (Box 11-3).

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box 11-3 of attention, the perspective of the whole and of the
individuals who are your patients may be lost.
Determining How to Maximze Your Time
Some activities must be done at a certain time.
• Set goals.
• Make a schedule. These activities structure the day or week to a great
• Write a to-do list. extent, and their timing may be out of your control.
• Revise and modify the to-do list; do not throw it out. However, in every job there are tasks that can be
• Identify time-wasting behaviors. done whenever you want to do them, as long as
they are done.
In certain nursing jobs, reports and presenta-
tions are often required. For these activities, you
may need to set aside blocks of time during which
Long-Term Planning Systems you can concentrate on the task. Trying to create
At the beginning of the semester, students are told and complete a report in 5- or 10-minute blocks of
the examination dates and when papers will be due. time is unrealistic. By the time you reorient yourself
Many students find it helpful to enter the dates on to the project, the time allotted is over, and nothing
a semester-long calendar so they can be seen at a has been accomplished. Setting aside large blocks
glance. Then the students can see when clusters of of time to do complex tasks is much more efficient.
assignments are due at the same time. This allows Consider energy levels when beginning a big
for advance planning or perhaps requests to change task. Start when levels are high and not at, say, 4:00
dates or get extensions. in the afternoon if that is when you find yourself
Personal digital assistants (PDAs), or hand-held winding down (Baldwin, 2002). For example, if you
organizers, have become quite popular. These are a morning person, plan your demanding work
devices allow both short-term and long-term in the morning. If you get energy spurts later in the
scheduling. PDAs permit storing of personal notes morning or early afternoon, plan to work on larger
and reminders, contact data, Internet access, and or heavier tasks at that time. Nursing shifts may be
other program files. Hand-held devices permit syn- designed in 8-, 10-, or 12-hour blocks. Many nurses
chronization with personal computers and working the night shifts (11 p.m. to 7 a.m. or
Internet-based calendars. 7 p.m. to 7 a.m.) find they have more energy a
little later into their shift rather than at the begin-
Schedules and Blocks of Time ning, whereas nurses working the day shifts (7 a.m.
Without some type of schedule, you are more likely to 3 p.m. or 7 a.m. to 7 p.m.) find they have the
to drift through a day or bounce from one activity to most energy at the beginning of their shift. Also,
another in a disorganized fashion. Assignment learn to delegate tasks that do not require profes-
sheets, worksheets, flow sheets, and critical pathways sional nursing skills.
are all designed to help you plan patient care and Some people go to work early to have a block of
schedule your time effectively. The critical pathway uninterrupted time. Others take work home with
is a guide to recommended treatments and optimal them for the same reason. This extends the work-
patient outcomes (see Chapter 10). Assignment sheets day and cuts into leisure time. The higher your
indicate the patients for whom each staff member is stress level, the less effective you will be on the
responsible. Worksheets are then created to organize job—do not bring your work home with you. You
the daily care that must be given to the assigned need some time off to recharge your batteries
patients (see Chapter 9 for examples of worksheets). (Turkington, 1996).
Flow sheets are lists of items that must be recorded
for each patient. Filing Systems
Effective worksheets and flow sheets schedule Filing systems are helpful for keeping track of
and organize the day by providing reminders of important papers. All professionals need to main-
various tasks and when they need to be done. The tain copies of licenses, certifications, continuing
danger in using them, however, is that the more education credits, and current information about
they divide the day into discrete segments, the their specialty area. Keeping these organized in an
more they fragment the work and discourage a easily retrievable system saves time and energy
holistic approach. If a worksheet becomes the focus when you need to refer to them. Using color-coded

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folders is often helpful. Each color holds docu- Some people have difficulty saying no.
ments that are related to one another. For example, Ambition keeps some people from declining any
all continuing education credits might be placed in opportunity, no matter how overloaded they are.
a blue folder, anything pertaining to licensure in a Many individuals are afraid of displeasing others
yellow folder, and so on. and therefore feel obligated to take on continuous-
ly all types of additional assignments. Still others
Setting Limits have such a great need to be needed that they con-
tinually give of themselves, not only to patients but
To set limits, it is necessary to identify your objec- also to their coworkers and supervisors.They fail to
tives and then arrange the actions needed to meet stop and replenish themselves, and then they
them in order of their priority (Haynes, 1991; become exhausted. Remember, no one can be all
Navuluri, 2001). The focus of time management things to all people at all times without creating
exists on two levels: temporal and spatial. Nurses serious guilt, anger, bitterness, and disillusionment.
need to focus on patient care needs during the shift “Anyone who says it’s possible has never tried it”
(temporal) or within the boundaries of the working (Turkington, 1996, p. 9).
environment (spatial).
Eliminating Unnecessary Work
Saying No
Some work has become so deeply embedded in
Saying no to low-priority demands on your time is one’s routines that it appears essential, although it
an important but difficult part of setting limits. is really unnecessary. Some nursing routines fall
Assertiveness and determination are necessary for into this category. Taking vital signs, giving baths,
effective time management. Learn to say no tact- changing linens, changing dressings, performing
fully at least once a day (Hammerschmidt & irrigations, and doing similar basic tasks are more
Meador, 1993). Patient care is a team effort. often done according to schedule rather than
Effective time management requires you to look at according to patient need, which may be much
other members of the team who may be able to more or much less often than the routine specifies.
take on the task. Some of these tasks may appropriately be delegated
The wisdom of time management is that you to others:
may have to let others help you while never giving
up ownership of your time. In other words, ■ If patients are ambulatory, bed linens may not
although supervisors and managers tell you what to need to be changed daily. Incontinent and
do, how you accomplish this remains up to you diaphoretic patients need to have fresh linens
(Navuluri, 2001). Is it possible to say no to your more frequently. Not all patients need a com-
supervisor or manager? It may not seem so at first, plete bed bath every day. Elderly patients have
but many requests are negotiable. Requests some- dry, fragile skin; giving them good mouth, facial,
times are in conflict with career goals. Rather than and perineal care may be all that is required on
sit on a committee in which you have no interest, certain days. This should be included in the
respectfully decline, and volunteer for one that patient’s care plan.
holds promise for you as well as meets the needs of ■ Much paperwork is duplicative, and some is alto-
your unit. gether unnecessary. For example, is it necessary
Can you refuse an assignment? Your manager to chart nursing interventions in two or three
may ask you to work overtime or to come in on places on the patient record? Charting by excep-
your scheduled day off, but you can decline. You tion, flow sheets, and computerized records are
may not refuse to care for a group of patients or to attempts to eliminate some of these problems.
take a report because you think the assignment is ■ Socialization in the workplace is an important
too difficult or unsafe. You may, however, discuss aspect in maintaining interpersonal relation-
the situation with your supervisor and, together, ships. When there is a social component to
work out alternatives. You can also confront the interactions in a group, the result is usually
issue of understaffing by filing an unsafe staffing positive. However, too much socialization can
complaint. Failure to accept an assignment may reduce productivity. Use judgment in deciding
result in accusations of abandonment. when socializing is interfering with work.

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You may create additional work for yourself without ■ When you set aside time to do a specific task
realizing it. How often do you walk back down the that has a high priority, stick to your schedule,
hall to obtain equipment when it all could have and complete it.
been gathered at one time? How many times do you ■ Do not allow interruptions while you are com-
walk to a patient’s room instead of using the inter- pleting paperwork, such as transcribing orders.
com, only to find that you need to go back to where
What else can you do to streamline your work? A
you were to get what the patient needs? Is the staff
few general suggestions follow, but the first one, a
providing personal care to patients who are well
time log, can assist you in developing others unique
enough to meet some of these needs themselves?
to your particular job. If you complete the log cor-
rectly, a few surprises about how you really spend
Streamlining Your Work your time are almost guaranteed.
Many tasks cannot be eliminated or delegated,
Keeping a Time Log
but they can be done more efficiently. There are
Perception of time is elastic.People do not accurate-
many sayings in time management that reflect the
ly estimate the time they spend on any particular
principle of streamlining work. “Work smarter, not
task; people cannot rely on their memories for accu-
harder” is a favorite one that should appeal to
rate information about how they spend their time.
nurses facing increasing demands on time. “Never
The time log is an objective source of information.
handle a piece of paper more than once” is a more
Most people spend a much smaller amount of their
specific one, reflecting the need to avoid procrasti-
time on productive activities than they estimate.
nation in your work. “A stitch in time saves nine”
Once you see how large amounts of your time are
reflects the extent to which preventive action saves
spent, you will be able to eliminate or reduce the
time in the long run.
time spent on nonproductive or minimally produc-
Avoiding Crisis Management tive activities (Drucker, 1967; Robichaud, 1986).
For example, many nurses spend a great deal of
Crisis management occurs when people procrasti-
time searching for or waiting for missing medications,
nate or do not pay attention to their intuitions.The
equipment,or supplies.Before beginning patient care,
key to avoiding crises is to anticipate possible prob-
assemble all the equipment and supplies you will
lems and intervene before they become overwhelm-
need, and check the patient’s medication drawer
ing. As a new nurse, it may be difficult to anticipate
against the medication administration record so you
everything; however, there are some things that you
can order anything that is missing before you begin.
can do by organizing your day. Several methods of
Figure 11.1 is an example of a time log in which
working smarter and not harder are:
you enter your activities every half hour. This
■ Gather materials, such as bed linen, for all of means that you will have to pay careful attention to
your patients at one time. As you go to each what you are doing so that you can record it accu-
room, leave the linen so that it will be there rately. Do not postpone record-keeping; do it every
when you need it. 30 minutes. A 3-day sample may be enough for you
■ While giving a bed bath or providing other per- to see a pattern emerging. It is suggested that you
sonal care, perform some of the aspects of the repeat the process again in 6 months, both because
physical assessment, such as taking vital signs, work situations change and to see if you have made
skin assessment, and parts of the neurological any long-lasting changes in your use of time.
and musculoskeletal assessment. Prevention is
always a good idea. Reducing Interruptions
■ If a patient does not “look right,” do not ignore Everyone experiences interruptions. Some of these
your intuition. The patient is probably having a are welcome and necessary, but too many interfere
problem. with your work. A phone call from the laboratory
■ If you are not sure about a treatment or medica- with a critical value is a necessary interruption.
tion, ask before you proceed. It is usually less Hobbs (1987) stated that necessary interruptions are
time-consuming to prevent a problem than it is not time wasters. Middle-level managers are inter-
to resolve one. rupted every 8 minutes, and senior managers suffer

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Activities Comments
6:30

7:00
7:30

8:00
8:30

9:00
9:30

10:00
10:30

11:00
11:30

12:00
12:30

1:00
1:30

2:00
2:30

3:00
3:30

4:00
4:30

5:00
5:30

6:00
6:30
7:00


Figure 11.1 Time log. (Adapted from Robichaud, A.M. [1986]).

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interruptions every 5 minutes.Patient-care managers— helps identify patients who must be without food
nurses—seem to be interrupted every minute. or fluids (NPO) for tests or surgery, those who
Interruptions need to be kept to a minimum or elim- require 24-hour urine collections, or those who
inated, if possible. Closing the door to a patient’s require special cultures. The information need not
room may reduce interruptions. You may have to ask be written or entered repeatedly if stickers are used.
visitors to wait a few minutes before you can answer Everyone talks about the amount of time wasted
their questions, although you must remain sensitive by physicians,nurses,and other clinicians in looking
to their needs and return to them as soon as possible. for such things as patient charts, equipment, and
There is nothing wrong about asking a col- even patients. Erica Drazen, vice president of First
league who wants your assistance to wait a few Consulting Group in Lexington, Massachusetts,
minutes if you are engaged in another activity. suggested using more sophisticated wireless tech-
Interruptions that occur when you are trying to nology, similar to the car tracking systems used by
pour medications or make calculations can cause law enforcement.Tiny transmitters can be activated
errors. Physicians and other professionals often from a central point to locate the items or individ-
request nursing attention when nurses are involved uals. Using electronic medical record systems
with patient-care tasks. Find out if an unlicensed decreases the amount of time spent looking for
person may help. If not, ask the physician to wait, patient records. By using approved access codes,
stating that you will be more than glad to help as health-care personnel can obtain information from
soon as you complete what you are doing. Be cour- anywhere within the institution. This also mini-
teous, but be firm; you are busy also. mizes time spent on paper charting.
Categorizing Activities Automating Repetitive Tasks
Clustering certain activities helps eliminate the Developing techniques for repetitive tasks is simi-
feeling of bouncing from one unrelated task to lar to finding the fastest method, but it focuses on
another. It also makes your caregiving more holis- specific tasks that are repeated again and again,
tic. You may, for example, find that documentation such as patient teaching.
takes less time if you do it while you are still with Many patients come to the hospital or ambula-
the patient or immediately after seeing a patient. tory center for surgery or invasive diagnostic tests
The information is still fresh in your mind, and you for same-day treatment. This does not give nurses
do not have to rely on notes or recall. Many health- much teaching time. Using videotapes and pam-
care institutions have switched to computerized phlets as teaching aids can reduce the time needed
charting, with the computers placed at the bedside. to share the information, allowing the nurse to be
This setup assists in documenting care and inter- available to answer individual questions and create
ventions while the nurse is still with the patient. individual adaptations. Many facilities are using
Also, try to follow a task through to completion these techniques for cardiac rehabilitation,preoper-
before beginning another. ative teaching, and infant care instruction.
Computer-generated teaching and instruction
Finding the Fastest Way guides permit patients to take the information
Many time-consuming tasks can be done more effi- home with them. This can decrease the number of
ciently by automation.Narcotic delivery systems that phone calls requiring repetition of information.
deliver the correct dose and electronically record the
dose, the name of the patient, and the name of the The Rhythm Model for Time Management
health-care personnel removing the medication are Navuluri (2001) looked at time management in
being used in many institutions. This system saves terms of a Rhythm Model—a PQRST pattern:
staff time in documentation and in performing a Prioritize, Question, Recheck, Self-reliance,Treat.
narcotic count at the end of each shift. Bar coding is By prioritizing, you can accomplish the most
another method used by health-care institutions.Bar important tasks first. Questioning permits you to
coding allows for scanning certain types of patient look at events and tasks in terms of effectiveness,
data, decreasing the number of paper chart entries efficiency, and efficacy. Rechecking unfinished
(Baldwin, 2002; Meyer, 1992). tasks quickly helps you to manage your time
Efficient systems do not have to be complex. efficiently. Self-reliance allows you to know the
Using a preprinted color-coded sticker system difference between events that are within your

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control and those that are not, as well as realizing about time and to assess your own time manage-
your limitations. No one knows better what you ment skills. Nursing requires that numerous activ-
are capable of doing than you. Treats are part of ities be performed within what often seems to be
life. It is okay to take a break or time out. It is very brief periods. Remember that there are only
important because doing so permits you to so many hours in the day. Knowing this can create
refresh. Table 11-1 summarizes the Rhythm stress. No one works well “under pressure.” Learn
Model for Time Management. to delegate. Learn to say, “I would really like to
help you; can it wait until I finish this?” Learn to
Conclusion say no. Most of all, learn how to make the most of
your day by working effectively and efficiently.
Time can be your best friend or worst enemy, Finally, remember that 8 hours should be desig-
depending on your perspective and how you man- nated as sleep time and several more as personal
age it. It is important to identify how you feel or leisure (“time off ”) time.



table 11-1
The Rhythm Model for Time Management
PRIORITIZE List tasks in order of importance.
Remember that some tasks must occur at specific times, whereas others can occur at any time.
Emergencies take precedence.
Identify events controlled by you and events controlled by others.
Use critical thinking skills to assign priorities.
QUESTION:
EFFECTIVENESS Did the task produce the desired outcome?
EFFICIENCY How can I accomplish the plan with the least expenditure of time?
Is there a way to break this down into simpler tasks?
EFFICACY Do I have the skill and ability to obtain the desired effect?
RECHECK Mentally and physically recheck an unfinished or delegated task.
SELF-RELIANCE Identify those tasks that are within your control and those that are not.
Use critical thinking skills and adaptability to revise priorities.
“Go with the flow.”
TREAT Treat yourself to a break when you can.
Treat yourself to time off.
Treat yourself to an educational experience: Commit yourself to excellence.
Treat others courteously and with respect.


Study Questions

1. Develop a personal time inventory. Identify your time wasters. How do you think you can eliminate
these activities?

2. Create your own patient care worksheet. How does this worksheet help you organize your clinical day?
3. Keep a log of your clinical day. Which activities took the most time? Why? Which activities took
the least time? What situations interfered with your work? What could you do to reduce the inter-
ference?
4. Identify a task that is done repeatedly in your clinical area. Think of a new, more efficient way to do
that task. How could you implement this new routine? How could you evaluate its efficiency?
5. Consider how many interruptions you had during the day. How did you handle them? How did
they interfere in your time management?

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Case Study to Promote Critical Reasoning
Antonio was recently hired as a team leader for a busy cardiac step-down unit. Nursing responsibilities
of the team leader, in addition to patient care, include meeting daily with team members, reviewing
all admissions and discharges for acuity and length of stay, and documenting all patients who
exceed length of stay and the reasons. At the end of each month, the team leaders are required to
meet with unit managers to review the patient care load and team member performance. This is the
last week of the month, and Antonio has a meeting with the unit manager at the end of the week.
He is 2 weeks behind on staff evaluations and documentation of patients who exceeded length of
stay. He is becoming very stressed over his team leader responsibilities.

1. Why do you think Antonio is feeling stressed?
2. Make a to-do list for Antonio.
3. Develop a time log for Antonio to use to analyze his activities.

4. How can Antonio organize and streamline his work?



References Haynes, M.E. (1991). Practical Time Management. Los Altos, Calif.:
Crisp Publications.
American Bar Association Career Resource Center (n.d.). Hobbs, S. (1987). Getting to grips with business plans, audit,
Identifying & conquering time wasters. Retrieved and applications. Nursing Standard.
December 20, 2005, from abanet.org/careercounsel Lundgren, S., & Segesten, K. (2001). Nurses’use of time in a
Baldwin, F.D. (2002). Making do with less. Healthcare Informatics, medical-surgical ward with all-RN staffing. Journal of Nursing
pp. 1–7. Online, March 2002. Management, 9, 13–20.
Bos, C.S., & Vaughn, S. (1998). Strategies for Teaching Students MacKenzie, A. (1990). The Time Trap. N.Y.: American Management
With Learning and Behavioral Problems, 4th ed. Boston: Association.
Allyn & Bacon. Matejka, J.K., & Dunsing, R.J. (1988). Time management:
Brider, P. (1992). The move to patient-focused care. American Changing some traditions. Management World, 17(2), 6–7.
Journal of Nursing, 92(9), 27–33. Meyer, C. (1992). Equipment nurses like. American Journal of
Brumm, J. (2004). Time can be on your side. Nursing Spectrum. Nursing, 92(8), 32–38.
http://nursingspectrum.com/StudentsCorner/StudentFeatures/ Moshovitz, R. (1993). How to Organize Your Work and Your Life.
TimeSide.htm. N.Y.: Doubleday.
Chappel, E.D. (1970). Culture and Biological Man: Exploration in Navuluri, R.B. (March 2001). Our time management in patient
Behavioral Anthropology. N.Y.: Holt, Rinehart, & Winston. care. Research for Nursing Practice, 1–8.
(Reprinted as The Biological Foundations of Individuality and Prescott, P.A. (1991). Changing how nurses spend their time.
Culture. Huntingdon, N.Y.: Robert Krieger, 1979.) Image, 23(1), 23–28.
Carroll, L. (1907). Alice’s Adventures in Wonderland. Reprint 2002. Robichaud, A.M. (1986). Time documentation of clinical nurse
N.Y.: North-South Books. specialist activities. Journal of Nursing Administration, 16(1),
Curry, P. (March 25, 2002). Pressure cooker: Hospital’s emphasis 31–36.
on productivity increases stress for nurses and patients. Smith, H.W. (1994). The Ten Natural Laws of Successful Time and
Nurseweek News, http://www.nurseweek. com Life Management: Proven Strategies for Increased Productivity
Drucker, P.E. (1967). The Effective Executive. N.Y.: Harper & Row. and Inner Peace. N.Y.: Warner Books.
Ferrett, S.K. (1996). Connections: Study Skills for College and Career Turkington, C.A. (1996). Reflections for Working Women: Common
Success. Chicago: Irwin Mirror Press. Sense, Sage Advice, and Unconventional Wisdom. N.Y.:
Gahar, A. (2000). Programming for College Students With Learning McGraw-Hill.
Disabilities. (Grant No.: 84–078C) http://www.csbsju.edu Webber, R.A. (1980). Time Is Money! Tested Tactics That Conserve
Gonzalez, S.I. (1996). Time management. The Nursing Spectrum Time for Top Executives. N.Y.: Free Press.
in Florida, 6(17), 5.
Hammerschmidt, R., & Meador, C.K. (1993). A Little Book of
Nurses’ Rules. Philadelphia: Hanley & Belfus.

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unit


Professional Issues







chapter 12 Promoting a Healthy Workplace

chapter 13 Work-Related Stress and Burnout

chapter 14 Your Nursing Career

chapter 15 Nursing Yesterday and Today

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Promoting a Healthy Workplace





OBJECTIVES OUTLINE
After reading this chapter, the student should be able to: Workplace Safety
■ Recognize the components of nurse job satisfaction. Threats to Safety
■ Describe quality indicators related to safety and quality. Reducing Risk
■ Recognize threats to safety in the workplace. OSHA
■ Identify agencies responsible for overseeing workplace safety. Centers for Disease Control and Prevention
■ Describe methods of dealing with violence in the workplace. NIOSH
■ Identify the role of the nurse in dealing with terrorism and ANA
other disasters. Joint Commission on the Accreditation of Healthcare Organizations
■ Recognize situations that may reflect sexual harassment. Institute of Medicine
■ Make suggestions for improving the physical and social Programs
environment.
■ Understand the American Nurses Association (ANA) Future Violence
Vision for Nursing. Sexual Harassment
Latex Allergy
Needlestick Injuries
Your Employer’s Responsibility
Your Responsibility
Ergonomic Injuries
Back Injuries
Repetitive Stress Injuries
Impaired Workers
Substance Abuse
Microbial Threats
Enhancing the Quality of Work Life
Rotating Shifts
Mandatory Overtime
Staffing Ratios
Using Unlicensed Assistive Personnel
Reporting Questionable Practices
Terrorism and Other Disasters
Enhancing the Quality of Work Life
Social Environment
Working Relationships
Support of One’s Peers and Supervisors
Involvement in Decision Making
Professional Growth and Innovation
Encourage Critical Thinking
Seek Out Educational Opportunities
Encourage New Ideas
Reward Professional Growth
Cultural Diversity
Physical Environment
Conclusion



171

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Almost half our waking hours are spent in the
workplace. For this reason alone, the quality of the Threats to Safety
workplace environment is a major concern. Yet, it is Working in a health-care facility is reported to be
neglected to a surprising extent in many health-care one of the most dangerous jobs in the United
organizations. It is neglected by administrators who States. The Department of Labor reports that a
would never allow peeling paint or poorly main- health-care worker in a nursing facility is more likely
tained equipment but who leave their staff, their to be injured on the job than a coal miner. Health
most costly and valuable resource, unmaintained and safety threats in the nursing workplace include
and unrefreshed. The “do more with less” thinking infectious diseases, physical violence, ergonomic
that has predominated many organizations places injuries related to the movement and repositioning
considerable pressure on staff and management of patients, exposure to hazardous chemicals and
alike (Chisholm, 1992). Improvement of the work- radiation, and sharps injuries (ANA, 2007).
place environment is more difficult to accomplish Health care is the second-fastest-growing sector
under these circumstances, but it is more important of the U.S.economy,employing more than 12 million
than ever. workers. Women represent nearly 80% of the
Much of the responsibility for enhancing the health-care workforce. Health-care workers face a
workplace rests with upper-level management, wide range of hazards on the job, including needle-
people who have the authority and resources to stick injuries, back injuries, latex allergy, violence,
encourage organization-wide growth and change. and stress. Although it is possible to prevent or
Nurses, however, have begun to take more respon- reduce health-care worker exposure to these haz-
sibility for identification of and problem solving for ards, health-care workers are experiencing increas-
workplace issues. This chapter focuses on these ing numbers of occupational injuries and illnesses;
issues, in addition to sexual harassment, impaired rates of occupational injury have risen over the past
workers, enhancement of work-life quality, diversity, decade. By contrast, two of the most hazardous
and disabled workers. industries, agriculture and construction, are safer
today than they were a decade ago. NIOSH-TIC-2
Workplace Safety is a searchable bibliographical database of occupa-
tional safety and health publications, documents,
Safety is not a new concept in the workplace. The grant reports, and journal articles supported in
modern movement began during the Industrial whole or in part by the NIOSH (cdc.gov/niosh/
Revolution. In 1913, the National Council for topics/healthcare/).
Industrial Safety (now the National Safety In spring 2001, a Florida nurse with 20 years’
Council) was formed.The Occupational Safety and psychiatric nursing experience died of head and
Health Act of 1970 created both the National face trauma. Her assailant, a former wrestler, had
Institute of Occupational Safety and Health been admitted involuntarily in the early morning to
(NIOSH) and the Occupational Safety and Health the private mental health–care facility. An investi-
Administration (OSHA). The OSHA, part of the gation found that the facility did not have a policy
U.S. Department of Labor, is responsible for devel- on workplace violence and no method of summon-
oping and enforcing workplace safety and health ing help in an emergency (Arbury, 2002).
regulations. The NIOSH, part of the U.S. Six hundred thousand to one million needlestick
Department of Health and Human Services, pro- injuries occur annually to U.S. health-care workers.
vides research, information, education, and training Percutaneous exposure is the principal route for
in occupational safety and health. The National human immunodeficiency virus (HIV) and hepatitis
Safety Council (NSC) partners with the OSHA to B and C virus transmission. Additionally, infections
provide training in a variety of safety initiatives. such as tuberculosis, syphilis, malaria, and herpes
The NSC maintains that safety in the workplace is can be transmitted through needlesticks.
the responsibility of both the employer and the Threats to safety in the workplace vary from one
employee.The employer must ensure a safe, health- setting to another and from one individual to
ful work environment, and employees are account- another. A pregnant staff member may be more
able for knowing and following safety guidelines vulnerable to risks from radiation; staff members
and standards (National Safety Council, 1992). working in the emergency room of a large urban

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public hospital are at more risk for HIV and may also trigger an OSHA inspection. OSHA
tuberculosis than the staff members working in the encourages employers and employees to work
newborn nursery. All staff members have the right together to identify and remove any workplace haz-
to be made aware of potential risks. No worker ards before contacting the nearest OSHA area
should feel intimidated or uncomfortable in the office. If the employee has not been able to resolve
workplace. the safety or health issue, the employee may file a
formal complaint, and an inspection will be ordered
Reducing Risk
by the area OSHA director (U.S. Department of
OSHA Labor, 1995). Any violations found are posted
The Occupational Safety and Health Act of 1970 where all employees can view them. The employer
and the Mine Safety and Health Act of 1977 were has the right to contest the OSHA decision. The
the first federal guidelines and standards related to law also states that the employer cannot punish or
safe and healthful working conditions. Through discriminate against employees for exercising their
these acts, the NIOSH and OSHA were formed. rights related to job safety and health hazards
OSHA regulations apply to most U.S. employers or participating in OSHA inspections (U.S.
that have one or more employees and that engage in Department of Labor, 1995).
businesses affecting commerce. Under OSHA reg- OSHA inspections have focused especially on
ulations, the employer must comply with standards blood-borne pathogens, lifting and ergonomic
for providing a safe, healthful work environment. (proper body alignment) guidelines,confined-space
Employers are also required to keep records of all regulations, respiratory guidelines, and workplace
occupational (job-related) illnesses and accidents. violence.Since September 11,2001,the OSHA has
Examples of occupational accidents and injuries added protecting the worksite against terrorism
include burns,chemical exposures,lacerations,hear- (osha.gov). Table 12-1 lists the major categories of
ing loss, respiratory exposure, musculoskeletal potential hazards found in hospitals as identified by
injuries, and exposure to infectious diseases. the OSHA. The U.S. Department of Labor pub-
OSHA regulations provide for workplace lishes fact sheets related to various OSHA guide-
inspections that may be conducted with or without lines and activities.They can be obtained from your
prior notification to the employer. However, cata- employer, at the local public library, or via the
strophic or fatal accidents and employee complaints Internet at osha.gov



table 12-1
Potential Hospital Hazards
Hazard Definition Examples
Biological Infectious/biological agents such as bacteria, HIV, vancomycin-resistant enterococcus,
viruses, fungi, parasites methicillin-resistant Staphylococcus aureus, hepatitis
B virus, tuberculosis
Chemical Medications, solutions, and gases that are Ethylene oxide, formaldehyde, glutaraldehyde, waste
potentially toxic or irritating to the body anesthetic gases, cytotoxic agents, pentamidine
system ribavirin
Psychological Factors and situations encountered in or Stress, workplace violence, shiftwork, inadequate
associated with the work environment staffing, heavy workload, increased patient acuity
that create or potentiate stress, emotional
strain, and/or interpersonal problems
Physical Agents that cause tissue trauma Radiation, lasers, noise, electricity, extreme temperatures,
workplace violence
Environmental, Factors in work environment that cause Tripping hazards, unsafe or unguarded equipment, air
mechanical, or lead to accidents, injuries, strain, quality, slippery floors, confined spaces, obstructed
biomedical or discomfort work areas or passageways, awkward postures,
localized contact stresses, temperature extremes,
repetitive motions, lifting and moving patients
Adapted from osha.gov/SLTC/healthcarefacilities/hazards

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Centers for Disease Control and Prevention NIOSH
The Centers for Disease Control and Prevention The NIOSH is part of the CDC and is the feder-
(CDC) is the lead federal agency for protecting the al agency responsible for conducting research and
health and safety of citizens both at home and making recommendations for the prevention of
abroad. The CDC partners with other agencies work-related disease and injury. Occupational
throughout the nation to investigate health prob- hazards for health-care workers continue to be
lems, conduct research, implement prevention enormous health and economic problems.
strategies, and promote safe and healthy environ- According to statistics from the NIOSH, more
ments. The CDC publishes continuous updates of than 6.1 million illnesses and injuries occur in the
recommendations for prevention of HIV transmis- workplace yearly, with more than 2.9 million lost
sion in the workplace and universal precautions workdays attributed to occupational illnesses and
related to blood-borne pathogens; it also publishes injuries (cdc.gov/niosh/about).
the most recent information on other infectious Box 12-1 lists the most important federal laws
diseases in the workplace, such as tuberculosis and enacted to protect individuals in the workplace.
hepatitis. Currently, the CDC is targeting public
health emergency preparedness and response relat- ANA
ed to biological and chemical agents and threats When looking at agencies that are instrumental in
(cdc.gov/). Information can be obtained by con- dealing with workplace safety, the ANA must be
sulting the Mortality and Morbidity Weekly included. The ANA is discussed more completely
Report (MMWR) in the library, via the Internet in Chapters 10 and 15.The ANA’s history embod-
(cdc.gov/health/diseases), or through the toll-free ies advocacy for the nurse.
phone number (800-311-3435). Interested health- In 1999 the Commission on Workplace
care workers can also be placed on the CDC’s Advocacy was established as part of the ANA.The
mailing list to receive any free publications. Commission consists of nine members, appointed


box 12-1
Federal Laws Enacted to Protect the Worker in the Workplace
• Equal Pay Act of 1963: Employers must provide equal pay for equal work, regardless of sex.
• Title VII of Civil Rights Act of 1964: Employees may not be discriminated against on the basis of race, color, religion, sex,
or national origin.
• Age Discrimination in Employment Act of 1967: Private and public employers may not discriminate against persons
40 years of age or older except when a certain age group is a bona fide occupational qualification.
• Pregnancy Discrimination Act of 1968: Pregnant women cannot be discriminated against in employment benefits if they
are able to perform job responsibilities.
• Fair Credit Reporting Act of 1970: Job applicants and employees have the right to know of the existence and content of
any credit files maintained on them.
• Vocational Rehabilitation Act of 1973: An employer receiving financial assistance from the federal government may not
discriminate against individuals with disabilities and must develop affirmative action plans to hire and promote individuals
with disabilities.
• Family Education Rights and Privacy Act—Buckley Amendment of 1974: Educational institutions may not supply
information about students without their consent.
• Immigration Reform and Control Act of 1986: Employers must screen employees for the right to work in the United
States without discriminating on the basis of national origin.
• Americans With Disabilities Act of 1990: Persons with physical or mental disabilities or who are chronically ill cannot be
discriminated against in the workplace. Employers must make “reasonable accommodations”to meet the needs of the
disabled employee. These include such provisions as installing foot or hand controls; readjusting light switches, telephones,
desks, tables, and computer equipment; providing access ramps and elevators; offering flexible work hours; and providing
readers for blind employees.
• Family Medical Leave Act of 1993: Employers with 50 or more employees must provide up to 13 weeks of unpaid leave for
family medical emergencies, childbirth, or adoption.
• Needlestick Safety and Prevention Act of 2001: This act directed the OSHA to revise the blood-borne pathogens stan-
dard to establish in greater detail requirements that employers identify and make use of effective and safer medical devices.
Adapted from Strader, M., & Decker, P. (1995). Role Transition to Patient Care Management. Norwalk, Conn.: Appleton and
Lange; osha.gov/needlesticks/needlefact

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by the ANA Board of Directors, and represent The first step in development of a workplace
constituent member associations. Additionally, safety program is to recognize a potential hazard and
state member associations often offer their own then take steps to control it. Based on OSHA reg-
workplace advocacy information. Issues such as ulations (U.S. Department of Labor, 1995), the
collective bargaining, workplace violence, mandatory employer must inform staff members of any poten-
overtime, staffing ratios, conflict management, del- tial health hazards and provide as much protection
egation, ethical issues, compensation, needlestick from these hazards as possible. In many cases, ini-
safety, latex allergies, pollution prevention, and tial warnings come from the CDC, NIOSH, and
ergonomics are addressed. other federal, state, and local agencies. For example,
The ANA Web site (www.nursingworld.org) employers must provide tuberculosis testing and
keeps up-to-date information related to workplace hepatitis B vaccine; protective equipment such as
advocacy and safety available to all nurses. gloves, gowns, and masks; and immediate treat-
ment after exposure for all staff members who may
Joint Commission have contact with blood-borne pathogens.
The Joint Commission (JC) is an independent, Employers are expected to remove hazards, educate
nonprofit organization. Established more than employees, and establish institution-wide policies
50 years ago, it is governed by a board that includes and procedures to protect their employees
physicians, nurses, and consumers. The JC evalu- (Herring, 1994; Roche, 1993). Nurses who are not
ates the quality and safety of care for more than provided with latex gloves may refuse to participate
15,000 health-care organizations. To earn and in any activities involving blood or blood products.
maintain accreditation, organizations must have an The employee cannot be subjected to discrimina-
extensive on-site review by a team of JC health- tion in the workplace, and reasonable accommoda-
care professionals at least once every 3 years. Many tions for safety against blood-borne pathogens
of the national patient safety goals discussed in must be provided. This may mean that the nurse
Chapter 10 were influenced by the safety of the with latex allergies is placed in an area where expo-
health-care worker. For example, fatigue due to sure to blood-borne pathogens is not an issue
mandatory overtime has been identified as causing (Strader & Decker, 1995; U.S. Department of
increased medication errors. Labor, 1995). The OSHA also has information
available on exposure to chemical or biological
Institute of Medicine agents related to terrorism. Terrorism response
The Institute of Medicine (IOM) is a private, non- exercises are conducted through OSHA to train
governmental organization that carries out studies health-care workers on responding to terrorism
at the request of many government agencies. The threats (http://www.osha.gov/). The second step in
mission of the IOM is to improve the health of peo- a workplace safety program is a thorough assessment
ple everywhere; thus, the topics it studies are very of the amount of risk entailed. Staff members, for
broad (iom.edu). In 1996 the IOM began a quality example, may become very fearful in situations that
initiative to assess the nation’s health. Part of this ini- do not warrant such fear. For example:
tiative was the 2004 report: Keeping Patients Safe:
Transforming the Work Environment of Nurses. Nancy Wu is the nurse manager on a busy geriatric
The report identified concerns and issues related to unit. Most patients require total care: bathing, feed-
organizational management, workforce deployment ing, and positioning. She observed that several of
practices, work design, and organizational culture the staff members working on the unit use poor body
(Beyea, 2004). Each of these issues will be discussed mechanics when lifting and moving the patients. In
in the section of this chapter on enhancing the the last month, several of the staff members were
quality of work life. referred to Employee Health for back pain. This
week, she noticed that the patients seemed to remain
Programs in the same position for long periods and were rarely
The primary objective of any workplace safety out of bed or in a chair for the entire day. When she
program is to protect staff members from harm confronted the staff, the response was the same from
and the organization from liability related to that all of them: “I have to work for a living. I can’t
harm. afford to risk a back injury for someone who may

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not live past the end of the week.” Nancy was An example of a safety program is the one for
concerned about the care of the patients as well as health-care workers exposed to HIV, instituted at
the apparent lack of information her staff had about the Department of Veterans Affairs Hospital,
prevention of back injuries. She decided to seek San Francisco (Armstrong, Gordon, & Santorella,
assistance from the nurse practitioner in charge of 1995). An HIV exposure can be stressful for health-
Employee Health in order to develop a back injury care workers and their loved ones. This employee
prevention program. assistance program includes up to 10 hour-long indi-
vidual counseling sessions on the meaning and expe-
Assessment of the workplace may require consider- rience of this traumatic event. Additional counseling
able data gathering to document the incidence of sessions for couples are also provided. Information
the problem and consultation with experts before a about HIV and about dealing with acute stress reac-
plan of action is drawn up. Health-care organiza- tions is provided. Counseling helps workers identify
tions often create formal committees, consisting of a plan to obtain assistance from their individual sup-
experts from within the institution and representa- port systems, identify practice methods of dealing
tives from the affected departments, to assess these with blood-borne pathogens, and return to work.
risks. It is important that staff members from vari- A systematic review related to needlestick injury pro-
ous levels of the organization be allowed to offer vides evidence for the use of tissue adhesives.
input into an assessment of safety needs and risks. In the past, the options for wound closure have
The third step is to create a plan to provide opti- been limited largely to sutures (needle and thread),
mal protection for staff members. It is not always a staples, and adhesive tapes.Tissue adhesives (glues)
simple matter to protect staff members without offer the advantages that there are no sutures to
interfering with the provision of patient care. For remove later for the patient and no risk of needle-
example, some devices that can be worn to prevent stick injury to the health-care worker.The adhesive
transmission of tuberculosis interfere with commu- is applied over the surgical wound and holds the
nication with the patient Some attempts have been edges together until healing has occurred.
made to limit visits or withdraw home health-care Adhesives have been compared with alternative
nurses from high-crime areas, but this leaves methods of surgical wound closure in eight ran-
homebound patients without care (Nadwairski, domized clinical trials involving 630 patients.
1992). A threat assessment team that evaluates There was no evidence of a difference in rates of
problems and suggests appropriate actions may wound dehiscence or infection after surgical inci-
reduce the incidence and severity of problems due sion closure with tissue adhesive, sutures, or adhe-
to violent behavior, but it may also increase sive tape. The recommendation from the evidence
employees’ fear of violence if not handled well. was that health-care providers may consider the use
Developing a safety plan includes the following: of tissue adhesives for the closure of incisions in the
operating room, and a protocol was published in
■ Seeking evidence-based practices and recom-
2004 (Coulthard et al., 2004).
mendations related to the problem
■ Consulting federal, state, and local regulations
■ Distinguishing real from imagined risks Violence
■ Seeking administrative support and enforcement
Violence in the workplace is a contemporary social
for the plan
issue. Newspapers and magazines have reported
■ Calculating costs of a program
numerous violent incidents; one of six violent crimes
The fourth and final stage in developing a work- occurs in the workplace, and homicide is the second
place safety program is implementing the program. leading cause of workplace death (Edwards, 1999).
Educating the staff, providing the necessary safety According to the Census of Fatal Occupational
supplies and equipment, and modifying the envi- Injuries, there were 551 workplace homicides and
ronment contribute to an effective program. 5703 workplace injuries in 2004.The rate of assaults
Protecting patient and staff confidentiality and on hospital workers is much higher than the rate of
monitoring adherence to control and safety proce- assaults for all private-sector industries. The Bureau
dures should not be overlooked in the implementa- of Labor Statistics measures the number of assaults
tion stage (Jankowski, 1992). resulting in injury per 10,000 full-time workers.

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The overall private sector injury incidence rate is 2; ■ Health-care personnel working in high-crime
the overall incidence rate for health service workers areas
9.3. Broken down further, the incidence rate for ■ Health-care personnel working in buildings
social service workers is 15, and the rate for nurses with poor security
and personal care workers is 25 (bls.gov/news/ ■ Health-care personnel treating weapon-carrying
release/cfoi.nr0). patients and families
The aggressor can be a disgruntled employee or ■ Health-care personnel working with inexperi-
employer, an unhappy significant other, or a person enced staff
committing a random act of violence. Nurses have ■ Health-care personnel working in units needing
been identified as a group at risk for violence from seclusion or restraint activities
patients, family members, and other staff members. ■ Health-care personnel transporting patients
Violence may also have negative organizational ■ Patients waiting long times for service
outcomes. Box 12-2 identifies some of the causes. ■ Overcrowded, uncomfortable waiting areas
Examples of violence include: ■ Health-care personnel lacking training and poli-
cies for managing crises
■ Threats. Expressions of intent to cause harm,
including verbal threats, threatening body lan- Nurses must know their workplace. For example
guage, and written threats (www/nursingworld.org/dlwa.osh/wp5?):
■ Physical assaults. Slapping, beating, rape, homi-
■ How does violence from the surrounding
cide, and the use of weapons such as firearms,
community affect your workplace?
bombs, and knives
■ Do services like trauma or acute psychiatric care
■ Muggings. Assaults conducted by surprise with
increase the likelihood of violence?
intent to rob (cdc.gov/niosh/pdfs/2002-101.pdf)
■ Does the facility’s physical layout invite
The circumstances surrounding health-care work violence—for example, do doors open to the
contributes to workers’ susceptibility to homicide street? are waiting rooms cramped?
and assault (Edwards, 1999; nursingworld.org/ ■ How frequently do assaultive incidents, threats,
dlwa/osh/wp5; cdc.gov/niosh/pdfs/2002-101.pdf; and verbal abuse occur? where? who is involved?
www.osha.gov/) are incidents reported?
■ Are current emergency response systems
■ Prevalence of handguns and other weapons
effective?
among patients, families, and friends
■ Are post-assaultive treatment and support
■ Increased use of hospitals for criminal holds and
available to staff?
violent individuals
■ Are staffing patterns sufficient? is the staff
■ Increased number of acute and chronic mentally
experienced?
ill patients being released without follow-up care
■ Health-care personnel having routine contact Earlier in the chapter, the Florida nurse who was
with the public in unrestricted areas attacked and killed by a patient in April 2001 was
■ Health-care personnel working alone or in small mentioned. Although assaults that result in severe
numbers injury or death usually receive media coverage,
■ Health-care personnel working late or until very most assaults on nurses by patients or coworkers are
early morning hours not reported by the nurse.
Ms. Jones works on the evening shift in the emergency
box 12-2 department (ED) at a large urban hospital. The
ED frequently receives patients who are victims of
Negative Organizational Outcomes
Due to Workplace Violence gunshot wounds, stabbings, and other gang-related
incidents. Many of the patients entering the ED are
• Low worker morale
• Increased job stress high on alcohol or drugs. Ms. Jones has just inter-
• Increased worker turnover viewed a 21-year-old male patient who is awaiting
• Reduced trust of management treatment as a result of a fight after an evening of
• Reduced trust of coworkers heavy drinking. Because his injuries have been deter-
• Hostile working environment
mined not to be life-threatening, he had to wait to see

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a physician. “I’m tired of waiting. Let’s get this show box 12-4
on the road,” he screamed loudly as Ms. Jones walked
When an Assault Occurs:
by. “I’m sorry you have to wait, Mr. P., but the doctor Placing Blame on Victims
is busy with another patient and will get to you as
• Victim gender: Women receive more blame than men.
soon as possible.”She handed him a cup of juice she had • Subject gender: Female victims receive more blame
been bringing to another patient. He grabbed the cup, from women than men.
threw it in her face, and then grabbed her arm. • Severity: The more severe the assault, the more often
Slamming her against the wall, he jumped off the the victim is blamed.
• Beliefs: The world is a just place, and therefore the
stretcher and yelled obscenities at her. He continued to
person deserves the misfortune.
scream in her face until a security guard intervened. • Age of victim: The older the victim, the more he or she is
held to blame.
Be aware of clues that may indicate a potential for
Adapted from Lanza, M.L., & Carifio, J. (1991). Blaming the victim: Complex
violence (Box 12-3). These behaviors may occur in
(nonlinear) patterns of causal attribution by nurses in response to
patients, family members, visitors, or even other vignettes of a patient assaulting a nurse. Journal of Emergency Nursing,
staff members. Even patients with no history of 17(5), 299–309.
violent behavior may react violently to medication
violence in the workplace at your institution.
or pain (Carroll & Sheverbush, 1996; Lanza &
Preventing an incident is better than having to
Carifio, 1991).
intervene after violence has occurred.The following
In the health-care industry, violence is underre-
are suggestions to nurses about how to participate in
ported, and there are persistent misperceptions that
workplace safety related to violence (nursingworld.
assaults are part of the job and that the victim
org/osh/wp5/htm):
somehow caused the assault. Causes of underre-
porting may be a lack of institutional reporting ■ Participate in or initiate regular workplace
policies and employee fear that the assault was a assessments. Identify unsafe areas and the
result of negligence or poor job performance (U.S. factors within the organization that contribute
Department of Labor, 1995). Box 12-4 lists some to assaultive behavior, such as inadequate
of the faulty reasoning that leads to placing blame staffing, high-activity times of day, invasion of
on the victim of the assault. personal space, seclusion or restraint activities,
Actions to address violence in the workplace and lack of experienced staff. Work with
include (1) identifying the factors that contribute to management to make and monitor changes.
violence and controlling as many as possible and ■ Be alert for suspicious behavior such as verbal
(2) assessing staff attitudes and knowledge regarding expressions of anger and frustration, threatening
violence in the workplace (Carroll & Sheverbush, body language, signs of drug or alcohol use, or
1996; Collins, 1994; Mahoney, 1991). presence of a weapon. Assess patients or suspi-
When you begin your new job, you may want cious workers, patients, and visitors for potential
to find out the policies and procedures related to violence. Evaluate each situation for potential
violence. Keep an open path for exiting.
■ Maintain behavior that helps to defuse anger.
box 12-3 Present a calm, caring attitude. Do not match
threats, give orders, or present with behaviors
Behaviors Indicating a Potential
for Violence that may be interpreted as aggressive.
Acknowledge the person’s feelings.
• History of violent behavior
• Delusional, paranoid, or suspicious speech ■ If you cannot defuse the situation, then remove
• Aggressive, threatening statements yourself from it quickly, call Security, and report
• Rapid speech, angry tone of voice the situation to management.
• Pacing, tense posture, clenched fists, tightening jaw ■ Know your patients. Be aware of any history
• Alcohol or drug use of violent behaviors, diagnoses of dementia,
• Male gender, youth
• Policies that set unrealistic limits alcohol, or drug intoxication.
Adapted from Kinkle, S. (1993). Violence in the ED: How to stop it before it Box 12-5 lists some additional actions that can be
starts. American Journal of Nursing, 93(7), 22–24; Carroll, C., & Sheverbush,
J. (September 1996). Violence assessment in hospitals provides basis for taken to protect staff members and patients from
action. American Nurse, 18. violence in the workplace.

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box 12-5 a superior presence. They attack aggressively, and
when the victim bleeds, the victim becomes a fatal-
Steps Toward Increasing Protection
From Workplace Violence ity. Broome has suggestions for dealing with bullies
in the workplace:
• Security personnel and escorts
• Panic buttons in medication rooms, stairwells, activity ■ Assume all identified “fish” are “sharks.” Until
rooms, and nursing stations
• Bulletproof glass in reception, triage, and admitting areas you get to know people, do not make assump-
• Locked or key-coded access doors tions one way or the other.
• Closed-circuit television ■ Do not “bleed.” Crying or arguing only makes
• Metal detectors the bully more aggressive. Remove yourself from
• Use of beepers and/or cellular car phones the presence of the shark.
• Handheld alarms or noise devices
• Lighted parking lots ■ Admit it is difficult not to bleed, but know
• Escort or buddy system you can. Control your anger, and deal with facts
• Enforced wearing of photo identification badges only.
Adapted from Simonowitz, J. (1994). Violence in the workplace: You’re ■ Counter any aggression promptly. Recognize
entitled to protection. RN, 57(11), 61–63; nursingworld.org/dlwa/osh/wp6. that aggression is often a prelude to an attack.
■ Avoid ingratiating behaviors. You might believe
that these will ward off the attack, but they will
What if, in spite of all precautions, violence occurs?
not, and you could still “lose your limb.”
What should you do? You should:
■ Respond to all inappropriate behaviors appro-
■ Report to your supervisor. Report threats as well priately. Bullies often believe that you will forget
as actual violence. Include a description of the what they did in the last attack. Always respond
situation; names of victims, witnesses, and per- appropriately.
petrators; and any other pertinent information. ■ Make it known that the behavior is unaccept-
■ Call the police. Although the assault is in the able and will not be tolerated. If the behavior
workplace, nurses are entitled to the same rights continues, file a written complaint with Human
as workers assaulted in another setting. Resources.
■ Get medical attention. This includes medical
care, counseling, and evaluation. Sexual Harassment
■ Contact your collective bargaining unit or your
state nurses association. Inform them if the A new supervisor on the unit needed to be hired.
problems persist. After months of interviewing, the candidate selected
■ Be proactive. Get involved in policy making was a young male nurse whom the staff members
(nursingworld.org/ajn/2001/jul/issues). jokingly described as “a blond Tom Cruise.”The new
supervisor was an instant hit with the predomi-
Violence in the workplace can also be the result of
nantly female executives and staff members.
horizontal violence or interactive workplace trauma.
However, he soon found himself on the receiving
These terms denote a workplace that is infested
end of sexual jokes and innuendoes. He had been
with one or more “bullies.” These bullies project
trying to prove himself a competent supervisor, with
domineering and aggressive behaviors toward oth-
hopes of eventually moving up to a higher manage-
ers, usually when the other person is preoccupied or
ment position. He viewed the behavior of the female
unaware. Individuals who desire to control others
staff members and supervisors as undermining his
may use a variety of approaches, including verbal
credibility, in addition to being embarrassing and
abuse, punishment, criticism, put-downs, and mali-
annoying. He attempted to have the unwelcome
cious gossip. Unfortunately, these individuals are
conduct stopped by discussing it with his boss, a
often not identified during the employment inter-
female nurse manager. She told him jokingly that it
view. Bullies in the workplace may be coworkers,
was nothing more than “good-natured fun” and
superiors, or subordinates. Regardless of their place
besides, “men can’t be harassed by women”
on the organizational chart, bullies can cause a great
(Outwater, 1994).
deal of distress to others in the workplace. Barbara
Broome (2008) states that bullies are like sharks. In spite of the requirement for workplace educa-
The shark tries to dominate the other fish and have tion, sexual harassment remains one of the most

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persistent problems. The reasons are complex, but behaviors would have resulted in deprivation of
sex-role stereotypes and the unequal balance of a job or benefits. Example: The administrator
power between men and women are major contrib- approaches a nurse for a date in exchange for
utors. Unfortunately, underreporting of this prob- a salary increase 3 months before the scheduled
lem is common, even though the emotional costs of review.
anger, humiliation, and fear are high (nursingworld. 2. Hostile environment. This is the most com-
org/dlwa/wpr/wp3/htm). mon sexual harassment claim and the most dif-
The laws that prohibit discrimination in the ficult to prove. The employee making the claim
workplace are based on the Fifth and Fourteenth must prove that the harassment is based on
Amendments to the Constitution, mandating due gender and that it has affected conditions of
process and equal protection under the law. The employment or created an environment so
Equal Employment Opportunity Commission offensive that the employee could not effective-
(EEOC) oversees the administration and enforce- ly discharge the responsibilities of the job
ment of issues related to workplace equality. (Outwater, 1994). In 1993, the Supreme Court
Although there may be exemptions from any law, it ruled that a plaintiff is not required to prove
is important that nurses recognize that there is sig- any psychological injury to establish a harass-
nificant legislation that prohibits employers from ment claim. If the environment could be shown
making workplace decisions based on race, color, to be hostile or abusive, then there was no fur-
sex, age, disability, religion, or national origin. The ther need to establish that it was also psycho-
employer may ask questions related to these issues logically injurious. Although sexual harassment
but cannot make decisions about employment against women is more common, men can be
based on them. Behaviors that could be defined as victims as well.
sexual harassment are identified in Box 12-6. The
EEOC issued a statement in 1980 that sexual Sexual harassment can cost an employer money,
harassment is a form of sex discrimination prohib- unfavorable publicity, expensive lawsuits, and large
ited by Title VII of the Civil Rights Act of 1964. damage awards. Low morale caused by a hostile
Two forms of sexual harassment are identified; work environment can cause significant decreases
both are based on the premise that the action is in employee productivity, increased absenteeism,
unwelcome sexual conduct: increases in sick leave and medical payments, and
decreased job satisfaction.
1. Quid pro quo. Sexual favors are given in
In addition to Title VII, other legal protections
exchange for favorable job benefits or continua-
include Title IX of the Education Amendments
tion of employment. The employee must
of 1972 and state fair employment statutes.Title IX
demonstrate that he or she was required to
of the Education Amendments of 1972 prohibits sex
endure unwelcome sexual advances to keep the
discrimination and sexual harassment in any educa-
job or job benefits and that rejection of these
tional program receiving financial assistance from
the federal government. Students and employees are
covered by this law. Most state fair employment
statutes apply to public and private employers,
box 12-6 employment agencies, and labor organizations.
Behaviors That Could Be Defined as Often, state workers’ compensation statutes provide
Sexual Harassment remedies for employees who have been injured,
• Pressure to participate in sexual activities either physically or psychologically, by sexual harass-
• Asking about another person’s sexual activities, fantasies, ment in the workplace. Prohibition against sexual
preferences harassment in the workplace may also be included in
• Making sexual innuendoes, jokes, comments, or suggestive
facial expressions collective bargaining agreements (nursingworld.org/
• Continuing to ask for a date after the other person has readroom/position/workplac/wkharass).
expressed disinterest Addressing the issue of sexual harassment in the
• Making sexual gestures with hands or body movements workplace is important. As an employee, be famil-
or showing sexual graffiti or visuals iar with the policies and procedures related to
• Making remarks about a person’s gender or body
reporting sexual harassment incidents. If you

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supervise other employees, regularly review your A midwife initially suffered hives, nasal conges-
agency’s policies and procedures. Seek appropriate tion, and conjunctivitis. Within a year, she devel-
guidance from your Human Resources personnel. oped asthma, and 2 years later she went into shock
If an employee approaches you with a complaint, after a routine gynecological examination during
then a confidential investigation of the charges which latex gloves were used.The midwife also suf-
should be initiated. Above all, do not dismiss any fered respiratory distress in latex-containing envi-
incidents or charges of sexual harassment involving ronments when she had no direct contact with latex
yourself or others as “just having fun” or respond products. She was unable to continue working
that “there is nothing anyone can do.” Responses (Bauer et al., 1993).
such as this can have serious consequences in the A physician with a history of seasonal allergies,
workplace (Outwater, 1994). runny nose, and eczema on his hands suffered
The ANA cites four tactics to fight sexual harass- severe runny nose, shortness of breath, and collapse
ment (nursingworld.org/dlwa/wpr/wp3/htm): minutes after putting on a pair of latex gloves. A
cardiac arrest team successfully resuscitated him
1. Confront. Indicate immediately and clearly to (Rosen et al., 1993).
the harasser that the attention is unwanted. Latex products are manufactured from the
If you are in a union facility, ask the nursing milky fluid of the rubber tree. Latex allergy was
representative to accompany you. first identified in the late 1970s. It has become such
2. Report. Report the incident immediately to a major health problem in the workplace that both
your supervisor. If the harasser is your supervi- the OSHA and the ANA have devoted Web sites
sor, report the incident to a higher authority. to the problem. It is estimated that currently
File a formal complaint, and follow the chain 8%–12% of health-care workers are sensitive to
of command. natural rubber latex products.Table 12-2 lists prod-
3. Document. Document the incident immedi- ucts commonly produced with latex.
ately while it is fresh in your mind—what Since the 1987 CDC recommendations for uni-
happened, when and where it occurred, and versal precautions, use of latex gloves has greatly
how you responded. Name any witnesses. Keep increased exposure of health-care workers to natu-
thorough records, and keep them in a safe place ral rubber latex (NRL). The two major routes of
away from work. exposure to NRL are skin and inhalation, particu-
4. Support. Seek support from friends, relatives, larly when glove powder acts as a carrier for NRL
and organizations such as your state nurses protein (OSHA latex alert: cdc.gov/niosh/latexalt).
association. If you are a student, seek support Reactions range from contact dermatitis, with scal-
from a trusted faculty member or advisor. ing, drying, cracking, and blistering skin, to allergic
Additionally, your employer has a responsibility contact dermatitis in the form of generalized hives.
to maintain a harassment-free workplace. You More serious reactions can progress to generalized
should expect your employer to demonstrate urticaria, rhinitis, wheezing, swelling, shortness of
commitment to creating a harassment-free breath, and anaphylaxis. According to the NIOSH,
workplace, provide strong written policies the most common reaction to latex products is
prohibiting sexual harassment and describing irritant contact dermatitis, the development of
how employees will be protected, and educate dry, itchy, irritated areas on the skin, usually the
all employees verbally and in writing. hands. This reaction is caused by irritation from
wearing gloves and by exposure to the powders
Latex Allergy added to them.
Allergic contact dermatitis (sometimes called
A nurse developed hives in 1987, nasal congestion chemical sensitivity dermatitis) results from the
in 1989, and asthma in 1992. She was diagnosed chemicals added to latex during harvesting, pro-
with latex allergy. Eventually she developed severe cessing, or manufacturing. These chemicals can
respiratory symptoms in the health-care environ- cause a skin rash similar to that of poison ivy.
ment even when she had no direct contact with Neither irritant contact dermatitis nor chemical
latex. The nurse was forced to leave her occupation sensitivity dermatitis is a true allergy (cdc.gov/
because of these health effects (Bauer et al., 1993). niosh/98-113).

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table 12-2
Latex Equipment
Emergency Equipment Personal Protective Equipment Office Supplies Hospital Supplies
Blood pressure cuffs Gloves Rubber bands Anesthesia masks
Stethoscopes Surgical masks Erasers Catheters
Disposable gloves Goggles Wound drains
Oral and nasal airways Respirators Injection ports
Endotracheal tubes Rubber aprons Rubber tops of multi-dose vials
Tourniquets Dental dams
IV tubing Hot water bottles
Syringes Baby bottle nipples
Electrode pads Pacifiers
Adapted from OSHA latex allergy: osha-slc.gov/SLTC/latexallergy/index; and OSHA latex alert: cdc.gov/niosh/latexalt?



Latex allergy should be suspected if an employee ■ Use latex-free procedure trays and crash carts.
develops symptoms after latex exposures. A com- ■ Use nonlatex gloves for activities that do not
plete medical history can reveal latex sensitivity, involve contact with infectious materials.
and blood tests approved by the U.S.Food and Drug ■ Avoid using oil-based creams or lotions, which
Administration are available to detect latex antibod- can cause glove deterioration.
ies.Skin testing and glove-use tests are also available. ■ Seek ongoing training and the latest informa-
Compete latex avoidance is the most effective tion related to latex allergy.
approach. Medications may reduce allergic symp- ■ Wash, rinse, and dry hands thoroughly after
toms, and special precautions are needed to prevent removing gloves or between glove changes.
exposure during medical and dental care. ■ Use powder-free gloves.
Encourage employees with a latex allergy to wear a
In spite of all precautions, what do you do if you
medical alert bracelet.
develop a latex allergy? At this point, never wear
Decreasing the potential for development of latex
latex gloves. Be aware of the following precautions
allergy consists of reducing unnecessary exposure to
(nursingworld.org/dlwa/osh/wp7):
NRL proteins for health-care workers. Many
employees in a health-care setting,such as food han-
■ Avoid all types of latex exposure.
dlers or gardeners, can use alternative gloves. If an
■ Wear a medical alert bracelet.
employee must use NRL gloves, gloves with a lower
■ Carry an Epi-kit with auto-injectible epinephrine.
protein content and those that are powder-free
■ Alert employers and colleagues to your latex
should be considered. Good housekeeping practices
sensitivity.
should be identified to remove latex-containing dust
■ Carry nonlatex gloves.
from the workplace. Employee education programs
to ensure appropriate work practices and hand wash- OSHA “right to know” laws require employers to
ing should be encouraged. Identification of employ- inform health-care workers of potentially danger-
ees with increased potential for latex allergies is not ous substances in the workplace. For continuing
possible. However, clinical evidence indicates that information on latex allergies, see the NIOSH
certain workers may be at greater risk, including home page at cdc.gov/niosh
those with histories of allergies to pollens, grasses, Patients as well as workers are at risk and should
and certain foods or plants (avocado, banana, kiwi, be screened for allergies. Patients with a history of
chestnut) and histories of multiple surgeries. hay fever, food allergies (especially to bananas, avo-
Decrease the potential for latex allergy problems cados, potatoes, tomatoes), asthma, or eczema can
(cdc.gov/niosh/98-113): be at risk.Taking a thorough health history is vital.
Treat any indication of potential latex sensitivity
■ Evaluate any cases of hand dermatitis or other seriously (Society of Gastroenterology Nurses and
signs or symptoms of potential latex allergy. Associates, 2001). As of 2006, most health-care

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personnel were well aware of issues related to latex included in the review of safer devices as well as in
allergies. In recent years, the number of new cases of making recommendations for replacement devices.
latex allergy has decreased due to improved diag- (osha.gov/needlesticks/needlefaq;http://www.joint
nostic methods, improved education, and more commission.org/SentinelEvents/SentinelEvent
accurate labeling of medical devices. Although cur- Alert/sea_22.htm)
rent research does not demonstrate whether the
amount of allergen released during shipping and Your Employer’s Responsibility
storage into medications from vials with rubber clo- According to the current OSHA requirements,
sures is sufficient to induce a systemic allergic reac- your employer must provide you with the following
tion, nurses should take special precautions when (ANA, 1993; nursingworld.org/dlwa/osh/wp2):
patients are identified as high risk for latex allergies.
■ Free hepatitis B vaccine
The nursing staff should work closely with the
■ Protective equipment that fits you (gloves,
pharmacy staff to follow universal one-stick-rule
gowns, goggles, masks)
precautions, which assume that every pharmaceuti-
■ Immediate, confidential medical evaluation,
cal vial may contain a natural rubber latex closure,
treatment, and follow-up if you are exposed
and the nurse should remain with any patient at the
■ Implementation of universal precautions
start of medication and keep frequent observations
institution-wide
and vital signs for 2 hours (Hamilton et al., 2005).
■ Adequate sharps disposal
■ Proper removal of hazards from the workplace
Needlestick Injuries ■ Annual employee training
In 1997 a 27-year-old nurse, Lisa Black, attended Many states have enacted their own laws related to
an in-service session on postexposure prophylaxis blood-borne pathogen exposures. These laws may
for needlesticks. A short time later, she was include some of the following requirements:
attempting to aspirate blood from a patient’s intra- ■ Listing of safety devices as engineering controls
venous line. The patient, in the advanced stages of ■ Development of a list of available safety devices
acquired immunodeficiency syndrome, moved, and by the state for use by employers
the needle went into Lisa’s hand.Nine months later ■ Development of a written exposure plan by
she tested positive for HIV and 3 months after that employers and periodic review and updates
for hepatitis C. She continues to share her story ■ Development of protocols for safety device
with nurses everywhere in an effort to prevent this identification and selection by employers
unfortunate accident from happening to one more and involvement by frontline workers in the
nurse (Trossman, 1999a). process
On April 18, 2001, the Needlestick Act, or ■ Development of a sharps injury log and report-
revised Bloodborne Pathogens Standard, went ing log information
into effect. The revised OSHA Bloodborne ■ Development of methods to increase use of vac-
Pathogens Standard obligates employers to con- cines and personal protective equipment
sider safer needle devices when they conduct their ■ Waivers or exemptions from safety device use
annual review of their exposure control plan. under certain circumstances (including patient
Frontline employees must be included in the and/or worker safety issues, use of alternative effec-
annual review and updating of standards process. tive strategies, market unavailability, and so on)
Stricter requirements are now in effect for annual ■ Placement of sharps containers in accessible
review and updating to reflect changes in technol- positions
ogy that eliminate or reduce exposure to blood- ■ Training for workers regarding safety device
borne pathogens. JC surveyors are now asking if use (http://www.cdc.gov/niosh/topics/bbp/
health-care organization leaders are familiar with ndl-law.htm)
the Needlestick Safety and Prevention Act and
whether any action being taken to comply Your Responsibility
includes staff that use sharps and needles and are What are your responsibilities related to this revised
therefore at risk for injury. The law requires legislation? Each year your institution must review
that these health-care workers and other staff be and update its blood-borne pathogen standards.You

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will need to take the time to learn new devices, and Ergonomic Injuries
make certain that the current safety requirements
are enforced with employees. Volunteer to partici- Occupational-related back injuries affect more
pate in evaluation committees, or work on teams than 75% of nurses over the lifetime of their
testing new devices. Follow these guidelines in your career. Poor ergonomics is a safety factor for both
daily nursing practice (ANA, 1993; Brooke, 2001; nurses and patients, whose safe nursing care is
nursingworld.org/dlwa/osh/wp2; Perry, 2001): already in jeopardy by the escalating nursing short-
age (Durr, 2004).
■ Always use universal precautions.
■ Use and dispose of sharps properly. Back Injuries
■ Be immunized against hepatitis B.
Back injuries are the most critical of ergonomic
■ Immediately wash all exposed skin with soap
injuries. Annually, 12% of nurses leave the profes-
and water.
sion as a result of back injuries, and more than
■ Flush affected eyes or mucous membranes with
52% complain of chronic back pain. Nursing aides,
saline or water.
orderlies, and attendants ranked second and regis-
■ Report all exposures according to your facility’s
tered nurses sixth in a list of at-risk occupations for
protocol.
strains and sprains (DOL, 2002). The problem
■ If possible, know the HIV/hepatitis B virus
with lifting a patient is not just one of overcoming
status of your patient.
heavy weight. Size, shape, and deformities of the
■ Comply with postexposure follow-up.
patient as well as balance and coordination, com-
■ Support others who are exposed.
bativeness, uncooperativeness, and contractures
■ Become active in the safety committee—be a
must be considered. Any unpredictable movement
change agent.
or resistance from the patient can throw the nurse
■ Educate others.
off balance quickly and result in a back injury.
Although health-care providers are aware of the Environmental considerations such as space,equip-
need to use gloves as a protection against blood- ment interference, and unadjustable beds, chairs,
borne pathogens, only one evidence-based summary and commodes also contribute to back injury risk
has been reported regarding blood-borne pathogens (Edlich, Woodard, & Haines, 2001).
and glove safety. The summary explored double This issue of back injuries and other ergonomic-
gloving versus single gloving in reducing the number related injuries has become so severe that in July
of infections. This includes postoperative wound 2001 the OSHA began to develop a comprehensive
infections or blood-borne infections in surgical approach to ergonomics. Public forums, meetings
patients and blood-borne infections in the surgical with stakeholder groups and individuals, and writ-
team and to determine if double gloving reduces the ten comments were analyzed. Out of this work, a
incidence of glove perforations compared with single four-pronged comprehensive approach to ergonom-
gloving. A total of 18 randomized controlled trials ics was developed to include (osha.gov/ergonomics/
met the inclusion criteria and were included in the ergofact02):
review.There is clear evidence from this review that
1. Task- or industry-specific written guidelines
double gloving reduces the number of perforations
2. Enforcement
to the innermost glove.There does not appear to be
3. Outreach/assistance
an increase in the number of perforations to the out-
4. Research
ermost glove when two pairs of gloves are worn.
Korniewicz et al. (2004) participated in the first The OSHA issued an ergonomics guideline for the
clinical trial to test the barrier integrity of nonlatex nursing home industry on March 13, 2003. The
sterile surgical gloves after use in the operating room. back injury guide for health-care workers
During the 14-month study, more than 21,000 (dir.ca.gov/dosh/dosh_publications/backinj.pdf )
gloves were collected from more than 4000 surgical and the OSHA guidelines for nursing homes
procedures. Based on results, Korniewicz et al. con- (osha.gov/ergonomics/guidelines/nursinghome/in-
cluded that nonlatex or intact latex gloves provide dex) are comprehensive resources. Although guide-
adequate barrier protection but that nonlatex gloves lines are less than legislated standards, the OSHA
may tear more frequently than latex during use. uses the General Duty Clause to cite employers for

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ergonomic hazards. Under this clause, employers ■ Align the keyboard so that your forearms,
must keep their workplaces free from recognized wrists, and hands are aligned parallel to the
serious hazards, including ergonomic hazards. This floor. Do not bend the hands back.
requirement exists whether or not there are voluntary ■ Position the mouse directly next to you and on
guidelines (osha.gov/ergonomics/FAQs-external). the same level as the keyboard.
The ANA, supported by the Johnson & ■ Keep thighs parallel to the floor as you sit on
Johnson Foundation, has begun a campaign enti- the chair. Feet should touch the floor, and the
tled “Handle with Care.”This initiative is aimed at chair back should be ergonomically sound.
preventing potentially career-ending back and ■ Vary tasks. Avoid long sessions of sitting. Do
other musculoskeletal injuries among nurses. not use excessive force when typing or clicking
Health-care facilities that have invested in these the mouse.
assistive patient handling programs report cost sav- ■ Keep fingernails short, and use fingertips when
ings in thousands of dollars both for direct costs of typing.
back injuries and lost workdays (nursingworld.org/
handlewithcare/factsheet). In addition, assistive Impaired Workers
patient handling equipment improves the quality
care of patients. Dr. de Castro, senior staff special- Substance Abuse
ist for occupational health and safety at the ANA,
Sue had been a nurse for 20 years. Current marital
observes that such equipment:
and family problems were affecting her at work. To
■ Improves the safety of the patient by decreasing ease the tension, she took a Xanax from a patient’s
the potential for manual patient-handling mishaps medication drawer. This seemed to ease her tension.
■ Increases patient comfort by taking away the She continued to take medications, working her way
human element of potentially awkward or force- up to narcotic analgesics.
ful handlings Bill had begun weekend binge-drinking in col-
■ Restores patient dignity, especially in situations lege. Ten years later, he continues the habit several
when difficult handling situations impede on a times during the month. He does not believe he is an
person’s privacy or self-esteem (de Castro, 2004) alcoholic because he can “control” his drinking. After
he begins showing up at work hung over and mak-
The investment in a safe patient-handling program
ing medication errors, he is fired for the medication
may seem daunting due to the cost of equipment
errors. At the exit interview, no mention is made of
such as mechanical lifts,transfer aids,and ergonom-
his drinking problem. The agency feared a lawsuit
ic beds and chairs. However, the cost savings in
for defamation of character.
time, reduction of injuries, and lost workdays—as
Mr. P., the unit manager, has noticed that Ms. J.
well as the improved quality of patient care—make
has been late for work frequently. She arrives with
this a sound return on investment.
a wrinkled uniform, dirty shoes, unkempt hair, and
Repetitive Stress Injuries broken nails. Lately she has been overheard making
Repetitive stress injuries (RSIs) have been called the terse remarks to patients such as, “Who do you think
workplace epidemic of the modern age. RSIs usually I am—your maid?,” and spends longer and longer
affect people who spend long hours at computers, periods off the unit. The floor has a large number of
switchboards, and other worksites where repetitive surgical patients who receive intramuscular and
motions are performed. The most common RSIs oral medications for pain. Lately, Ms. J.’s patients
are carpal tunnel syndrome and mouse elbow. As continue to complain of pain even after medication
technology expands in health-care facilities, the use administration has been charted. Ms. J. frequently
of computers increases for all health-care personnel. forgets to waste her intramuscular narcotics in front
Badly designed computer workstations present the of another nurse. Mr. P. is concerned that Ms. J. may
highest risk of RSIs. Preventive measures (Krucoff, be an impaired nurse.
2001) include the following:
As nursing education moved from the untrained
■ Keep the monitor screen straight ahead of you, nurse—embodied in the character of Sairey Gamp
about an arm’s length away. Position the center in the Dickens novel Martin Chuzzlewit—to the
of the screen where your gaze naturally falls. educated Florence Nightingale model, nurses were

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expected to be of good moral character.The problem The National Council of State Boards lists all
of addiction among nurses was not discussed until state boards of nursing. Information on support
the 1950s, with addicted nurses receiving little sym- programs for impaired nurses can be obtained
pathy or treatment from their peers. Research on from each state board (ncsbn.org/regulation/
addicted medical professionals increased in the nursingpractice_npa_pennrn.asp).
1970s,followed by major help for nurses with addic- Upholding the standards of the nursing profes-
tive disease in 1980. At this time, the National sion is everyone’s responsibility. Often coworkers,
Nurses’ Society on Addictions (NNSA) task force noticing a change in another’s behavior, become
and the ANA task force on addictions and psycho- protective and take on more work to ease the bur-
logical functions jointly passed a resolution calling den of their coworker. Although it is difficult to
for acknowledgment of the problem and guidelines report a colleague, covering up or ignoring the
for impaired nurse programs (Heise, 2003). problem can cause serious risks for the patient and
Alcohol and drug abuse continue to be major the nurse. Many state boards make it mandatory
health problems in the United States. Health-care for nurses to report suspected impaired coworkers;
professionals are not immune to alcoholism or most states accept anonymous reports. In many
chemical dependency. In addition, various kinds of states, state law requires hospitals and health-care
mental illnesses may also affect a nurse’s ability to providers to report impaired practitioners, but the
deliver safe, competent care. Impaired workers can law also grants immunity from civil liability if the
adversely affect patient care, staff retention, morale, report was made in good faith (Blair, 2005; Sloan
and management time as team members try to pick & Vernarec, 2001).
up the slack for the impaired worker (Damrosch &
Scholler-Jaquish, 1993). The most common signs Microbial Threats
of impairment are (Blair, 2005; Damrosch & Health-care workers are an at-risk group for several
Scholler-Jaquish, 1993): microbial threats. Severe acute respiratory syn-
dromes (SARS) is a respiratory illness that has
■ Witnessed consumption of alcohol or other sub-
been reported in Asia, Europe, and North America.
stances on the job
According to the World Health Organization,
■ Changes in dress, appearance, posture, gestures
8098 people worldwide became sick with SARS
■ Slurred speech; abusive/incoherent language
during the 2003 outbreak.
■ Reports of impairment or erratic behavior from
SARS begins with a high fever and mild respi-
patients and/or coworkers
ratory symptoms. Other symptoms may include
■ Witnessed unprofessional conduct
headache, an overall feeling of discomfort, and
■ Significant lack of attention to detail
body aches. It is not uncommon for the person to
■ Witnessed theft of controlled substances
have diarrhea and develop a dry cough. Most
■ When assigned patients routinely request pain
patients develop pneumonia. The virus that causes
medication within a short period of being
SARS is thought to be transmitted most readily by
medicated
respiratory droplets. The virus can also spread
Most employers and state boards of nursing have when a person touches a surface or object contam-
strict guidelines related to impaired nurses. inated with infectious droplets and then touches
Impaired-nurse programs, which are conducted by his or her mouth, nose, or eyes. In addition, it is
state boards of nursing, work with the employer to possible that the SARS virus might spread more
assist the impaired nurse to remain licensed while broadly through the air (airborne spread) or by
receiving help for the addiction problem. It is other ways that are not known.The CDC provides
important that you become aware of workplace current information on the handling of SARS in
issues surrounding the impaired worker, signs and the workplace (cdc.gov).
symptoms of impairment, and the policies and Unlike the newer microbial threat SARS, tuber-
reporting procedures concerning an impaired culosis (TB) was a leading cause of death among
worker. Compassion from coworkers and supervi- infectious diseases from the 19th into the mid-
sors is of utmost importance in assisting the 20th centuries. Although TB rates declined in the
impaired worker to seek help (Damrosch & 1990s, they are currently on the rise as resources
Scholler-Jaquish, 1993; Sloan & Vernarec, 2001). that were committed to fighting the disease were

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withdrawn. A more serious form of TB, mutidrug- ■ Limit caffeine intake, especially toward the end
resistant tuberculosis (MDR-TB) is on the rise. of the shift.
Nurses often come in contact with persons with ■ If you work evenings or nights, do not eat a big
active TB. At times, patients do not know they are meal at the end of the shift. This interferes with
infected until coming to the hospital with another sleep.
complaint. As with SARS, the CDC provides cur- ■ Try to sleep a continuous block of time instead
rent information and guidelines for dealing with of catching a few hours here and there.
TB in the workplace (cdc.gov/nchstp/tb/pubs/ ■ Make the room you are sleeping in as dark and
TB_HIVcoinfection/default). noise-free as possible.
■ Maintain good nutrition and an exercise
Enhancing the Quality of Work Life program.
■ Negotiate your schedule with your manager.
The continued nursing shortage enforces an aware- If you and your colleagues feel strongly about
ness to “treat with kindness”the nurses who remain eliminating rotating shifts, work together to
in the workforce. make changes (Trossman, 1999b).

Mandatory Overtime
Rotating Shifts
When nurses are forced routinely to work beyond
Safety in the workplace involves nurses working
their scheduled hours, they can suffer a range of
rotating shifts. Nurses who work permanently at
emotional and physical effects. As patient acuity
night often readjust their sleep-wake cycle.
and workloads increase, nurses working overtime
However, even permanent night-workers may be
put both patients and nurses at greater risk.
subjected to continuous sleep deprivation. Nurses
Mandatory overtime is seen by nurses as a control
who randomly rotate shifts throw off their circa-
issue. Working overtime should be a choice, not a
dian rhythm. Fatigue, the primary complaint of
requirement. In some facilities, nurses are being
these nurses, is the result of the body never get-
threatened with dismissal or charge of patient aban-
ting the chance to adapt to changing sleep-wake
donment if they refuse to participate in mandatory
cycles. The literature links some of the world’s
overtime (nursingworld.org/tan/98mayjun/ot).
worst disasters, such as the Chernobyl nuclear
The ANA presented the following message to
reactor catastrophe and the Exxon Valdez oil
the 107th Congress in 2001: “ANA opposes the use
spill, to rotating shift work and the changes in
of mandatory overtime as a staffing tool. We urge
circadian rhythm. Other effects of shift work
you to support legislation that would ban the use of
include a higher risk of miscarriage and prema-
mandatory overtime through Medicare and
ture labor, menstrual and digestive problems, and
Medicaid law. Nurses must be given the opportuni-
respiratory irritation. One of the most serious
ty to refuse overtime if we believe that we are too
results of rotating night shifts is the increasing
fatigued to provide quality care” (nursingworld.org
number of nurses affected by coronary heart dis-
/gova/federal/legis/107/ovrtme).Dembe,Erickson,
ease (CHD). Studies indicate that nurses who
Delbros, and Banks (2005) analyzed the occurrence
rotate to nights for 6 years have a 70% greater
of occupational injury and illness between 1987
risk of developing CHD than nurses who never
and 2000. After a review of 10,793 participants
rotated shifts due to the circadian effect of lower-
working at least 12 hours per day, working overtime
ing of blood pressure and heart rate at night
was associated with a 23% increased work hazard
(Trossman, 1999b). Suggestions for nurses who
and a 61% higher injury hazard rate compared with
rotate shifts:
jobs without overtime. More recently, Rogers et al.
■ Try to schedule working the same shifts for an (2004) found that nurses’error rates increase signif-
entire scheduling period instead of rotating icantly during overtime, after 12 hours and over
different shifts in one schedule. more than 60 hours per week. Currently, there are
■ Try to schedule to same days off within the no regulations governing nurses’work hours. About
schedule. half of staff nurses are scheduled routinely to work
■ If you become sleepy during the shift, take a 12-hour shifts, and 85% of staff nurses routinely
walk or climb stairs. work longer than scheduled hours.