Editor s Note To continue providing safe, effective patient care, the healthcare industry is constantly transforming. It s up to healthcare professionals to stay current on frequently evolving elements such as your facility s policies and procedures, and services to new patient populations. The articles included in this issue outline topics related to potential healthcare changes and how to best handle the new situations you ll likely encounter. nso nurses service organization Nurses Service Organization Risk Advisor for Nurses Advanced Practice Nurses Improving health literacy improves patient outcomes NSO Risk Advisor Imagine you re an advanced practice nurse (APN) in a family practice clinic. One morning you see a new patient, whom you diagnose with hypertension. You provide education, including how to take his antihypertensive medications, and send him on his way. Late the next day you get a call that your patient ended up in the Emergency Department (ED) because he overdosed on his medication, taking six pills instead of two. His family wants to sue you for not giving him the right instructions. You recall that talking with the patient, he shook his head no when you asked, Do you have any questions? What happened in this situation? The answer is that like many healthcare providers, you probably overestimated the patient s health literacy. According to a 2003 report from the Department of Health and Human Services (the most recent available data), only 12 percent of U.S. adults have proficient health literacy, meaning they can understand and use health information effectively, and more than a third have a basic or below basic level. That translates into millions of people in the United States who don t understand the vital health information we give them. Such lack of knowledge can be deadly. A 2011 report from the Agency for Healthcare Research and Quality (AHRQ) found that low health literacy is linked to poorer health status and a higher risk of death. It can also result in communication failures that lead to adverse events and potentially, the courtroom. To change this paradigm, APNs need to recognize the issue of health literacy and use tools such as teach-back and patient-friendly education materials to help ensure comprehension. The value of health literacy Patients have to understand instructions so they can manage their own care and improve outcomes. February s Health Affairs cites studies of strategies that improve patient adherence. For instance, medication counseling using a plain language, pictogram-based intervention resulted in fewer dosage errors and greater adherence, compared to standard care, which consisted of routine counseling about the medication. Three 2010 initiatives recognize the vital role of health literacy The Affordable Care Act, the National Action Plan to Improve Health Literacy from the Department of Health and Human Services, and the Plain Writing Act. The Joint Commission s new standards on patient-centered communication also include guidelines on health literacy. These initiatives have prompted facilities to develop policies related to health literacy, which nurses need to use to guide their practice. In addition, health literacy is part of a competency for Standard 1 (Assessment) from the American Nurses Association: Identifies barriers (e.g., psychosocial, literacy, financial, cultural) to effective communication and makes appropriate adaptations. An additional competency for APNs is Assesses the effect of interactions among individuals, family, community, and social systems on health and illness, which required competency in health literacy. The current healthcare environment is a place
where APNs will be held accountable for meeting their patients health literacy needs. Legislation, facility policies, and professional standards of practice could be cited in litigation involving mishaps related to a patient s taking incorrect action because he or she didn t understand the provided information. A universal resource You can t tell a patient s health literacy by looking at him or her. However, in this busy world of healthcare, there is little time to conduct a formal assessment. That s why the North Carolina Program on Health Literacy says that just as we use universal precautions to prevent spread of bloodborne disease for all patients, we need to use health literacy universal precautions for all patients. The North Carolina program developed the Health Literacy Universal Precautions Toolkit, available as a free download at www.nchealthliteracy.org/ toolkit. The toolkit, commissioned by the Agency for Healthcare Research and Quality, includes steps that healthcare providers can easily implement in their practice such as selecting provided tools, applying them, and assessing how effective they were in the interaction with the patient. Tools include how to use teach-back (see The power of teach-back), a reminder of key communication strategies, and a handout of systems patients can use to keep track of their medications. Boosting understanding You can use several simple strategies to address health literacy when working with patients. For example: Ask a patient how he or she prefers to receive information (by reading, hearing, or seeing). Avoid medical jargon and speak in simple, easyto-understand terminology. Speak slowly, so patients can more easily absorb the information. Encourage patients to participate as you teach. For example, you might have the patient hold the syringe as you are talking about it. Repeat key points. The power of teach-back If asked, Do you understand? after receiving health information, most patients will say yes rather than admit their lack of knowledge. Teach-back is a powerful method that ensures a patient truly comprehends what you have said. In this method, ask him or her to teach you the information. For example, you might say to patient starting on a statin medication, I want to be sure that I explained your medication correctly. Can you tell me how you are going to take this medicine? Teach-back can help you ensure that the patient understands the information you provided so he or she is more likely to adhere to instructions, thus reducing the likelihood of complications and a possible lawsuit. Source: North Carolina Program on Health Literacy. Health Literacy Universal Precautions Toolkit. http:// nchealthliteracy.org/toolkit. Accessed Feb. 10, 2012. Use pictures, if possible, to help explain concepts. Don t try to cover too much in one session. Document the communication methods used in the patient s medical record. The website for the North Carolina Program on Health Literacy also contains links to evidencebased self-management programs on diabetes and heart failure. A team approach Any method you use, from speaking slowly to encouraging questions, will help patients be more informed. More informed patients are less likely to sue because they are able to follow instructions and give themselves the best opportunity for successful self-management. By developing trust and promoting open communication, nurses can address health literacy and build a relationship with their patients that achieves the best possible outcomes. RESOURCES American Nurses Association. Nursing: Scope & Standards of Practice, 2nd Ed. 2010. Silver Spring, Md.: Author. Health Literacy Interventions and Outcomes: An Update of the Literacy and Health Outcomes Systematic Review of the Literature. 2011. http://www. ahrq.gov/clinic/tp/lituptp.htm. Accessed Feb. 10, 2011. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals. Accessed Feb. 6, 2012. Koh HK, Berwick DM, Clancy CM, et al. New Federal Policy Initiatives to Boost Health Literacy Can Help the Nation Move Beyond the Cycle of Costly Crisis Care. Health Affairs. 2012;31(2):434-443. National Patient Safety Foundation. Ask Me 3. http://www.npsf.org/forhealthcare-professionals/programs/ask-me-3. Accessed Feb. 10, 2012.
Are you competent in cultural care? A diverse group of people call the United States home, so advanced practice nurses (APNs) routinely encounter patients of different cultures in their practice. But how confident are you in your ability to meet varied cultural needs? Your competency is key, not just to achieve excellent patient outcomes, but also to protect yourself from possible litigation. What is cultural competence? According to the U.S. Office of Minority Health (OMH), culture refers to patterns of behavior of racial, ethnic, religious, or social groups. Cultural competence is the ability to meet the needs of diverse patient populations so delivered healthcare is safe and equitable. The National Quality Forum (NQF) says culturally competent care tries to eliminate misunderstandings and improve patient adherence with treatments. OMH notes that cultural competence is essential for closing the disparities gaps in healthcare because culture and language can affect someone s beliefs about health, disease, and the behaviors that lead to both. Integrating cultural competence into care The best way to understand patient s cultural needs is to simply ask. One general question that might be helpful is, Are there any cultural, religious, or spiritual beliefs that might influence your care? There are also more formal assessment tools such as the TransCultural Nursing Assessment Tool, which is available online at www.culturediversity.org/assmtform.htm. Below are a few examples of action steps you might want to consider to integrate cultural competency into the care you give your patients. In each case, the most important point is to provide options that are acceptable to the patient. Identify any cultural beliefs that may inhibit a patient s response to treatment. For instance, patients of certain cultures may use medicinal herbs that interfere with the absorption of their prescribed medications. Identify if the patient has cultural-based modesty issues about care provided by staff of the opposite sex. Determine if there are certain garments or items that the patient must wear while being treated. Identify any special dietary needs. For example, a patient may fast on certain holidays. Collaborate with patients and families to develop solutions to requests that can t be met. Provide education materials in the patient s preferred language and have translators available. This is especially important in the case of informed consent. Use professional interpreters not the patient s family or friends as needed if you don t speak the patient s language. Document communication strategies used and the patient s response in the medical record. Obligations for cultural competence Being respectful of and responsive to individuals cultural needs ensures more effective communication, improving outcomes and reducing the risk of errors that could turn into adverse events. The Joint Commission (TJC) recognizes the importance of patient-centered communication with its new standards, effective July 1, 2012, which address cultural competency. (For more information about the standards, read Appendix C in Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals, available online at www.jointcommission.org/advancing_effective_communication.) Several other documents and practices support the need for APNs to be culturally competent. Almost all hospitals and most healthcare providers are subject to federal civil rights laws such as Title VI of the Civil Rights Act of 1964 and Age Discrimination Act of 1975. These two acts were created to prevent federally funded organizations from discriminating
against staff or patients based on their skin color, race, ethnicity, or age. Cultural competence requires you to not only be aware of these types of discrimination, but to avoid it yourself and report it if you see or hear it happening. Many APN standards specifically address cultural competence. For instance, the National Organization of Nurse Practitioner Faculties competencies for independent practice includes: Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision-making. Another source of standards are those from the American Nurses Association. One of the competencies for Standard 3 (Outcomes Identification) states: Defines expected outcomes in terms of the healthcare consumer, healthcare consumer culture, values, and ethical considerations, and a competency for Standard 4 (Planning) requires nurses to consider culture when developing an individualized care plan. For example, patients need to be asked on admission about their preferred language for discussing healthcare issues so education information in the plan is provided in the preferred language. To not do so could place the patient in jeopardy because of misunderstanding. An additional competency specific for APNs listed for Standard 1 (Assessment) states: Assesses the effect of interactions among individuals, family, community, and social systems on health and illness. Cultural competence is essential to fulfill this standard. Organizations develop policies to guide staff so they can practice within legal and regulatory guidelines. You need to know and follow those policies. Failure to meet regulatory and legal guidelines and to follow policies and standards could result in a lawsuit if a patient s cultural needs aren t met and an injury occurs. Fulfilling your obligations also will help an attorney better defend you if a court case occurs. Developing cultural competence There is one important caveat to remember when building cultural competence don t stereotype. Culture is just one factor that shapes us; others include environment, socioeconomic status, genetics, and psychological factors. All these factors shape different people in different ways. The first place to start is to assess your own competence. One useful online resource is the Cultural Competence Health Practitioner Assessment, which you can access on the National Center for Cultural Competence website at http://nccc. georgetown.edu/features/cchpa.html. Be aware of your own possible biases. In cases of legal action, attorneys will examine whether you followed these standards.
The next step is to educate yourself. Appendix E in TJC s Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals contains a comprehensive list of resources for cultural competency training. Another resource is A Physician s Practical Guide to Culturally Competent Care, a free, selfdirected education program (registration required) from the OMH that is also useful for APNs and includes case studies. Lack of knowledge is no excuse in a court case. Take the example of a female patient of a culture that requires a woman to be cared for by someone of the same sex. The female patient who is examined by a male APN who does not discuss the situation with the woman beforehand may view the action as an offensive contact, or more commonly known as legal battery. The APN s lack of understanding would not negate the perception. Meeting patients cultural needs in practice The TJC Roadmap publication is also a valuable resource for integrating culture into your clinical practice. It contains a checklist of how to improve effective communication (including cultural competence) across the care continuum, including admission, assessment, treatment, end-of-life care, discharge, and transfer. These tools can help you be sensitive to patients cultural needs. Be sure to document your actions and results of your assessment of a patient s culture in the medical record. Flag any key information through use of stickers or other techniques to ensure other healthcare providers are aware of the patient s cultural needs. At times, it may be challenging to meet a patient s cultural needs. Remember to keep an open mind so you can negotiate a mutually agreed upon solution. Ongoing learning One of the NQF s guiding principles of cultural competency is that it should be an ongoing process. It s LEARN a resource for cultural competence The following mnemonic can help you remember important guidelines for working with people of different cultures. L = Listen with sympathy and understanding to the patient s perception of the problem. E = Explain your perceptions of the problem. A = Acknowledge and discuss the differences and similarities R = Recommend treatment. N = Negotiate treatment. Source: Berlin EA, Fowkes WC. A teaching framework for cross-cultural health care: application in family practice. West J Med. 1983;139:934-938. important to update your cultural competence skills in the same way you update your clinical skills. Doing so will help ensure your patients receive the care they need and help you avoid a day in court. RESOURCES American Nurses Association. Nursing: Scope & Standards of Practice, 2nd Ed. 2010. Silver Spring, Md.: Author. Byrne, MM. Cultural aspects of health. In: Ignatavicius DD and Workman ML, Medical Surgical Nursing: Critical Thinking for Collaborative Care. 5th ed. Saint Louis: Elsevier; 2006:54-62. Campinha-Bacote, J. Delivering patient-centered care in the midst of a cultural conflict: The role of cultural competence. Online Journal of Issues in Nursing. 2011;16(2):May. http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents/vol-16-2011/ No2-May-2011/Delivering-Patient-Centered-Care-in-the-Midst-of-a-Cultural- Conflict.html. Accessed Feb. 6, 2012. The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals. Accessed Feb. 6, 2012. National Quality Forum. Cultural Competency: An Organizational Strategy for High-performing Delivery Systems. No. 14, April 2009. National Center for Cultural Competence. Cultural and Linguistic Policy Assessment. http://www.clcpa.info/. Accessed Feb. 6, 2012. National Organization of Nurse Practitioner Faculties. 2011 Nurse Practitioner Core Competencies. http://www.nonpf.com/displaycommon. cfm?an=1&subarticlenbr=14. Accessed Feb. 10, 2012. The Office of Minority Health. What is cultural competency? http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=11. Accessed Feb. 6, 2012. The Office of Minority Health. A Physician s Guide to Culturally Competent Care. https://cccm.thinkculturalhealth.hhs.gov/guis/gui_intro_overview. asp. Accessed Feb. 10, 2012.
APNs and medical malpractice: A case study with risk management strategies Medical malpractice claims can be asserted against any healthcare provider, including APNs. Although there may be a perception that physicians are held responsible for the majority of lawsuits, the reality is that APNs are more frequently finding themselves defending the care they provide. In this case, the decedent/ plaintiff was a 76-year-old female admitted to the hospital for congestive heart failure. She was placed on a respirator and sedated. ICU staff obtained telephone consent from the plaintiff s daughter for placement of a peripherally inserted central catheter (PICC). The defendant APN was a PICC specialist employed by an agency that contracted with the hospital for placement of PICC lines for its inpatients... To read the full case with risk management recommendations, go to www.nso.com/casestudies/casestudy-article/302. jsp. Are you consulting, teaching, or training? Your professional liability insurance policy provides coverage for medical incidents that result in injury or damage. But, losses that arise from consulting, teaching, or training activities, or through expert testimony, would not typically be covered by your professional liability insurance policy. For only $25, the Consulting Services Liability Endorsement can be added to your professional liability insurance policy. Go to www.nso.com/ services to download a request form. Or, look for the offer in your renewal notice.
Aesthetic procedures coverage for self-employed practitioners Are you working independently and providing cosmetic services within the scope of your state s practice act? If you are thinking about performing non-surgical aesthetic procedures in the near future, please call NSO to add this endorsement to your current professional liability policy so you are covered for any non-surgical aesthetic procedures you are performing. This product protects you against covered claims of medical malpractice for nearly 100 non-surgical aesthetic procedures, including: dermal fillers microdermabrasion IPL skin rejuvenation permanent cosmetics laser skin resurfacing Botox injections mesotherapy collagen injections laser hair removal chemical peels Call NSO today to add this coverage endorsement to your current professional liability policy. There is an additional charge for this coverage. If you are an employed practitioner (receiving a W2 from your employer) and are providing aesthetic services on behalf of your employer working within the scope of your license, the aesthetics endorsement is extended to your NSO policy. No action is required. nso nurses service organization Service your account, day or night, by visiting My Account l www.nso.com NSO Risk Advisor is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO Risk Advisor, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. The professional liability insurance policy is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Coverages, rates and limits may differ or may not be available in all States. All products and services are subject to change without notice. This material is for illustrative purposes only and is not a contract. It is intended to provide a general overview of the products and services offered. Only the policy can provide the actual terms, coverages, amounts, conditions and exclusions. CNA is a service mark and trade name registered with the U.S.Patent and Trademark Office. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc.; in CA (License #0795465), MN & OK, AIS Affinity Insurance Agency, Inc.; and in NY, AIS Affinity Insurance Agency. NSO Risk Advisor is published by Affinity Insurance Services, Inc., with headquarters at 159 East County Line Road, Hatboro, PA 19040-1218. Phone: (215) 773-4600. 2012 Affinity Insurance Services, Inc. All world rights reserved. Reproduction without permission is prohibited.