Texas Nursing 2021 Issue 1

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TEXASNURSING M A G A Z I N E

NURSES GET IT DONE How Members Further Nursing and Policy

T N A : E m p o w e r i n g Te x a s N u r s e s t o a d v a n c e t h e p r o f e s s i o n | I s s u e 1 , 2 0 2 1

ISSUE 1, 2021 Volume 95, Number 1 EDITOR IN CHIEF: Cindy Zolnierek, PhD, RN, CAE MANAGING EDITOR: Kanaka Sathasivan, MPH COPY EDITORS: Serena Bumpus, DNP, RN, NEA-BC and Shanna Howard

BOARD OF DIRECTORS OFFICERS:

Tamara “Tammy” Eades, DNP, MSN, RN, President eades@uta.edu

4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 P: 800.TNA.2022 or 512.452.0645; F: 512.452.0648 tna@texasnurses.org | texasnurses.org

MISSION Empowering Texas Nurses to advance the profession

Amy McCarthy, MSN, RNC-MNN, NE-BC, Secretary amykoshy@gmail.com

Gayle Dasher, PhD, RN, ANP-BC, Treasurer gayle.dasher@christushealth.org Jeff Watson, DNP, RN, NEA-BC, Past President jeff.watson@ttuhsc.edu

DIRECTORS:

Melinda Hester, DNP, RN-BC melhester@austin.rr.com

Donna Wallis, MBA, MSN, RN drwallis@baptisthealthsystem.com

VISION

Nurses transforming health

Patricia Freier, MSN, RN-BC, CPHQ pfreier@covhs.org

Ernestine "Tina" Cuellar, PhD, RN, PMHCNS-BC tinaatutmb@aol.com

Lucindra Campbell-Law, PhD, ANP, APRN, PMHNP, BC campbel1@stthom.edu

TEXAS NURSING (ISSN 0095-36X) is published quarterly— Winter, Spring, Summer, Fall—by the Texas Nurses Association, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444 Periodical postage is paid in Austin, Texas.

One-year subscriptions: $25 (nursing schools, libraries, hospitals, non-nurses, out-of-state nurses), foreign $30; single copy $2.50.

Subscription is not available to non-member Texas nurses.

Some back issues may be viewed online at texasnurses.org.

PUBLISHING PARTNER Monarch Media & Consulting, Inc. P: 512.680.3989 or 512.293.9277; F: 866.328.7199 monarchmediainc.com | chellie@monarchmediainc.com Advertising inquiries: call Chellie Thompson at 512.293.9277.

TEXAS NURSING is indexed in The Cumulative Index to Nursing and Allied Health Literature and in the International Nursing Index.

16mm, 35mm microfilm, 105mm microfiche, article copies available from University Microfilms International: 1.800.521.3044.

Statements of fact and opinion are made on the responsibility of the authors alone and do not imply an opinion on the part of the officers or the membership of TNA. POSTMASTER Send address changes to TEXAS NURSING, 4807 Spicewood Springs Rd., Bldg 3, Suite 100, Austin, TX 78759-8444.

ARE YOU MOVING? Need to change your address? If so, provide it quickly and easily in the Members Only section of the TNA website, texasnurses.org.

Or mail your new address—at least six weeks prior to your move— to Texas Nurses Association headquarters. We’ll make sure your TEXAS NURSING makes the move with you.

FEEDBACK EMAIL OR LETTER GUIDELINES TEXAS NURSING will select emails/letters on the basis of readership interest and relevance to current nursing/health care events. TEXAS NURSING reserves the right to edit all letters. Guide: Limit to 200 words; focus on single issue; include writer’s name, mailing address, and daytime phone. Send to: editor@texasnurses.org.

CHIEF EXECUTIVE OFFICER:

Cindy Zolnierek, PhD, RN, CAE

TNA DISTRICT AND PRESIDENT Dist.1:

Teresa Acosta, RN shadowmon@sbcglobal.net

Dist. 3:

K. Renee’ Yarbrough-Yale, DNP, APRN, ACCNS-AG, CDCES reneeyy@zoho.com; District office: Jamie R. Rivera, JamieRivera@texashealth.org

Dist. 4:

Natalie D. Garry, MSN, APRN, GNP-BC Ngarry1617@gmail.com, https://tnad4.nursingnetwork.com/

Dist. 5:

Terry Long, DNP, RN, NEA-BC, CPHQ President.TNAd5@gmail.com, https://www.tna5.org/

Dist. 7:

Lisa Kelly lisakelly0212@yahoo.com, tnadistrict7@gmail.com

Dist. 8:

Patricia E. Alvoet, EdD, MSN, RN-BC pe.alvoet@gmail.com

Dist. 9:

Kimberly Curtin, DNP, APRN, ACNS-BC, CCRN, CEN, CNL kcurtin@mdanderson.org; District office: Melanie Truong, RN, Executive Secretary, tna9@tnadistrict9.com, tnadistrict9.com

Dist. 17: Mari Cuellar, NEA-BC, MSN, RN mgrace2329@yahoo.com Dist. 18: Janice L. Miller, MSN janice.miller@umchealthsystem.com Dist. 19: Anita Lowe, RN alowe@uttyler.edu Dist. 35: Chrystal G. Brown, MSN, RN cbrown@ntcc.edu At-Large: Contact TNA, 800-862-2022, ext. 129 brichey@texasnurses.org

Copyright 2021 © Texas Nurses Association

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ADVANCING HEALTH THROUGH NURSING

LEGISLATIVE FORECAST

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Everything is Bigger in Texas!

How TNA Members Can Shape Nursing in Texas AS THE LARGEST STATE AFFILIATE OF ANA, TNA MEMBERS HAVE IMPACT FROM LOCAL TO NATIONAL INVOLVEMENT.

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Contents IN EVERY ISSUE

FEATURES

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15

18

20

PRESIDENT’S NOTES

EXAMINING A FAILURE TO REPORT CHANGES IN PATIENT CONDITION

JUSTICE AND HEALTH

NURSING BURNOUT IN TEXAS

Springtime in Texas

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Joining a COVID-19 Vaccine Trial

Communication Error or Incompetence?

TNA MEMBER NEWS 2021 Election Results, Kudos, In Memoriam

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Data from the 2020 TNA Wellness Survey

Read more at texasnurses.org.

TNA members receive stories, news, and practice tips every Tuesday in the Check Up e-newsletter. If you haven't been getting your Check Up, see your email spam filter or contact us at tna@texasnurses.org.

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Pain is complex.

Discussing it doesn’t have to be.

Talking with your patients about the Texas PMP and safely managing pain can be challenging. Evidence-based guidelines, talking points, and videos designed to support you in having productive and satisfying patient conversations are available at txpmp.org. Sign on before you sign off.

txpmp.org

President’s Notes Tammy Eades, DNP, MSN, RN

SPRINGTIME IN TEXAS Nurse Resiliency on Display WINTER STORM URI took us by surprise in February. We are not used to this type of weather in Texas, and many of us found ourselves in survival mode with temperatures below our normal, no electricity, hot water, food, etc. Not to mention major accidents around the state. But as nurses always do, we adapted, survived, and helped where we could.

We heard stories of many health care workers walking to work so that they could take care of their patients. Thanks to each and every one of you for always being there for others no matter what your situation happens to be. However, please remember to take care of your-

self first. When you listen to the airline attendants, they always state to put your oxygen mask on first before you help others. As nurses, we need to remember that the healthier we are, the better we can take care of our patients.

As nurses, we need to remember that the healthier we are, the better we can take care of our patients.

This winter, we have also seen the rollout of the COVID-19 vaccines, and many of you and your families are getting them.

This is hopeful and exciting. We know so many nurses have been volunteering outside their jobs to help make sure we get the vaccine out to Texans across the state. I commend you and share my appreciation for going above and beyond.

tive and need to set the example.

Spring always reminds me that better times are on the horizon. It provides a new outlook on life. I can never express how much I appreciate all of you and how you put others first before yourselves.

Gov. Abbott announced the relaxation of mandated masks in March. While this is a little scary and created uncertainty, this is a time for you to be the voice and set precedence. Even as we get vaccinated, please remember that we must still follow COVID-19 guidelines of wearing masks, social distancing, and hand hygiene for now. We have seen many people relax regarding prevention measures, and we as nurses need to encourage and remind others we are not out of danger. We are the driver of this initia-

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Finally, the 87th Legislative Session has started here in Texas. I hope you were able to attend Nurse Day at the Capitol.

We had over 400 nurses engaged in learning about health care policy and attending virtual meetings with their legislators. We are making our voices heard.

If you have not had a chance to meet with your legislator or you would like to follow a certain bill, please check the Texas Nurses Association (TNA) website under the Policy tab as they have documents about the bills and how you can get involved. There are several other articles on the website too that may be of great interest to you. Also, TNA has created a new Texas Nurses app that you can download for free on your phone.

It makes it easy to access all TNA’s information from your mobile device.

As we move into warmer spring weather and more sunshine, take time to stop and smell the flowers and appreciate the greenery. Spring always reminds me that better times are on the horizon. It provides a new outlook on life. I can never express how much I appreciate all of you and how you put others first before yourselves. Please take some time for yourself this next month. You deserve it.

Happy Spring!

Tammy i

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TNA MEMBER NEWS SPOTLIGHT ON YOU 2021 ELECTION RESULTS This ballot was conducted between January 25–February 8, 2021, and in accordance with the Policies Regarding Nominations and Elections for TNA Offices, every nurse who was a member of Texas Nurses Association on December 31, 2020, was eligible to vote.

Congratulations to the newly appointed Texas Nurses Association officers.

President-Elect, 2021-2025: Joyce Batcheller, DNP, RN, NEA-BC, FAONL, FAAN ANA Membership Assembly Representatives, 2021-2022: Robert Ramos, BSN, RN, LP; Lisa Boss, PhD, RN, CNS, CEN, CNE; Amy Boothe, DNP, RN, CHSE; Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPPS; J. Michael Leger, PhD, MBA, RN, NEA-BC, CNE, CNL; Edtrina Moss, PhD, RN-BC, NE-BC, CLSSGB

KUDOS Congratulations to the TNA District 8 members selected to be among the Best 25 Nurses of South Central Texas 2020, presented by the San Antonio Nursing Consortium.

Irene Rosales Adelita Cantu Norma Martinez-Rogers Sarah Williams Romeo Escobar

where her work on “The Influence of End of Life Education on Stress, Anxiety, and Attitude of the Healthcare Profession Student” is still being sustained at her implementation organization. Davis has been published in the Education Edition

by American Nurse Today and Texas Nursing. She was also a fellow of the 2018 TNA Doctor of Nursing Practice Policy Fellowship, where she was assigned to be on the End of Life Committee.

IN MEMORIUM TNA District 8 member Caroline Josephine Spana, PhD, MSN, MSSW, BSN, RN, passed away January 14, 2021. Spana served the University of the Incarnate Word for 50 years as a faculty member and administrator, retiring from her role as Director of Student Affairs in December 2013. She previously worked as a case worker and clinical nurse. In 2009, she was honored as the UIW Alumni of Distinction for Professional Achievement and recipient of the Robert J. Connelly award for Faculty Leadership. Spana strongly believed that nurses’ voices

Chiquesha Davis, DNP, MSN, RN, is one of the 2020 recipients of the national and international End of Life Nursing Education Consortium Excellence Award.

Davis is department head of PostLicensure Nursing Programs at Tarleton State University. She was a part of the second cohort at The University of Texas at Tyler Doctor of Nursing Practice program, graduating class of 2020,

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must be heard in setting policy for nursing and health, and she acted in many local and state roles with Texas Nurses Association. She received her BSN from University of the Incarnate Word, an MSSW from Our Lady of the Lake University in 1966, an MSN from UT Health San Antonio in 1979, and a PhD in Nursing from The University of Texas at Austin in 1994. In lieu of flowers, donations may be made to the nursing scholarship Spana established, the Margaret Wallace Nursing Scholarship at University of the Incarnate Word.

IN CASE YOU MISSED IT TNA is officially the largest American Nurses Association affiliate with over 16,000 members! We are excited to welcome all our new members. We hope you will invite even more of your peers and colleagues to join TNA so we can continue to advocate for nursing statewide!

After an unprecedented year responding to COVID-19, TNA has been awarded the MarCom Platinum Award for its COVID-19 crisis communications campaign. Watch for even more COVID-19 materials in 2021. i

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ADVANCING HEALTH THROUGH NURSING Envisioning a New Future

By Cindy Zolnierek, PhD, RN, CAE

With renewed purpose and focus, the Strategic Advisory Committee envisions a new collaborative model for engaging multiple partners across various sectors for the next iteration of the action coalition.

Grants) there was no financial support for infrastructure. As turnover occurred in coalition roles, vacancies continued on key teams, challenging the sustainability of efforts.2 In 2020, the Strategic Advisory Committee, Texas Nurses Association, and Texas Nurses Foundation agreed that the effort needed a refresh, aligning Texas’ future work with the anticipated 2020-2030 Future of Nursing Report by the National Academies of Sciences.

FOLLOWING THE 2010 INSTITUTES OF MEDICINE report The Future of Nursing: Advancing Health, Leading Change, Robert Wood Johnson Foundation (RWJF) and the Center to Champion Nursing in America (a RWJF program within AARP) challenged each state to establish an action coalition to implement the eight recommendations. Ten years ago this spring, the Texas Nurses Association and Blue Cross Blue Shield of Texas signed up to be sponsoring organizations, and Texas Team Action Coalition was launched.1 Over 500 individuals and organizations would commit to advancing the recommendations, and many successes were celebrated, for example: Registered nurses prepared with a baccalaureate grew from 48.8% in 2010 to 66.0% in 2019.

The number of Texas nurses with doctorates more than doubled, from 0.5% in 2010 to 1.3% in 2019.

Over 200 nurses participated in Nurses on Boards training; about half entered board service.

Through the Texas Center for Nursing Workforce Studies, Texas expanded its workforce data through two supply-and-demand projection studies, newly implemented surveys on the public health and school nurse workforce, and studies on workplace violence against nurses.

Site-based restrictions on advanced practice registered nurses (APRNs) were removed in 2013, and slow but steady progress to remove barriers to practice continues each session.

Texas Team had employed a matrix structure comprised of volunteers with cooperative decision-making. While funding for special projects was available until 2020 through an agreement with Johnson and Johnson (Promise of Nursing

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With renewed purpose and focus, the Strategic Advisory Committee envisions a new collaborative model for engaging multiple partners across various sectors for the next iteration of the action coalition. The Prevention Institute provides a Collaboration Multiplier tool for organizing and maximizing collaborative efforts by bringing together groups with diverse assets and strengths toward a shared goal.3 Rather than a separate entity, such as Texas Team, future work to advance a culture of health through nursing would occur through collaborative partnerships organized around specific goals or recommendations from the 2020-2030 Future of Nursing Report, expected to be published in May. All Texas nursing organizations and other stakeholders would be welcome to participate. Work would be aligned with the assets, strengths, expertise, and resources each organization had and could commit to the effort. Stay tuned for future announcements as this new iteration of the action coalition is launched in 2021. i REFERENCES 1. Green, A. et al (2011). Building academic partnerships through statewide partnerships. Journal of Professional Nursing, 27 (6) e51-e57.

2. Zolnierek, C., Watson, J. J., Ruiz, D. (2020). Texas Team Action Coalition advancing health through nursing past, present, and future. Nursing Administration Quarterly, 45 (1) 35-45.

3. Collaboration multiplier: enhancing the effectiveness of multi-field collaboration (2011). The Prevention Institute.

Accessed from https://www.preventioninstitute.org/sites/ default/files/publications/Collaboration%20Multiplier.pdf.

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LEGISLATIVE FORECAST Bills of Interest to Nurses in the 2021 Session

LEGISLATORS GAVELED IN TO LAUNCH the Texas 87th Legislature on Tuesday, January 12, 2021, but that may be all that is usual about this year’s session.

After each chamber adopted rules, and the House elected a speaker, both adjourned for two weeks, in part to limit possible spread of COVID-19. At least one legislator tested positive for coronavirus after being on the chamber floor for three consecutive days.

Accordingly, the session will proceed with mandatory masking, testing, and special procedures for committee hearings and testimony. Governor Greg Abbott’s priorities for the session include at least one initiative supported by Texas Nurses Association: broadband internet access, an essential resource for telehealth, education, work, and commerce. The value of telehealth is just one of the lessons learned in 2020 that will inform legislative attention this session. Speaker Dade Phelan and Lieutenant Governor Dan Patrick have both announced their priorities, and needless to say, the storm, the budget, and disaster response will get a lot of attention this session.

Governor Greg Abbott’s priorities for the session include at least one initiative supported by Texas Nurses Association: broadband internet access, an essential resource for telehealth, education, work, and commerce.

The value of telehealth is just one of the lessons learned in 2020 that will inform legislative attention this session.

Overall, the chambers will be filing and considering fewer bills than past years.

The failures of Texas's electrical grid during Winter Storm Uri are in the spotlight and have prompted several bills that will take priority. Redistricting has also been postponed due to delays in completing the census due to the pandemic.

The pace of the session continues to be sluggish, including at the Legislative Council, the agency responsible for the official drafting, filing, and numbering of bills.

Committee assignments were announced in early February, giving nurses good cause to celebrate the appointment of Representative Stephanie Klick, RN, as chair of the House Public

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Health Committee. Committee chairs wield significant influence among their colleagues as well as determining the outcome for bills assigned to their committee.

In addition to regular items like full practice authority for advanced practice registered nurses, workplace violence, and nursing education funds, this year’s Nursing Legislative Agenda priorities include protecting nurses who contract COVID-19 and addressing surgical smoke. i Stay up-to-date with the progress of Nursing’s Legislative Agenda at texasnurses.org/ ActionCenter.

NURSING LEGISLATIVE AGENDA DISASTER RESPONSE

HB 396, SB 433, SB 439

To create a legal presumption that if a nurse contracts COVID-19, it was contracted during the course of employment

WORKPLACE

HB 326

To prevent workplace violence, such as by establishing a committee and procedures in certain health care facilities

SB 429

To require facilities to maintain a policy to address smoke evacuation

APRN PRACTICE

HB 2029, SB 915

To grant full practice authority to all four APRN roles

HB 1524

To allow APRNs and PAs to prescribe schedule IIs under any circumstance and repeal the current carveout for hospital facility-based practices and hospice care

LICENSURE

HB 982

To create an expedited licensure process for APRNs who are licensed out of state

SCHOOL NURSES

SB 238

To allow schools to use their school safety allotment to employ school nurses and purchase testing equipment and PPE

HB 181

To require schools to employ at least one full-time nurse at each campus and maintain an average ratio of one nurse for every 750 students

HB 1055

To require one registered nurse or other health care professional at each campus for not less than half of the school day

HB 3225

To allow local educational agencies to request reimbursement for the provision of health care services to students under Medicaid

BUDGET ISSUES

SB 575, HB 1559

To allow part-time nursing faculty to access NFLRP funds

SB 146, HB 2062

To create a loan repayment program for nurses who work in long-term care

TELEHEALTH

HB 515, HB 522, HB 980, SB 228

To include mental health providers in existing parity requirements and require insurers to provide the same reimbursement for in-person and telehealth services

HB 4, SB 412

To expand Medicaid telehealth reimbursement, including audio-only behavioral health services and home tele-monitoring services

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Everything is Bigger in Texas!

How TNA Members Can Shape Nursing in Texas WITH 16,000 MEMBERS, Texas Nurses Association (TNA) is now the largest state affiliate of the American Nurses Association (ANA).

Members are the backbone of the organization. Not only do the dues you pay allow us to affect nursing policy and health care issues in our state, but our numbers give us clout at the Capitol during the biennial legislative session, make us the go-to-organization when nurses are needed to serve on government coalitions or advisory groups, and put us at the forefront of media opportunities to provide a nurse perspective on health care issues, disasters, or policy.

Currently there are over 1,000 members serving the organization at the local, state, and national level. We need member involvement and expertise to keep us at the top of our game. Below are several ways members are, and can be, involved.

INDIVIDUAL STORIES: Nurses join TNA for a variety of reasons, and TNA members have varied experiences, education, job positions, and specialties. Consider telling your

story through a video or article. Let us know why you joined TNA, your personal motivation for being a nurse, or recount a success or challenge you went through in your career. Nurse stories can inspire future students, show graduate nurses different career paths, and humanize abstract concepts for the public.

RECRUITMENT: While we are number one among all ANA affiliates, we are still small compared to other associations in Texas.

Out of 66,000 physicians in Texas, 90% are members of Texas Medical Association (TMA). In contrast, out of 300,000 registered nurses in Texas, only 7% are members of any association at all. For decades, TMA has been a policy powerhouse in Texas with tens of thousands more members than TNA. However, nurses have the potential to be an even greater influence on health care and health care policy in Texas if only they could come together. Spread the word about TNA and the need for more members.

PARTICIPATION: Let your voice be heard and help TNA decide its direction. Vote in the annual election to choose who you want to represent your Texas Nurses As-

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sociation. In addition, TNA hosts townhall meetings, holds Q&A sessions, and sends out surveys—take the time to participate so your voice will be heard.

LOCAL DISTRICT: If you live in one of TNA’s 10 active districts—Austin, Dallas, El Paso, Fort Worth, Houston, Lubbock, Mt. Pleasant, San Antonio, Temple, or Tyler—you can serve as a district officer, serve on a committee, present CNE at their meetings, or volunteer for any other opportunities they may have. Contact your District President using the information found in the front cover of this Texas Nursing. District participation is a great way to grow your leadership skills at TNA, especially if you are considering board service in the future.

AT-LARGE: If you live in another part of the state that is part of the at-large membership you can contact TNA staff at 512-452-0645 x 133 for information about calling an informal gathering of members in your area to discuss local nursing issues or other community health care topics. TNA staff can even help you facilitate virtual meetings as needed.

TEXAS NURSE TALKS EMPOWERMENT SERIES CHAMPIONS: All members are eligible to serve as champions for one or more of TNA’s nine annual Nurse Talks. Champions are asked to spread the word to their colleagues, nurse friends, and students by posting flyers or emailing event information. TNA staff will provide print and digital materials for you. Members are also able to attend Nurse Talks at no charge and earn 1 contact hour per event.

SERVE ON A COUNCIL OR COMMITTEE: The TNA Board of Directors makes appointments to committees and councils following their annual strategic planning. Periodically the board fills vacancies or appoints just-in-time committees or task forces based on emerging issues.

ISSUE ADVISORS: We know our members have a myriad of expertise we would like to tap into. Members collaborate to contribute their expertise and experience in many ways: a Texas Nursing article, a weekly practice tip, a resource guide, a 1-pager, or a policy document. Members can also help provide continuing nursing education for TNA’s 24/7 Learning Curve.

TNA contacts registered issue advisors regularly with new opportunities.

RUN FOR STATEWIDE ELECTION: Members have the opportunity every September to complete a biographical data form and submit their curriculum vitae for consideration by the Leadership Succession Committee for offices on the annual TNA Ballot. Information on elections will be found on the TNA website under Member Zone: Leadership Opportunities.

NATIONAL ANA has similar opportunities as TNA including committees, advisors, and task

forces. Calls for volunteers come through ANA publications or you can access the information at nursingworld.org.

In addition, TNA is often asked to nominate nurses for national boards, media interviews, film documentaries, or other opportunities. While these opportunities will be listed in the TNA Check Up, we also want to get to know our members, in order to provide the best nominee possible with a strong recommendation letter. As you get involved at the individual, local, and state level, the board and staff will grow more familiar with your unique skills and value.

No matter how you choose to get involved, we hope to work with you soon! i To get involved or learn more about any of these opportunities, visit texasnurses. org/involved.

AUDIT/FINANCE COMMITTEE Gayle Dasher (chair) Kimberly Curtin Stephanie Foster Colleen Matzke Jackie Michael Shawn Tindell Laura Opton Farah Buck Theresa Acosta AWARDS COMMITTEE Jennifer Cook (chair) Belinda Gallegos Nisha Jobin Mathews Ebony Mitchell Benjamin Rosinbaum Alaina Tellson BYLAWS COMMITTEE Chrystal Brown (chair) Robert Bunney Carol Hawkins-Garcia Michelle Kuchta Phalassa “Lasi” McArthur Michael LoSasso

COMMUNICATIONS COMMITTEE Lisa Boss Cory D. Church Kimber Cockerell Christine C. Roberts Amy McCarthy PROFESSIONAL DEVELOPMENT COMMITTEE Patricia “Pat” Morrell (chair) Lydia Butcher Nisha Jobin Mathews Lee Harrison Denise McNulty Stacy Cooper Joanne Dalusung Stephanie Foster Laurie Robbins Pamela Sandvig Serena Jackson

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EXAMINING A FAILURE TO REPORT CHANGES IN PATIENT CONDITION Communication Error or Incompetence?

By Omobola Awosika Oyeleye, EdD, JD, MSN, MEd, RN-BC, CNE, CHSE

This article has been adapted for space and originally appeared in the November 2019 issue of Nursing © 2019 Wolters Kluwer Health, Inc.

THE ABILITY OF A REGISTERED NURSE (RN) to recognize and respond to changes in a patient’s condition is a crucial element of professional nursing practice. Failure to respond appropriately to clinical changes can lead to complications and even death.1 These cases often result in huge financial consequences in cost of care and legal damages.2 A 2019 judgment illustrates the human and monetary costs of failing to communicate clinical changes to the appropriate practitioner.3 While physicians were also implicated in the case, only elements related to nursing are discussed here.

FACTS OF THE CASE On February 22, Mary Trout* was admitted to the hospital with an abscess that caused swelling in the floor of the mouth, her neck, and her airway related to Ludwig’s angina (a bilateral infection of the submandibular space). The abscess was successfully drained, and a tracheotomy was performed on February 23. The following day, the tracheostomy site started to bleed, and Trout complained of a choking sensation, but the bleeding resolved over several days.

On February 27, bleeding resumed. Judith Massey, RN, redressed the site. A few hours later, she observed “bloody, watery” drainage from the tracheostomy but she did not notify a physician.

While performing a procedure on February 28, the physician observed persistent bleeding from the patient’s stoma. He cauterized it and packed it with gauze. The patient was returned to the medical–surgical unit, where she was cared for by Doris Fox, RN. Sometime during the shift, Trout’s sister alerted the nurse that Trout was bleeding from the tracheostomy site. Upon assessing the patient, Fox observed blood trickling from the stoma and blood stains on the hospital gown. She gave gauze to the patient’s sister to press it against the tracheostomy. When the

gauze was soaked and the bleeding worsened, Fox gave the sister towels to soak up the blood. She contacted a physician, who ordered two units of red blood cells and four bags of fresh frozen plasma, which were administered by Joan Duke, RN, during the next shift at 1900. Duke reinforced the dressing and suctioned the tracheostomy all night.

At 2300, Trout was coughing blood with clots. She communicated that she was in pain and that the blood clots were choking her. Duke contacted the resident physician on duty, who examined the patient but did not note the visit in the medical record, later explaining that the patient was stable upon examination, with no evidence of active bleeding.

After a second page to the resident at midnight, he paged another physician. While the second physician was examining Trout, she lost consciousness. They called a code, and she was resuscitated. However, she was deprived of oxygen for 20 to 25 minutes.

When she was discharged a month later, she had brain damage and was partially paralyzed. The patient sued the hospital for malpractice, alleging that negligence by the hospital’s nurses and physicians allowed a clot to occlude the patient’s tracheostomy tube, leading to respiratory arrest and severe brain injury.

TRIAL TESTIMONY At trial, the hospital’s nurse expert witness testified that the nurses met the standard of care for tracheostomy management and were not required to call a physician any sooner than they did. In contrast, the plaintiff’s expert witness testified that the standard of care is to keep the stoma clean and the airway clear with regular suctioning, and that an occlusion in the tracheostomy requires a nurse to contact a physician promptly. She concluded that the nurses who did not contact the physician as soon as they observed bleeding failed to meet

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the minimum standard of care, which led to the clot formation and respiratory arrest.

The patient died after the case was submitted to the jury but before a verdict was returned. The jury returned a verdict in favor of Trout for over $22 million, with $15 million of this for future damages. The hospital appealed the verdict, but the appellate court agreed with the initial findings. However, because Trout had passed away and would not be incurring any future damages, the court deducted the $15 million and awarded $7 million.3

COMMUNICATION MISHAPS Communication of patient status has been the focus of much attention and research and can be problematic or stressinducing for nurses.4 Communication frameworks have been generated to facilitate clinical communication among health care professionals about patient status.5,6 Widely used examples include SBAR (situation, background, assessment, and recommendation) and ISBARR (introduction, situation, background, assessment, recommendation, and read back).

Many factors can play into why nurses may not communicate a patient’s status promptly or at all. These include a busy schedule, a reluctance to “bother” the physician, or a failure to recognize the circumstances under which a physician should be notified due to a lack of clinical competence.2 When considering what could have been done to prevent this tragedy, lack of adequate communication on the part of the nurses seems to have played a key role. The testimony and expert for the defense in this case did not allege that the shift was too busy or that the nurses were intimidated or reluctant to call the physician.

What is apparent is that the nurses did not recognize the severity and emergent nature of the patient’s condition. The events in this case were not about the nurses’ ability to communicate with physicians. Rather, they were about the lack of competence and decision-making skills that enable a nurse to assess a patient’s condition and determine the appropriate intervention.

Critical thinking extends beyond mere information, attentiveness, and assessment. The clinical competence needed to make decisions, especially in acute situations, develops over time as the nurse advances from novice to expert.8 In this case, nurses gave their patient a great deal of attention, but the patient’s needs required a higher level of competence in tracheostomy care.

IMPLICATIONS FOR PRACTICE Nurses and health care employers are obligated to maintain patient safety by ensuring that nursing practices meet professional standards. The implications of this case affect nursing leaders who create processes and policies, those who determine nurses’ assignments, and nurses themselves.

To determine appropriate interventions and recognize when it is necessary to escalate care, nurses must:

Accept only patients that they are capable of caring for.9

Develop the education and skills necessary to recognize when interventions are not effective.1

Escalate the patient’s care to a more experienced health care provider when they find that a patient’s status change is beyond their capability.10

ERRORS IN JUDGEMENT Competence as a nurse requires knowing when to escalate care and seek the expertise of appropriate personnel. It also includes the ability to delegate appropriately. The principles of delegation require nurses to delegate only to those who possesses the appropriate skills, training, and competence. A glaring indication of incompetence is the impermissible delegation when the nurse asked the patient’s relative to attempt to contain the bleeding. There was no indication that the patient’s sister was prepared for the task assigned.

In addition, an RN may not delegate the nursing process—assessing bleeding, developing a plan, determining when to intervene or how to intervene—to anyone who is not a nurse.7 Even if the patient’s sister had been a nurse, her role as family member would exclude her from being delegated such a task.

During the trial, one nurse testified that she suctioned copious amounts of blood as the patient coughed up blood clots for hours before paging a physician—a clear emergency. The nurse’s failure to recognize this emergency indicates a lack of competence in nursing fundamentals and a lack of knowledge about the possible physiological consequences. This gap in knowledge contributed to a catastrophic deterioration in the patient’s condition.

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Follow the facility’s chain of command, documenting the recognition of an urgent situation, evaluation of changes in the patient’s condition, and steps taken to escalate appropriately, including the persons consulted and the actions that resulted. 11,12 Be aware that they can be held legally liable for actions they omit or fail to take in a timely manner.10

GUIDELINES FOR PRACTICE When documenting adverse events, follow your facility’s policies and procedures. The record should be objective, including only clinical facts without any guesses, assumptions, speculations about the cause of the event, or personal opinions.13 In addition, keep these general guidelines in mind:

Listen to family members’ concerns. They are often at the bedside much longer than the clinical staff. They know the patient and are likely already engaging in the care of the patient at home. They are a valuable source of information and their concerns should be taken seriously.14 Consider carrying liability insurance, both for malpractice suits and for disciplinary actions taken by the Board of Nursing.15

patient. By meeting the standards of professional nursing care, nurses can and should avoid these costly consequences. i *All names have been changed to protect the privacy of individuals involved.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Texas Nurses Association (TNA) endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.

REFERENCES 1. Massey, D., Chaboyer, W., & Anderson, V. (2016). What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6–23.

2. Crico Strategies. Malpractice risks in communication failures. 2015 Annual benchmarking report. www.rmf.harvard.edu/Malpractice-Data/AnnualBenchmark-Reports/Risks-in-Communication-Failures.

3. Joi Jefferson v. Mercy Hospital & Medical Center, 2018 IL App (1st) 162219 4. Lanz, A. S., & Wood, F. G. (2018). Communicating Patient Status: Comparison of Teaching Strategies in Prelicensure Nursing Education. Nurse Educator, 43(3), 162–165.

5. Institute for Healthcare Improvement. SBAR Tool: Situation-BackgroundAssessment-Recommendation.

6. Cudjoe, K. G. (2016). Add identity to SBAR. Nursing Made Incredibly Easy, 14(1):6-7.

7. National Council of State Boards of Nursing. (2016). National guidelines for nursing delegation. Journal of Nursing Regulation, 7(1):5-14.

Understand and help create processes and policies with employers or leadership to ensure that nurses are equipped to handle their patient assignments and tasks and that they are able to determine when more experienced or more qualified help is required.2 In this case, nurses who care for patients with tracheostomies should receive specific and targeted training, at a minimum to recognize and manage common complications of tracheostomy care.16 Developing appropriate processes and policies requires agency-wide and multidisciplinary cooperation.

8. Benner, P. (1982). From novice to expert. The American Journal of Nursing, 82(3), 402–407.

9. Buppert, C. (2019, April 26). A “safe harbor” for unsafe nursing assignments. Medscape.

10. Nurses Service Organization. (2012). Failure to report changes in the patient’s medical condition to practitioner.

11. Thielen, J. (2014). Failure to rescue as the conceptual basis for nursing clinical peer review. Journal of Nursing Care Quality, 29(2):155-163.

12. American Nurses Association. (2010). ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. Silver Spring, MD: American Nurses Association.

13. Austin, S. (2011). Stay out of court with proper documentation. Nursing, 41(4), 24–30.

14. Sherman, D. W. (2019). A Review of the Complex Role of Family Caregivers as Health Team Members and Second-Order Patients. Healthcare (Basel, Switzerland), 7(2), 63.

Ultimately, failure to report changes in a patient’s condition can have serious health consequences for the patient as well as legal and financial implications for all involved in the care of the

15. Brous, E. (2017). Reciprocal enforcement and other collateral issues with licensure discipline. The Journal for Nurse Practitioners, 13(2):118-122.

16. Zhu, H., Das, P., Woodhouse, R., & Kubba, H. (2014). Improving the quality of tracheostomy care. Breathe, 10(4):286-294.

If you have received: Letter of Investigation from the Texas Board of Nursing Notice of Peer Review

Joyce Stamp Lilly RN JD Registered Nurse and Attorney

713.759.6430 jslilly@me.com www.nurse-lawyer.com

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JUSTICE AND HEALTH Joining a COVID-19 Vaccine Trial

By Lev Baesh, RN

IT WASN’T LONG AFTER COVID-19 was discovered, and the Mayor of Austin cancelled SXSW, that I realized we were in trouble. And by “we,” I mean the population of the world.

It is not hope that overrides my fear. It is my understanding that justice is so important, that overrides my fear and supports my hope.

Having come out as a gay man in 1981—at the beginning of the AIDS epidemic—and remembering the devastation a novel illness wrought on my new community, I thought about how I could participate differently this time than I was able to back in ‘81. Then, I was a college student on my way to law school, after, a rabbi, and now, I’ve added nursing to my education and my roles in the world.

the Moderna study, and I am with Pfizer.

As a child, I learned from my family and my Jewish heritage that all of life was about justice. Our role as human beings was pursuing justice, not simply sitting back and commenting on it, or worse, sitting back and benefitting from an unjust world. During the height of the AIDS epidemic, I volunteered for community organizations in New York City, one of the epicenters for the disease. As a rabbinic student and as a rabbi, I fight alongside Palestinians in Israel and Muslims here in the United States to support justice efforts related to my heritage and religious community. Now I have the privilege of thinking about, and acting on, justice as it relates to local and world health.

It was not that opting in for the COVID-19 vaccine trials didn’t scare me. I don’t trust government, or the pharmaceutical industry, to have our best interests at heart. Their greed frightens me, and I know the dollar is a main reason for their existence. I hope that the medical issues that touch us, also touch them. I hope that their humanity rides side by side with their greed. I also know that pursuing justice is not meant to be easy work.

If it were, it wouldn’t be at the heart of

Pfizer and Moderna were trialing COVID-19 vaccines in Austin. So, after a conversation with my husband Andrew Martin, also a nurse, we both volunteered to be in the trials. Due to our respective ages, and some minor medical conditions that come with age, we joined two different Phase 3 trials. He is in

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PAGE 18

religious and spiritual teachings from all traditions throughout history.

However, it is not hope that overrides my fear. It is my understanding that justice is so important that overrides my fear and supports my hope.

I chose to be in the study for several reasons. I thought I could be a role model for others. The risk we took would make it possible for others to eventually be protected and for advances in health care to be developed safely and effectively. I also opted in because I know that other

As nurses, we risk our health every day we go to work.… I hope, in the end, that my choice to be voluntarily injected with a trial vaccine, is seen simply as one more offering we nurses make for the welfare of our family, friends, communities, and the wider world. people in trials often face the choice to become guinea pigs because there is a not insignificant financial gain from being in a study, especially one that needs a lot of subjects quickly and will directly benefit companies with future proceeds.

human being who knows that the goal of a just world, and of world health—the justice issue at hand—is what matters. If I am to imagine my life making a difference, getting a couple of shots in the arm is par for the course.

As a privileged middle-class white male, I felt that I should be in the trenches with the people who regularly risked their health for my benefit. I decided that I could join them and not take livelihood away from them by contributing the study payments back into the community. My share was used to provide food for people in our neighborhood who are experiencing housing insecurity. There is a sweetness to walking up to someone, asking what they need from a local grocery store, going in, and buying it, always adding extra for them.

As nurses, we risk our health every day we go to work. Needle sticks, patient outbursts, airborne diseases, chemical contaminants, and other risks are part of showing up for our shift. I hope, in the end, that my choice to be voluntarily injected with a trial vaccine, is seen simply as one more offering we nurses make for the welfare of our family, friends, communities, and the wider world.

I don’t consider myself a martyr or a selfless person, who should be identified as a hero. I consider myself a frightened

If my participation means one more person acts justly, one more nurse is recognized for the work they do by just showing up, and one more person is protected by a vaccine, then I know, whatever the outcome of the trial, justice was done. i

BELOW (from left): Baesh is awarded his Doctor of Divinity degree from Hebrew Union College-Jewish Institute of Religion in Cincinatti after 25 years as a rabbi. Baesh teaches community building to an international group of interns in Tel Aviv, Israel, who were working with Eritrean and Sudanese refugees in Israel. Baesh received his first Pfizer COVID-19 vaccine injection at the research facility and shows off his Hebrew tattoo of the letter Aleph, the symbol of all the sounds and colors of the universe.

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Nursing

Burnout in Texas

AS WE PASS THE ONE-YEAR MARK OF COVID-19 on American soil, the public has never been more aware of the stress nurses face. Burnout has skyrocketed, exacerbating already heavy workloads and low levels of staffing. Combined with an increased pressure to perform and enter more demanding roles, the pandemic of burnout seems ubiquitous in nursing.

In September, Texas Nurses Association surveyed nurses across Texas on the state of their wellbeing. There were 192 completed survey responses. Among survey respondents, 61% had 16 or greater years of experience. Health care settings varied among survey participants, with 50% of them working in the acute care hospital setting and 25% working in the ambulatory setting. The majority of the survey participants considered themselves Baby Boomers (41%) or part of Generation X (40%).

The purpose of this survey was to determine if nurses in Texas

Burnout has skyrocketed, exacerbating already heavy workloads and low levels of staffing.… In September, Texas Nurses Association surveyed nurses across Texas on the state of their wellbeing. were experiencing distress or burnout, including moral distress, burnout syndrome, compassion fatigue, physical distress, emotional distress, secondary trauma, or nothing. Half the respondents indicated they were experiencing one of the syndromes listed, a third reported two to three of the syndromes listed, and a fourth indicated they were experiencing four or more (Table 1).

Data from the 2020 TNA Survey

By Serena Bumpus, DNP, RN, NEA-BC

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When asked how often they experienced these over the last year, 38% indicated they experienced them weekly. When asked if they have ever left a position because of one or more of these factors, 50% said yes (Table 2). The survey indicated that several resources were available in Texas health care organizations to support the wellbeing of staff (Table 3); however,

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TABLE 1

Are you experiencing any of the following?

Moral Distress – The emotional state that arises from a situation when a nurse feels that the ethically correct action to take is different from what he or she is tasked with doing.

When policies or procedures prevent a nurse from doing what he or she thinks is right, that presents a moral dilemma.

Moral Distress

Burnout Syndrome – Results from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.

Burnout Syndrome Compassion Fatigue

Compassion Fatigue – The physical and mental exhaustion and emotional withdrawal experienced by those who care for sick or traumatized people over an extended period resulting from taking on the emotional burden of a patient's agony.

Physical Distress

Physical Distress – The physical discomfort of such a degree that it causes physical and ergonomic symptoms such as pain, numbness, tingling, swelling, inflammation, and/or muscle weakness.

Emotional Distress

Emotional Distress – Mental suffering as an emotional response to an experience that arises from the effect or memory of a particular event, occurrence, pattern of events or condition causing anxiety, depression, loss of ability to perform tasks, or physical illness.

Secondary Trauma None

Secondary Trauma – The emotional duress that results when an individual hears about the

0%

10%

20%

30%

40%

50%

firsthand trauma 60% 70% experiences 80% of another.

90%

100%

TABLE 2

Have you ever left a position because of one or more of these factors?

48%

57% of the participants indicated they have never utilized these resources.

Psychological safety is a critical factor in preserving the wellbeing of nurses. Participants were asked about the psychological safety of their organization and if they felt comfortable talking with someone inside the organization about their mental health, with 46% of the participants indicating they disagreed or strongly disagreed their organization was psychologically safe (Table 4).

The majority of the respondents (64%) indicated self-care and wellness were encouraged (Table 5) and the majority (58%) believed their leader role modeled these behaviors.

However, it was the candid comments the participants provided that indicated their work environment, workflows, staffing, and leadership presence played a much larger role in preserving the wellbeing of staff.

52%

No

Yes

TABLE 3

Do you have the following resources available to you in your organization?

Ethics Committee Peer-to-Peer Support Debriefing Sessions Counseling & Employee Assistance Programs Schwartz Rounding None Other 0%

10%

20%

30%

40%

50%

60%

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30%

40%

50%

60%

70%

70%

Psychological safety is a critical factor in preserving the wellbeing of nurses.

Participants were asked if they felt comfortable talking with someone inside the organization about their90%mental health.

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80%

90%

100%

TABLE 4

How psychologically safe is your organization?

I am comfortable discussing my mental health needs with someone inside my organization without fear of judgment.

Strongly Agree

Agree

Disagree

Strongly Disagree 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

TABLE 5

In my organization, self-care and wellness is: Frowned Upon

3%

It was the candid comments the participants provided that indicated their work environment, workflows, staffing, and leadership presence played a much larger role in preserving the wellbeing of staff.

33%

64% Encouraged

Ignored

This survey was limited by the number of responses, and future work should aim for a greater number of nurse participants. In addition, more research is needed on leadership behaviors that impact burnout and how changes or improvements in the work environment can prevent nursing burnout. i

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You take care of your patients.

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CARE FOR THE

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In disaster situations, nurses must care for others while caring for themselves and their family. Texas Nurses Association and Texas Organization of Nurse Executives, with support from Johnson & Johnson, developed Care for the Caregiver to help nurses before, during and after disasters.

Represented over 100 nurses before the Texas Board of Nursing since 2006 Former State and Federal Prosecutor State-wide nursing licensure defense practice

Watch videos, download free resources, information on preparedness, 40% and get more 50% 60% 70% resiliency, and self-care.

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4807 Spicewood Springs Rd. Bldg. 3, Suite 100 Austin, TX 78759

ALLMAN & ASSOCIATES, INC. CERTIFIED PUBLIC ACCOUNTANTS INDEPENDENT AUDITORS' REPORT OPINION: In our opinion, the financial statements referred to [in the audit] present fairly, in all material respects, the financial position of the Texas Nurses Association, Inc., as of June 30, 2020, and the changes in its net assets and cash flows for the year then ended in accordance with accounting principles generally accepted in the United States of America.

Current members can log in to view the audit at texasnurses.org/aboutus.

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