CONTINUING EDUCATION
Perianesthesia Nursing—Beyond the Critical Care Skills Heather Ead, RN, BScN, MHSc Provision of patient care within the perianesthesia specialty is demanding in nature. Although a nurse may be well equipped with the assessment, planning, and critical thinking skills required for these fastpaced areas, there are other competencies to be developed. These include skills in mentorship, communication, crisis management, and competency as an ambassador of patient safety. Barriers to developing these skills may include a high patient acuity and turnover, a sense of isolation from other departments, and strong hierarchical structures. However, there are resources and strategies that nurses can leverage to facilitate development of these less-technical, ‘‘softer’’ skills. In this article, the author reviews some of the unique demands commonly seen within the perianesthesia specialty. Methods to address these challenges are shared to facilitate an enjoyable career in this dynamic environment. Keywords: perianesthesia, competencies, PACU, critical thinking. Ó 2014 by American Society of PeriAnesthesia Nurses
OBJECTIVES—AFTER READING THIS ARTICLE, the participant should be able to: 1. Describe the skills around communication, mentorship and crisis management within perianesthesia nursing. 2. Identify two communication tools that support patient safety. 3. Describe methods that address interpersonal conflict. Nurses within the large umbrella of the perianesthesia specialty provide care to a wide range of patients. Whether the setting is a postanesthesia care unit (PACU), ambulatory care department, or dental surgery clinic, there are competencies that all perianesthesia nurses share. These include, but are not limited to, excellent assessment skills, Heather Ead, RN, BScN, MHSc, is a Clinical Educator, Trillium Health Centre, Mississauga, Ontario, Canada. Conflict of interest: None to report. Address correspondence to Heather Ead, Trillium Health Centre, 100 The Queensway West, Mississauga, Ontario, Canada L5B 2B6.; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.05.012
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critical thinking, knowledge of pharmacology, and certification in basic or advanced cardiac life support. Perianesthesia nursing is much more than coordinating patient care and ensuring that comforts and hemodynamic stability are achieved. The perianesthesia nurse requires another set of competencies that may be thought of as a softer set of skills, but important nonetheless. These include communication skills, crisis management, mentorship, and acting as an ambassador for safety (Figure 1). Working day after day in a department such as a PACU that was designed without exterior windows can create a sense of confinement and lead to isolation from other departments. There are times when it seems all efforts to transfer a stable patient to the next phase of care are met with resistance and numerous barriers. The nurse who consistently receives a cold reception from staff outside her unit can start to develop feelings of resentment. Although we cannot always shape the behavior of others, we can work to improve our own attitudes and the coping and communication skills that we apply in patient care.
Journal of PeriAnesthesia Nursing, Vol 29, No 1 (February), 2014: pp 36-49
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Figure 1. Balancing technical and nontechnical skills.
Communication Skills Needless to say, good communication skills are a key competency for any nurse. Improving communication skills can enhance patient safety, as communication failures have been linked to adverse events that otherwise may have been prevented.1 The perianesthesia nurse is often receiving and providing reports to a number of health care providers. By gathering a clear assessment from the patient, family, and staff, the perianesthesia nurse ensures that all vital information is clearly communicated across the continuum of care. For example, through use of effective communication skills, the perianesthesia nurse confirms that the consent the patient has provided is informed in nature and is not simply the patient’s signature on yet another form. It is through discussion with the patient and family that the nurse can identify knowledge gaps and provide clarification and health teaching. Moreover, the nurse advocates for the patient by requesting the surgeon to provide additional information or answer questions as necessary.2 Communication skills support patient safety, particularly when providing a transfer of care report from the PACU to another department. The
transfer of care report may also be referred to as a transfer of accountability (TOA) report, as the accountability of the patient’s care is being taken over by a new provider. The TOA report should be an interactive process between the perianesthesia nurse and the nurse assuming care of the patient. The College of Nurses of Ontario and the American Society of PeriAnesthesia Nurses recommend using a standardized process to complete the TOA report to ensure effective communication and information sharing occurs across the care continuum.3,4 Another transition point where communication skills are of great importance is when preparing patients for home discharge. At this time, the patient and/or family must be provided information that is relevant and easily understood. For example, the clarity of health teaching provided must ensure that the patient and/or family understand the normal postoperative expectations, as well as situations that would require them to seek medical help. It is well known that poor communication is a factor in 70% of adverse events.5 Communication failures during shift reports are a leading cause of
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sentinel events.5 Having a standard template for the TOA report can improve the quality and consistency of information provided in a brief but comprehensive report. Outlining the transfer report process to new staff and periodically reviewing with all staff can ensure their communications support patient safety and optimal outcomes. Development of a standard TOA form is an opportunity for the perianesthesia team to work together to identify a process that supports patient safety. At Trillium Health Partners, the nursing staff within the PACU developed a TOA form that was modified from one that is used in the inpatient areas. After piloting a few drafts, a final version was approved (Figure 2). Despite the value the TOA process has to patient safety, the skill of patient handover is not often formally taught to health care providers.6 Instead, this skill is learned on the job in a manner that can be lacking in consistency and/or structure. Considering the risks associated with poor communication, this gap in formal education and training may pose a significant risk. Learning how to provide a good TOA report by trial and error is a less than ideal strategy. This gap provides an opportunity for perianesthesia nurses to develop a more formalized process in teaching TOA to new staff. TOA is described as complex, cognitively taxing but a vital part of patient care.7 By ensuring that time is dedicated to education and periodic review of the TOA process, we can support a consistent manner of ensuring clarity and safety in our interactions with health care providers, patients, and families.
Crisis Management In Phase I recovery, the perianesthesia nurse may be accustomed to working through crises such as respiratory distress, cardiac arrest, or a patient presenting with a postoperative hemorrhage. However, in any phase of perianesthesia care, unanticipated complications can arise. The nurse must be able to respond calmly and prioritize the care needed in this time-sensitive situation. Unfortunately stress can impair cognition and result in decisions that are made too slowly, too rapidly, or incorrectly.8 Communication between two or more individuals can be described as informal, disorganized, and variable.1 However, in urgent situations, it is essential for structure to be part of the
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information exchange. Structure can be achieved by following the SBAR process; ‘‘SBAR’’ is an acronym for Situation, Background, Assessment, and Recommendations. SBAR is a standardized reporting process that is recommended by the World Health Organization (WHO).5 This tool creates a standardized discussion that facilitates communication in an urgent situation. Although SBAR originated in the US Navy to enhance communication, it is commonly used in health care.1 SBAR can be used as a template and printed for nursing staff to use as a working tool. The SBAR form can be completed by the nurse to pull all the relevant information together succinctly prior to consulting with a physician or other care provider. The SBAR tool can enhance communication in stressful and other failure-prone situations (Figure 3).1 Applying the SBAR process assists the nurse to focus and share only pertinent information. For example, the Situation may be ‘‘Mr. X’’ who is being cared for in PACU following a laparoscopic cholecystectomy. The Background may be that despite provision of analgesia, Mr. X continues to have intense and worsening abdominal pain. Information to share in the Assessment parameter of the SBAR report may include the patient’s most recent vital signs, oxygenation status, and any relevant blood work. Finally, the nurse provides a Recommendation, such as suggesting that the surgeon come assess the patient to rule out postoperative bleeding. At Trillium Health Partners, the tool has been particularly helpful for novice staff. By providing a focused and efficient report, the physician is able to provide directives to the nurse in a timely manner. With experience, the nurse may find that SBAR becomes part of his or her communication style, and documenting on the SBAR forms is not required. Human factors engineering (HFE) examines how humans interface with technology, processes, and protocols. By having an awareness of human factors in clinical care, we can make great inroads into patient safety in crises management.8 Human factors have been linked to tragic outcomes such as the Elaine Bromiley case of 2005.8 This case illustrates that even highly experienced and competent staff can respond to stress with decision making that is based largely on intuition, instead
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Figure 2. Transfer of Accountability form. Trillium Health Partners, 2009; Used with permission.
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Figure 3. SBAR (Situation, Background, Assessment, and Recommendations) communication tool. Trillium Health Partners, 2009; Used with permission.
of using cognitive skills or implementing an evidence-based algorithm. In the Elaine Bromiley case, complications with airway patency occurred at the initiation of anesthesia for minor, elective surgery. Some team members became so focused on endotracheal intubation attempts they were blinded to the fact that oxygen deprivation had persisted for an alarming period of time, warranting a refocus of energies to initiate a tracheotomy.8 Additionally, nursing staff did not feel comfortable questioning the strategies of the anesthesiologist and surgeon, even though Elaine’s condition continued to deteriorate. In hindsight, the nurses described what interventions should have taken place, but did not feel empowered to speak up and provide direction to the physicians who ranked higher within the organizational hierarchy.8 We can learn a great deal from this tragic case, such as the practices of team building, assertive communication and awareness of human factors.
the most appropriate decision when placed in a highly stressful situation. By having an awareness of this human flaw, we can develop processes to help mitigate poor outcomes.8 These processes include access to algorithms to guide staff through emergent situations such as a malignant hyperthermia crises or loss of airway patency. Awareness of how human factors can impact safety also includes supporting an environment where it is acceptable and encouraged for staff to ask questions and speak up when they feel unsure of the current treatment plan.
Humans by nature have a capacity for becoming overly focused on technical problems and losing sight of the big picture in emergent situations. Even expert staff can become blinded to making
Mentorship
To address hierarchy-related barriers to effective communication, nurses should be provided opportunities to practice assertive communication, and work through mock emergent scenarios with tools such as the SBAR process. Assertive communication takes time to develop, but through practice staff can have increased confidence in their communication skills and ability to speak up.
A mentor acts as a guide, advisor, and teacher for another nurse. The term mentor comes from the
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Greek character Mentor who was characterized as a protector and guardian of Odysseus’s son Telemachus.9 Teaching critical care assessment and communication skills to novice nurses supports learning and adaptation to a new clinical area. Although technical skills such as care of an arterial line may be included on an orientation skills checklist, the mentor should also review provision of report at transition of care, as well as using assertive language when speaking to a surgeon or anesthesiologist. The nurse who is mentored learns how to advocate for the patient by observing how the mentor clarifies, challenges, or questions unclear physician orders. The mentor should reassure newer staff that it is acceptable and necessary at times to question orders that may not appear appropriate or legible, particularly for a physician who may be approaching exhaustion from extended hours of being on call. Using these teachable moments to enhance another nurse’s practice will support their transition to becoming an experienced and confident perianesthesia nurse. The mentor leverages opportunities for hands-on learning and uses interactive, varied approaches that complement the classroom teaching, and pull all the information and learning together.9 It is recognized that patient care transfers from one department to another have a high safety consequence.10 TOA should be included on the perianesthesia list of competencies to be met during the staff’s orientation period. The mentor can review the department’s TOA template, demonstrate the standardized process of completing patient hand-off, and then have the novice nurse demonstrate back application of this skill. The mentor shares his or her knowledge and experience in a hands-on manner that pulls didactic learnings into action in the clinical world.7 The mentor in perianesthesia has the noble task of teaching and guiding another nurse to develop technical and nontechnical skills. Perianesthesia nurses can be described as role models for critical thinking, adaptability, flexibility, and clinical wisdom.9 By addressing communication skills, conflict management, and the role of safety ambassador, the mentor can have a great impact in ensuring our future perianesthesia nurses are well equipped to provide the highest level of care in
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this dynamic specialty. The mentor can demonstrate how to use assertive communication to advocate for the patient’s needs and ensure optimal outcomes are achieved.
Ambassador of Patient Safety Canadian adverse event studies reinforce that health care is not inherently safe or reliable.7 Retrospective multicenter studies have illustrated an adverse event rate of 7.5% in hospitalized patients, with 21% of these events causing an unexpected death.7 We are aware that human fallibility will guarantee some percentage of errors regardless of the health care provider’s years of experience. Organizations that adopt a reporting culture versus one of blame empower the staff to monitor and identify the presence of real or potential risks in patient safety. By using a supportive and nonpunitive approach regarding adverse events, the message to the staff is that their organization views errors as opportunities to learn, improve, and address the gaps in their current processes. Pulling the staff together to review and reflect following an adverse event is an opportunity to turn a negative outcome into a learning opportunity that can positively affect patient care. To support sustainability, safety and work flow should be a regular agenda item at staff meetings. Providing staff the opportunity to share their suggestions on how to improve processes and avoid adverse events can help staff feel empowered. In addition, staff should be recognized for their efforts when they take time to report near misses and adverse events, or intervene to prevent an error from occurring. Reward and recognition can be used to facilitate a culture of safety, rather than employing a punitive approach to risk management. Although HFE is well applied in the design of medical equipment such as intravenous infusion and feeding pumps, it is still in its early stages in regards to structuring our behaviors, processes, and application of protocols.5 The field of HFE recognizes that in stressful situations we can lose sight of the gravity of a situation and our sense of time, which can result in a situation of failure to rescue.5 The concerns of situational awareness can be
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addressed by increasing the frequency of conversations around patient safety and consistently wearing a ‘‘safety lens.’’ For example, staff should be encouraged to be on the alert for medication labeling that is confusing or difficult to read, and they should communicate their concerns to their manager. The occurrence of an error does not indicate that a staff member is incompetent. All humans are vulnerable to becoming overwhelmed when stressed, particularly in a rapidly changing or deteriorating clinical scenario. When under stress, all individuals have limits in their cognition and capacity of interpreting and responding to information, but there are steps one can take to minimize these limitations. The elements of patient safety should be included in the continued education that is provided to staff. By dedicating efforts to support education on topics such as human factors, situational awareness, and cultures of safety, all perianesthesia nurses can be ambassadors of safety and gate keepers of preventing adverse events. With education and awareness, staff can fully integrate the optics of patient safety into their practice. The science of HFE examines what, how, and why things go wrong.7 Clinicians are often managing the balance between efficiency and safety. However, there are times where a mismatch exists between the demands and the provider’s capacity to address all clinical needs. However, safety and thoroughness should never be a trade-off for efficiency.7 An example is the constant pressure on a PACU to maintain patient flow and avoid putting an operating room’s (OR’s) schedule on hold. During times of high acuity, it may be necessary to place OR on hold to ensure appropriate staffing so nurse-to-patient ratios can be maintained. A standardized communication method such as SBAR can be used to communicate that the PACU cannot receive further admissions from the OR until the volume or acuity of care has improved. When acuity levels improve, the perianesthesia nurse can alert the OR they are able to safely receive additional patients in the Phase I or II recovery area. The aviation industry has successfully adopted a process termed crew resource management
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training (CRM) to train and review processes with staff. Through CRM, staff have the opportunity to apply and appreciate specific human factors that become barriers to efficiently responding to emergency situations.8 The aviation industry reinforces the crucial lesson to their staff regularly: ‘‘if in doubt speak up.’’ This message empowers staff to share their concerns and even question an individual in a position of higher authority. For example, if a staff member observes a senior colleague omitting a step within the safety check, it is expected of the staff member to speak up immediately. This culture of safety is an inseparable part of the aviation industry. The health care industry continues to look to the airline industry for methods to better incorporate safety to the complexities of clinical care.8 To assist staff to be prepared for emergent situations, it is important that they are provided opportunities during their orientation period (and through annual reviews) to practice the application of advanced cardiac life support algorithms and responding to airway patency issues. Hands-on practice can facilitate a smooth response when a medical crisis does occur. With practice, the practitioner can learn to maintain a focus of situational awareness in an emergency and overcome human factors such as becoming overwhelmed or having an impaired capacity to comprehend essential information.5 Moreover, with increased familiarity of algorithms and procedures, staff are less prone to lose sense of time or fail to recognize that a situation has worsened and the plan of rescue warrants an adjustment. An opportunity for the nurse to challenge a physician’s directions should be included within the mock emergent scenarios. For example, in a deteriorating patient scenario, the nurse could state her disagreement with a physician’s directions and provide concise information; for example, ‘‘the patient needs to be transferred to the intensive care unit as the surgical unit will not be able to provide 1:1 nursing care.’’ This takes a level of courage and experience, but with practice the nurse can become more comfortable advocating for the patient’s needs. Having established protocols will not provide benefits to patients if the staff are lacking the skills or confidence to advocate for implementation of the protocol, when
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confronted with strong or resistive personalities.8 Taking an opportunity to practice assertive language can assist the staff to be an ambassador of safety and adopt a culture of safety within their care area.
Conflict Management Within any team environment, one can expect the occasional conflict or personality clash. Providing nursing care involves much more than the application of a set of clinical skills and requires insight, empathy, and compromise. A common struggle for the PACU nurse can be observed in the task of providing a verbal report allowing the patient to be transferred from the PACU. It is not uncommon to be asked to delay a patient’s transfer; ‘‘we are really busy,’’ or ‘‘it is change of shift,’’ or ‘‘that nurse is on her break right now.’’ Although this can become tiresome, the nurse should use an empathetic approach while asserting that the patient’s needs remain the priority. This is where the skills of conflict management and compromise can prove effective. In addition, the perianesthesia nurse should not take personally the negative or unprofessional behaviors of others but maintain a focus on meeting the needs of the patient first and foremost. Talking it out is completed using professional but assertive language. Where a colleague feels that they have been spoken to in a rude manner, they are encouraged to verbalize their feelings and provide the offending individual with alternative methods to state his or her concerns. For example, ‘‘When you raise your voice, it makes me uncomfortable and it gives an appearance to the patients of a lack of a team approach. In future, I ask you to speak to me away from the patient, but in a more professional manner.’’ An approach of talking it out is empowering and can lead to a more productive work environment.11 Conflict management need not be a sophisticated process. The tools used to handle conflict are shared in primary school, yet are transferable to the adult world. Elements in managing conflict include compromise, negotiation, talking it out, and humor.11 The act of compromise shows consideration for another person’s view. In the example above, the PACU nurse could state, ‘‘I
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can defer bringing the patient to you for 15 to 20 minutes, but we are expecting a complicated case from the OR. I’ll ensure that the patient’s blood transfusion is completed so you don’t have to juggle that, too.’’ Using this approach, the PACU nurse acknowledges that others are challenged with demanding workloads as well. In a collaborative approach, the nurse can make some accommodations to assist with the processes in coordinating patient care while not being expected to defer the patient transfer beyond what is reasonable. When challenged with conflict management in hierarchal structures, using assertive language can support the clinician. For example, when interacting with an intimidating personality using phrases such as ‘‘I’m concerned’’ or ‘‘I need a little clarity’’ can redirect the attention away from power struggles back to resolving the situation. Assertive and critical language is neutral but direct, and fosters an environment where there is no threat to an individual’s ego.5 Further, by using assertive language, one can trigger corrective actions and avoid poor outcomes.6 In addition to SBAR, another tool to support use of assertive language is DESC. This stands for Describe the situation, Explain the concerns, Suggest alternatives, and state potential Consequences or risks to the patient.5 Such tools help frame the clinician’s message to be specific, direct, and assertive. It is necessary that health care providers can politely assert themselves as needed to support patient safety and optimal outcomes. Using assertive language is another nontechnical skill that perianesthesia nurses can develop through programs provided during orientation and at annual skills review days. Finally, in the hectic pace of health care, a sense of humor is vital to survival. Humor is a powerful tool and can combat tension while encouraging creativity and a more pleasant work environment.11 Using humor appropriately can go a long way to refocus and diffuse a conflict, rather than magnifying the issue. Although there may be times where conflict cannot be avoided entirely, using the above tactics can help to minimize and resolve irritations before they snowball into major issues.
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Failure to provide training around the factors that interfere with effective communication is a common gap in training systems.8 Teams can address this gap by providing staff opportunities to practice using assertive language, SBAR, and DESC. This in turn can create enhanced communication, which supports patient safety.
Team Building Working in an OR or PACU can make one feel closed off from other departments in the organization. Spending long hours in restricted areas that have artificial lighting, no windows, and low ambient temperatures can be challenging. Some staff address this by ensuring they take their breaks away from the unit to get a few minutes of fresh air or change of scenery. However, this is not always feasible because of the demands of high surgical volumes and staffing and other factors. Team functioning has a direct link to patient safety. The components of a high-functioning team include communication, collaboration, and conflict management.5 Improving competency in these three areas can enhance team functioning and patient safety. Regular staff meetings led by the unit manager can provide opportunities for staff to practice and develop these skills. Developing a close-knit team can diffuse the strain of working in a busy perioperative environment where staff must work in close quarters with one another. In addition, supporting staff to achieve certification in the perianesthesia specialty can increase team pride, belonging, and cohesiveness.12 Promoting networking, collaboration, and involvement in perianesthesia associations such as the American Society of PeriAnesthesia Nurses can help instill a sense of pride and dedication to the profession. Being a part of a team that has similar goals such as continued learning, patient safety, and excellence in care can pull the team together. A strong sense of team is a great asset, particularly when faced with stressful situations. Cohesive team functioning is one of the pillars of effective patient care.5 The complexities and challenges within perianesthesia care continue to grow, as does the complexity and acuity level of patients. However, having a strong sense of team with a balance of technical and nontechnical skill sets can
facilitate excellence in patient care throughout the phases of anesthesia. It is through a high-functioning and cohesive team that we can adapt to the complex and unpredictable environment of perianesthesia. Working conditions in the health care and aviation industries never completely match what may have been taught or outlined through procedures and policies.7 Communication and collaboration of a strong team supports the ability to respond to stressful conditions and avoid errors linked to human factors. When an adverse event has taken place, having a debriefing following the event can provide a learning opportunity. In addition to learning, debriefing sessions can provide a cathartic benefit and be team building as the staff pull together and review how the current gaps in processes can be improved.6 Having a no-blame culture coupled with education around communication methods and human factors supports patient safety.6
Summary Traditionally health care has regarded technical skills and competence as the central key to patient safety. More recently we are seeing an increased discussion of the need to balance technical skills with softer competencies such as communication, team building, awareness, and application of HFE to processes such as patient hand-off and responding to emergent clinical scenarios.5 Nontechnical competencies are seen as separate from taskrelated skills but should not be omitted from the perianesthesia nurse’s list of core competencies. Through heightened awareness on HFE, all providers are less likely to develop a false sense of security that compliance to a protocol will ensure avoidance of errors. Supporting a culture of safety and understanding of the limitations in human cognition are the first steps to reducing the occurrence of human factor–related errors. Having the softer competencies taught to new staff and reviewed regularly can enhance our ability to sustain a balanced set of technical and nontechnical skills. These approaches require the support of an organization’s leadership team to ensure that a culture of safety is adopted and ingrained within the complex processes in the perianesthesia care environment.
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References 1. Wacogne I, Diwakar V. Handover and note-keeping. Clin Risk. 2010;16:173-175. 2. Cole C. Implied consent and nursing practice: Ethical or convenient. Nurs Ethics. 2012;16:550-557. 3. College of Nurses of Ontario. Professional Standards. 2002;1-16. Available at: http://www.cno.org/Global/docs/prac/ 41006_ProfStds.pdf?epslanguage5en. Accessed June 14, 2013. 4. American Society of Perianesthesia Nursing. 2013-2014 Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: The Society; 2012. 5. Lisha L. Teamwork and communication in healthcare— A literature review. Canadian Patient Safety Institute. Available at: http://www.patientsafetyinstitute.ca/English/tools Resources/teamworkCommunication/Documents/Canadian%20 Framework%20for%20Teamwork%20and%20Communications% 20Lit%20Review.pdf. Accessed June 14, 2013.
6. Scovell S. Role of the nurse-to-nurse handover in patient care. Nurs Stand. 2010;24:35-39. 7. Hill W, Nyce J. Human factors in clinical shift handover communication. Can J Respir Ther. 2010;46:44-51. 8. Bromiley M. Clinical human factors: The need to speak up and improve patient safety. Nurs Stand. 2012; 26:35-40. 9. Iacono M. Mentoring for perianesthesia nurses. J Perianesth Nurs. 2002;16:118-122. 10. Shendell-Falik N, Feinson M, Mohr B. Enhancing patient safety: Improving the patient handoff process through appreciative inquiry. J Nurs Adm. 2007;37:95-104. 11. Hagemann B, Stroope S. Conflict management—Lessons from the second grade. Train Dev. 2012;7:58-61. 12. Iacono M. Perianesthesia staffing—Thinking beyond the numbers. J Perianesth Nurs. 2006;21:346-352.
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Perianesthesia Nursing—Beyond the Critical Care Skills .97 Contact Hours Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing. Purpose of this CNE Activity: To enable the perianesthesia nurse to implement effective communication skills in order to improve communication in the clinical environment. Target Audience: All perianesthesia nurses. Article Objectives: (1) Describe the skills around communication, mentorship, and crisis management within perianesthesia nursing. (2) Identify two communication tools that support patient safety. (3) Describe methods that address interpersonal conflict. Accreditation American Society of Perianesthesia Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114. Registered nurse participants can receive .97 contact hours for this activity. Disclosure: All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below. Planner and Author Disclosure: The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose. The author for this continuing nursing education activity does not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose. Verification of Participation: Verification of your participation in this educational activity is done by having you complete the registration form and submit the form along with the post test and evaluation form to the ASPAN national office. Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must submit the posttest and evaluation form to the ASPAN national office and achieve a minimum grade of 80% on the posttest. Commercial Support: No commercial support has been received for this educational activity.
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Directions: The multiple-choice examination below is designed to test your understanding of Perianesthesia Nursing –Beyond the Critical Care Skills according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article, (2) complete the posttest by indicating the answers
in the test grid provided, and (3) tear out the page (or photocopy) and submit postmarked before February 28, 2016, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test) and return to ASPAN, 90 Frontage Road, Cherry Hill, NJ 08034–1424. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Communication skills for the perianesthesia nurse are: A. A required competency B. An important means to support patient safety C. Necessary when confirming patient consent, providing transfer of care report or patient health teaching D. All of the above 2. Gaps in providing a comprehensive report at transition of care may be due to: A. The skill of patient handover not being formally taught in a nursing school program B. The presence of a standard transfer of accountability form C. The process of transfer of care being simple and not cognitively taxing D. The process of transfer of care being learned on the job in a consistent manner 3. The SBAR communication tool refers to: A. Sensory, blood pressure, airway, recovery score B. Situation, baseline, assessment, recommendations C. Situation, background, assessment and recommendations D. None of the above 4. Human factors engineering: A. Examines the interface between machines and technology B. Is only relevant when designing medical devices and equipment C. Has little relevance to patient safety D. Examines how humans interface with technology, processes and protocols
5. In responding to a crisis, humans by nature can: A. Become distracted and overly focused on a technical problem B. Have difficulty making decisions despite their expertise C. Provide optimal care without a guiding algorithm D. a & b 6. Being a mentor involves: A. Being a role model in critical thinking and communication skills B. Pulling didactic learning into action C. a & b D. Focusing only on technical skills 7. Adverse events rates in hospitalized patients are: A. 1.5% B. 15% C. 25% D. 7.5% 8. Strategies to support patient safety include: A. Use of a punitive approach following adverse events B. c & d C. Including topics such as safety and workflow as agenda items at staff meetings D. Providing educational opportunities such as mock airway emergencies for staff to increase their familiarity with algorithms 9. To manage power struggles, using the following phrases can redirect attention to resolving a situation: A. You are not being helpful B. I need a little clarity C. b & d D. I’m concerned
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10. Another tool to support the use of assertive language is: A. DESC; describe, educate, summarize, collaborate B. DESC; describe, explain, suggest alternatives, state the potential consequences to the patient C. DESR; define, explain, summarize, recommendations D. SBSR; situation, background, suggest alternatives, reflect
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________________________________________________________________________________________ Please Print Name__________________________________Nursing License No./State____________________________ Address__________________________________________________________________________________ City_______________________________State_______________________Zip_________________________ ASPAN Member #__________________________________________________________________________ E-Mail____________________________________________________________________________________ EVALUATION: Perianesthesia Nursing–Beyond the Critical Care Skills
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Evaluation Form SD5strongly disagree; D5disagree; N5neutral; A5agree; SA5strongly agree 1. After completion of this educational activity, I am able to describe the skills around communication, mentorship, and crisis management within perianesthesia nursing. 2. After completion of this educational activity, I am able to identify two communication tools that support patient safety. 3. After completion of this educational activity, I am able to describe methods that address interpersonal conflict. 4. The program content was relevant to my nursing practice. 5. Learner paced was an appropriate format for the content. 6. This educational activity was free from commercial bias. 7. The planner and presenter disclosure information was included in this educational activity.
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8. Identify the amount of time required to review the on demand video module, take the test and complete the evaluation form: a. Over 120 minutes b. 91-120 minutes c. 61-90 minutes d. 30-60 minutes e. Under 30 minutes 9. Will the knowledge gained through this educational activity change your practice?
a. Yes b. No 10. If you answered yes above – please explain: 11. Additional comments
Test answers must be submitted before February 28, 2016 to receive contact hours.
Perianesthesia Nursing—Beyond the Critical Care Skills Heather Ead, RN, BScN, MHSc Provision of patient care within the perianesthesia specialty is demanding in nature. Although a nurse may be well equipped with the assessment, planning, and critical thinking skills required for these fastpaced areas, there are other competencies to be developed. These include skills in mentorship, communication, crisis management, and competency as an ambassador of patient safety. Barriers to developing these skills may include a high patient acuity and turnover, a sense of isolation from other departments, and strong hierarchical structures. However, there are resources and strategies that nurses can leverage to facilitate development of these less-technical, ‘‘softer’’ skills. In this article, the author reviews some of the unique demands commonly seen within the perianesthesia specialty. Methods to address these challenges are shared to facilitate an enjoyable career in this dynamic environment. Keywords: perianesthesia, competencies, PACU, critical thinking. Ó 2014 by American Society of PeriAnesthesia Nurses
OBJECTIVES—AFTER READING THIS ARTICLE, the participant should be able to: 1. Describe the skills around communication, mentorship and crisis management within perianesthesia nursing. 2. Identify two communication tools that support patient safety. 3. Describe methods that address interpersonal conflict. Nurses within the large umbrella of the perianesthesia specialty provide care to a wide range of patients. Whether the setting is a postanesthesia care unit (PACU), ambulatory care department, or dental surgery clinic, there are competencies that all perianesthesia nurses share. These include, but are not limited to, excellent assessment skills, Heather Ead, RN, BScN, MHSc, is a Clinical Educator, Trillium Health Centre, Mississauga, Ontario, Canada. Conflict of interest: None to report. Address correspondence to Heather Ead, Trillium Health Centre, 100 The Queensway West, Mississauga, Ontario, Canada L5B 2B6.; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.05.012
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critical thinking, knowledge of pharmacology, and certification in basic or advanced cardiac life support. Perianesthesia nursing is much more than coordinating patient care and ensuring that comforts and hemodynamic stability are achieved. The perianesthesia nurse requires another set of competencies that may be thought of as a softer set of skills, but important nonetheless. These include communication skills, crisis management, mentorship, and acting as an ambassador for safety (Figure 1). Working day after day in a department such as a PACU that was designed without exterior windows can create a sense of confinement and lead to isolation from other departments. There are times when it seems all efforts to transfer a stable patient to the next phase of care are met with resistance and numerous barriers. The nurse who consistently receives a cold reception from staff outside her unit can start to develop feelings of resentment. Although we cannot always shape the behavior of others, we can work to improve our own attitudes and the coping and communication skills that we apply in patient care.
Journal of PeriAnesthesia Nursing, Vol 29, No 1 (February), 2014: pp 36-49
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Figure 1. Balancing technical and nontechnical skills.
Communication Skills Needless to say, good communication skills are a key competency for any nurse. Improving communication skills can enhance patient safety, as communication failures have been linked to adverse events that otherwise may have been prevented.1 The perianesthesia nurse is often receiving and providing reports to a number of health care providers. By gathering a clear assessment from the patient, family, and staff, the perianesthesia nurse ensures that all vital information is clearly communicated across the continuum of care. For example, through use of effective communication skills, the perianesthesia nurse confirms that the consent the patient has provided is informed in nature and is not simply the patient’s signature on yet another form. It is through discussion with the patient and family that the nurse can identify knowledge gaps and provide clarification and health teaching. Moreover, the nurse advocates for the patient by requesting the surgeon to provide additional information or answer questions as necessary.2 Communication skills support patient safety, particularly when providing a transfer of care report from the PACU to another department. The
transfer of care report may also be referred to as a transfer of accountability (TOA) report, as the accountability of the patient’s care is being taken over by a new provider. The TOA report should be an interactive process between the perianesthesia nurse and the nurse assuming care of the patient. The College of Nurses of Ontario and the American Society of PeriAnesthesia Nurses recommend using a standardized process to complete the TOA report to ensure effective communication and information sharing occurs across the care continuum.3,4 Another transition point where communication skills are of great importance is when preparing patients for home discharge. At this time, the patient and/or family must be provided information that is relevant and easily understood. For example, the clarity of health teaching provided must ensure that the patient and/or family understand the normal postoperative expectations, as well as situations that would require them to seek medical help. It is well known that poor communication is a factor in 70% of adverse events.5 Communication failures during shift reports are a leading cause of
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sentinel events.5 Having a standard template for the TOA report can improve the quality and consistency of information provided in a brief but comprehensive report. Outlining the transfer report process to new staff and periodically reviewing with all staff can ensure their communications support patient safety and optimal outcomes. Development of a standard TOA form is an opportunity for the perianesthesia team to work together to identify a process that supports patient safety. At Trillium Health Partners, the nursing staff within the PACU developed a TOA form that was modified from one that is used in the inpatient areas. After piloting a few drafts, a final version was approved (Figure 2). Despite the value the TOA process has to patient safety, the skill of patient handover is not often formally taught to health care providers.6 Instead, this skill is learned on the job in a manner that can be lacking in consistency and/or structure. Considering the risks associated with poor communication, this gap in formal education and training may pose a significant risk. Learning how to provide a good TOA report by trial and error is a less than ideal strategy. This gap provides an opportunity for perianesthesia nurses to develop a more formalized process in teaching TOA to new staff. TOA is described as complex, cognitively taxing but a vital part of patient care.7 By ensuring that time is dedicated to education and periodic review of the TOA process, we can support a consistent manner of ensuring clarity and safety in our interactions with health care providers, patients, and families.
Crisis Management In Phase I recovery, the perianesthesia nurse may be accustomed to working through crises such as respiratory distress, cardiac arrest, or a patient presenting with a postoperative hemorrhage. However, in any phase of perianesthesia care, unanticipated complications can arise. The nurse must be able to respond calmly and prioritize the care needed in this time-sensitive situation. Unfortunately stress can impair cognition and result in decisions that are made too slowly, too rapidly, or incorrectly.8 Communication between two or more individuals can be described as informal, disorganized, and variable.1 However, in urgent situations, it is essential for structure to be part of the
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information exchange. Structure can be achieved by following the SBAR process; ‘‘SBAR’’ is an acronym for Situation, Background, Assessment, and Recommendations. SBAR is a standardized reporting process that is recommended by the World Health Organization (WHO).5 This tool creates a standardized discussion that facilitates communication in an urgent situation. Although SBAR originated in the US Navy to enhance communication, it is commonly used in health care.1 SBAR can be used as a template and printed for nursing staff to use as a working tool. The SBAR form can be completed by the nurse to pull all the relevant information together succinctly prior to consulting with a physician or other care provider. The SBAR tool can enhance communication in stressful and other failure-prone situations (Figure 3).1 Applying the SBAR process assists the nurse to focus and share only pertinent information. For example, the Situation may be ‘‘Mr. X’’ who is being cared for in PACU following a laparoscopic cholecystectomy. The Background may be that despite provision of analgesia, Mr. X continues to have intense and worsening abdominal pain. Information to share in the Assessment parameter of the SBAR report may include the patient’s most recent vital signs, oxygenation status, and any relevant blood work. Finally, the nurse provides a Recommendation, such as suggesting that the surgeon come assess the patient to rule out postoperative bleeding. At Trillium Health Partners, the tool has been particularly helpful for novice staff. By providing a focused and efficient report, the physician is able to provide directives to the nurse in a timely manner. With experience, the nurse may find that SBAR becomes part of his or her communication style, and documenting on the SBAR forms is not required. Human factors engineering (HFE) examines how humans interface with technology, processes, and protocols. By having an awareness of human factors in clinical care, we can make great inroads into patient safety in crises management.8 Human factors have been linked to tragic outcomes such as the Elaine Bromiley case of 2005.8 This case illustrates that even highly experienced and competent staff can respond to stress with decision making that is based largely on intuition, instead
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Figure 2. Transfer of Accountability form. Trillium Health Partners, 2009; Used with permission.
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Figure 3. SBAR (Situation, Background, Assessment, and Recommendations) communication tool. Trillium Health Partners, 2009; Used with permission.
of using cognitive skills or implementing an evidence-based algorithm. In the Elaine Bromiley case, complications with airway patency occurred at the initiation of anesthesia for minor, elective surgery. Some team members became so focused on endotracheal intubation attempts they were blinded to the fact that oxygen deprivation had persisted for an alarming period of time, warranting a refocus of energies to initiate a tracheotomy.8 Additionally, nursing staff did not feel comfortable questioning the strategies of the anesthesiologist and surgeon, even though Elaine’s condition continued to deteriorate. In hindsight, the nurses described what interventions should have taken place, but did not feel empowered to speak up and provide direction to the physicians who ranked higher within the organizational hierarchy.8 We can learn a great deal from this tragic case, such as the practices of team building, assertive communication and awareness of human factors.
the most appropriate decision when placed in a highly stressful situation. By having an awareness of this human flaw, we can develop processes to help mitigate poor outcomes.8 These processes include access to algorithms to guide staff through emergent situations such as a malignant hyperthermia crises or loss of airway patency. Awareness of how human factors can impact safety also includes supporting an environment where it is acceptable and encouraged for staff to ask questions and speak up when they feel unsure of the current treatment plan.
Humans by nature have a capacity for becoming overly focused on technical problems and losing sight of the big picture in emergent situations. Even expert staff can become blinded to making
Mentorship
To address hierarchy-related barriers to effective communication, nurses should be provided opportunities to practice assertive communication, and work through mock emergent scenarios with tools such as the SBAR process. Assertive communication takes time to develop, but through practice staff can have increased confidence in their communication skills and ability to speak up.
A mentor acts as a guide, advisor, and teacher for another nurse. The term mentor comes from the
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Greek character Mentor who was characterized as a protector and guardian of Odysseus’s son Telemachus.9 Teaching critical care assessment and communication skills to novice nurses supports learning and adaptation to a new clinical area. Although technical skills such as care of an arterial line may be included on an orientation skills checklist, the mentor should also review provision of report at transition of care, as well as using assertive language when speaking to a surgeon or anesthesiologist. The nurse who is mentored learns how to advocate for the patient by observing how the mentor clarifies, challenges, or questions unclear physician orders. The mentor should reassure newer staff that it is acceptable and necessary at times to question orders that may not appear appropriate or legible, particularly for a physician who may be approaching exhaustion from extended hours of being on call. Using these teachable moments to enhance another nurse’s practice will support their transition to becoming an experienced and confident perianesthesia nurse. The mentor leverages opportunities for hands-on learning and uses interactive, varied approaches that complement the classroom teaching, and pull all the information and learning together.9 It is recognized that patient care transfers from one department to another have a high safety consequence.10 TOA should be included on the perianesthesia list of competencies to be met during the staff’s orientation period. The mentor can review the department’s TOA template, demonstrate the standardized process of completing patient hand-off, and then have the novice nurse demonstrate back application of this skill. The mentor shares his or her knowledge and experience in a hands-on manner that pulls didactic learnings into action in the clinical world.7 The mentor in perianesthesia has the noble task of teaching and guiding another nurse to develop technical and nontechnical skills. Perianesthesia nurses can be described as role models for critical thinking, adaptability, flexibility, and clinical wisdom.9 By addressing communication skills, conflict management, and the role of safety ambassador, the mentor can have a great impact in ensuring our future perianesthesia nurses are well equipped to provide the highest level of care in
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this dynamic specialty. The mentor can demonstrate how to use assertive communication to advocate for the patient’s needs and ensure optimal outcomes are achieved.
Ambassador of Patient Safety Canadian adverse event studies reinforce that health care is not inherently safe or reliable.7 Retrospective multicenter studies have illustrated an adverse event rate of 7.5% in hospitalized patients, with 21% of these events causing an unexpected death.7 We are aware that human fallibility will guarantee some percentage of errors regardless of the health care provider’s years of experience. Organizations that adopt a reporting culture versus one of blame empower the staff to monitor and identify the presence of real or potential risks in patient safety. By using a supportive and nonpunitive approach regarding adverse events, the message to the staff is that their organization views errors as opportunities to learn, improve, and address the gaps in their current processes. Pulling the staff together to review and reflect following an adverse event is an opportunity to turn a negative outcome into a learning opportunity that can positively affect patient care. To support sustainability, safety and work flow should be a regular agenda item at staff meetings. Providing staff the opportunity to share their suggestions on how to improve processes and avoid adverse events can help staff feel empowered. In addition, staff should be recognized for their efforts when they take time to report near misses and adverse events, or intervene to prevent an error from occurring. Reward and recognition can be used to facilitate a culture of safety, rather than employing a punitive approach to risk management. Although HFE is well applied in the design of medical equipment such as intravenous infusion and feeding pumps, it is still in its early stages in regards to structuring our behaviors, processes, and application of protocols.5 The field of HFE recognizes that in stressful situations we can lose sight of the gravity of a situation and our sense of time, which can result in a situation of failure to rescue.5 The concerns of situational awareness can be
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addressed by increasing the frequency of conversations around patient safety and consistently wearing a ‘‘safety lens.’’ For example, staff should be encouraged to be on the alert for medication labeling that is confusing or difficult to read, and they should communicate their concerns to their manager. The occurrence of an error does not indicate that a staff member is incompetent. All humans are vulnerable to becoming overwhelmed when stressed, particularly in a rapidly changing or deteriorating clinical scenario. When under stress, all individuals have limits in their cognition and capacity of interpreting and responding to information, but there are steps one can take to minimize these limitations. The elements of patient safety should be included in the continued education that is provided to staff. By dedicating efforts to support education on topics such as human factors, situational awareness, and cultures of safety, all perianesthesia nurses can be ambassadors of safety and gate keepers of preventing adverse events. With education and awareness, staff can fully integrate the optics of patient safety into their practice. The science of HFE examines what, how, and why things go wrong.7 Clinicians are often managing the balance between efficiency and safety. However, there are times where a mismatch exists between the demands and the provider’s capacity to address all clinical needs. However, safety and thoroughness should never be a trade-off for efficiency.7 An example is the constant pressure on a PACU to maintain patient flow and avoid putting an operating room’s (OR’s) schedule on hold. During times of high acuity, it may be necessary to place OR on hold to ensure appropriate staffing so nurse-to-patient ratios can be maintained. A standardized communication method such as SBAR can be used to communicate that the PACU cannot receive further admissions from the OR until the volume or acuity of care has improved. When acuity levels improve, the perianesthesia nurse can alert the OR they are able to safely receive additional patients in the Phase I or II recovery area. The aviation industry has successfully adopted a process termed crew resource management
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training (CRM) to train and review processes with staff. Through CRM, staff have the opportunity to apply and appreciate specific human factors that become barriers to efficiently responding to emergency situations.8 The aviation industry reinforces the crucial lesson to their staff regularly: ‘‘if in doubt speak up.’’ This message empowers staff to share their concerns and even question an individual in a position of higher authority. For example, if a staff member observes a senior colleague omitting a step within the safety check, it is expected of the staff member to speak up immediately. This culture of safety is an inseparable part of the aviation industry. The health care industry continues to look to the airline industry for methods to better incorporate safety to the complexities of clinical care.8 To assist staff to be prepared for emergent situations, it is important that they are provided opportunities during their orientation period (and through annual reviews) to practice the application of advanced cardiac life support algorithms and responding to airway patency issues. Hands-on practice can facilitate a smooth response when a medical crisis does occur. With practice, the practitioner can learn to maintain a focus of situational awareness in an emergency and overcome human factors such as becoming overwhelmed or having an impaired capacity to comprehend essential information.5 Moreover, with increased familiarity of algorithms and procedures, staff are less prone to lose sense of time or fail to recognize that a situation has worsened and the plan of rescue warrants an adjustment. An opportunity for the nurse to challenge a physician’s directions should be included within the mock emergent scenarios. For example, in a deteriorating patient scenario, the nurse could state her disagreement with a physician’s directions and provide concise information; for example, ‘‘the patient needs to be transferred to the intensive care unit as the surgical unit will not be able to provide 1:1 nursing care.’’ This takes a level of courage and experience, but with practice the nurse can become more comfortable advocating for the patient’s needs. Having established protocols will not provide benefits to patients if the staff are lacking the skills or confidence to advocate for implementation of the protocol, when
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confronted with strong or resistive personalities.8 Taking an opportunity to practice assertive language can assist the staff to be an ambassador of safety and adopt a culture of safety within their care area.
Conflict Management Within any team environment, one can expect the occasional conflict or personality clash. Providing nursing care involves much more than the application of a set of clinical skills and requires insight, empathy, and compromise. A common struggle for the PACU nurse can be observed in the task of providing a verbal report allowing the patient to be transferred from the PACU. It is not uncommon to be asked to delay a patient’s transfer; ‘‘we are really busy,’’ or ‘‘it is change of shift,’’ or ‘‘that nurse is on her break right now.’’ Although this can become tiresome, the nurse should use an empathetic approach while asserting that the patient’s needs remain the priority. This is where the skills of conflict management and compromise can prove effective. In addition, the perianesthesia nurse should not take personally the negative or unprofessional behaviors of others but maintain a focus on meeting the needs of the patient first and foremost. Talking it out is completed using professional but assertive language. Where a colleague feels that they have been spoken to in a rude manner, they are encouraged to verbalize their feelings and provide the offending individual with alternative methods to state his or her concerns. For example, ‘‘When you raise your voice, it makes me uncomfortable and it gives an appearance to the patients of a lack of a team approach. In future, I ask you to speak to me away from the patient, but in a more professional manner.’’ An approach of talking it out is empowering and can lead to a more productive work environment.11 Conflict management need not be a sophisticated process. The tools used to handle conflict are shared in primary school, yet are transferable to the adult world. Elements in managing conflict include compromise, negotiation, talking it out, and humor.11 The act of compromise shows consideration for another person’s view. In the example above, the PACU nurse could state, ‘‘I
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can defer bringing the patient to you for 15 to 20 minutes, but we are expecting a complicated case from the OR. I’ll ensure that the patient’s blood transfusion is completed so you don’t have to juggle that, too.’’ Using this approach, the PACU nurse acknowledges that others are challenged with demanding workloads as well. In a collaborative approach, the nurse can make some accommodations to assist with the processes in coordinating patient care while not being expected to defer the patient transfer beyond what is reasonable. When challenged with conflict management in hierarchal structures, using assertive language can support the clinician. For example, when interacting with an intimidating personality using phrases such as ‘‘I’m concerned’’ or ‘‘I need a little clarity’’ can redirect the attention away from power struggles back to resolving the situation. Assertive and critical language is neutral but direct, and fosters an environment where there is no threat to an individual’s ego.5 Further, by using assertive language, one can trigger corrective actions and avoid poor outcomes.6 In addition to SBAR, another tool to support use of assertive language is DESC. This stands for Describe the situation, Explain the concerns, Suggest alternatives, and state potential Consequences or risks to the patient.5 Such tools help frame the clinician’s message to be specific, direct, and assertive. It is necessary that health care providers can politely assert themselves as needed to support patient safety and optimal outcomes. Using assertive language is another nontechnical skill that perianesthesia nurses can develop through programs provided during orientation and at annual skills review days. Finally, in the hectic pace of health care, a sense of humor is vital to survival. Humor is a powerful tool and can combat tension while encouraging creativity and a more pleasant work environment.11 Using humor appropriately can go a long way to refocus and diffuse a conflict, rather than magnifying the issue. Although there may be times where conflict cannot be avoided entirely, using the above tactics can help to minimize and resolve irritations before they snowball into major issues.
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Failure to provide training around the factors that interfere with effective communication is a common gap in training systems.8 Teams can address this gap by providing staff opportunities to practice using assertive language, SBAR, and DESC. This in turn can create enhanced communication, which supports patient safety.
Team Building Working in an OR or PACU can make one feel closed off from other departments in the organization. Spending long hours in restricted areas that have artificial lighting, no windows, and low ambient temperatures can be challenging. Some staff address this by ensuring they take their breaks away from the unit to get a few minutes of fresh air or change of scenery. However, this is not always feasible because of the demands of high surgical volumes and staffing and other factors. Team functioning has a direct link to patient safety. The components of a high-functioning team include communication, collaboration, and conflict management.5 Improving competency in these three areas can enhance team functioning and patient safety. Regular staff meetings led by the unit manager can provide opportunities for staff to practice and develop these skills. Developing a close-knit team can diffuse the strain of working in a busy perioperative environment where staff must work in close quarters with one another. In addition, supporting staff to achieve certification in the perianesthesia specialty can increase team pride, belonging, and cohesiveness.12 Promoting networking, collaboration, and involvement in perianesthesia associations such as the American Society of PeriAnesthesia Nurses can help instill a sense of pride and dedication to the profession. Being a part of a team that has similar goals such as continued learning, patient safety, and excellence in care can pull the team together. A strong sense of team is a great asset, particularly when faced with stressful situations. Cohesive team functioning is one of the pillars of effective patient care.5 The complexities and challenges within perianesthesia care continue to grow, as does the complexity and acuity level of patients. However, having a strong sense of team with a balance of technical and nontechnical skill sets can
facilitate excellence in patient care throughout the phases of anesthesia. It is through a high-functioning and cohesive team that we can adapt to the complex and unpredictable environment of perianesthesia. Working conditions in the health care and aviation industries never completely match what may have been taught or outlined through procedures and policies.7 Communication and collaboration of a strong team supports the ability to respond to stressful conditions and avoid errors linked to human factors. When an adverse event has taken place, having a debriefing following the event can provide a learning opportunity. In addition to learning, debriefing sessions can provide a cathartic benefit and be team building as the staff pull together and review how the current gaps in processes can be improved.6 Having a no-blame culture coupled with education around communication methods and human factors supports patient safety.6
Summary Traditionally health care has regarded technical skills and competence as the central key to patient safety. More recently we are seeing an increased discussion of the need to balance technical skills with softer competencies such as communication, team building, awareness, and application of HFE to processes such as patient hand-off and responding to emergent clinical scenarios.5 Nontechnical competencies are seen as separate from taskrelated skills but should not be omitted from the perianesthesia nurse’s list of core competencies. Through heightened awareness on HFE, all providers are less likely to develop a false sense of security that compliance to a protocol will ensure avoidance of errors. Supporting a culture of safety and understanding of the limitations in human cognition are the first steps to reducing the occurrence of human factor–related errors. Having the softer competencies taught to new staff and reviewed regularly can enhance our ability to sustain a balanced set of technical and nontechnical skills. These approaches require the support of an organization’s leadership team to ensure that a culture of safety is adopted and ingrained within the complex processes in the perianesthesia care environment.
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References 1. Wacogne I, Diwakar V. Handover and note-keeping. Clin Risk. 2010;16:173-175. 2. Cole C. Implied consent and nursing practice: Ethical or convenient. Nurs Ethics. 2012;16:550-557. 3. College of Nurses of Ontario. Professional Standards. 2002;1-16. Available at: http://www.cno.org/Global/docs/prac/ 41006_ProfStds.pdf?epslanguage5en. Accessed June 14, 2013. 4. American Society of Perianesthesia Nursing. 2013-2014 Standards, Practice Recommendations and Interpretive Statements. Cherry Hill, NJ: The Society; 2012. 5. Lisha L. Teamwork and communication in healthcare— A literature review. Canadian Patient Safety Institute. Available at: http://www.patientsafetyinstitute.ca/English/tools Resources/teamworkCommunication/Documents/Canadian%20 Framework%20for%20Teamwork%20and%20Communications% 20Lit%20Review.pdf. Accessed June 14, 2013.
6. Scovell S. Role of the nurse-to-nurse handover in patient care. Nurs Stand. 2010;24:35-39. 7. Hill W, Nyce J. Human factors in clinical shift handover communication. Can J Respir Ther. 2010;46:44-51. 8. Bromiley M. Clinical human factors: The need to speak up and improve patient safety. Nurs Stand. 2012; 26:35-40. 9. Iacono M. Mentoring for perianesthesia nurses. J Perianesth Nurs. 2002;16:118-122. 10. Shendell-Falik N, Feinson M, Mohr B. Enhancing patient safety: Improving the patient handoff process through appreciative inquiry. J Nurs Adm. 2007;37:95-104. 11. Hagemann B, Stroope S. Conflict management—Lessons from the second grade. Train Dev. 2012;7:58-61. 12. Iacono M. Perianesthesia staffing—Thinking beyond the numbers. J Perianesth Nurs. 2006;21:346-352.
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Perianesthesia Nursing—Beyond the Critical Care Skills .97 Contact Hours Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver education specific to the body of knowledge unique to the practice of perianesthesia nursing. Purpose of this CNE Activity: To enable the perianesthesia nurse to implement effective communication skills in order to improve communication in the clinical environment. Target Audience: All perianesthesia nurses. Article Objectives: (1) Describe the skills around communication, mentorship, and crisis management within perianesthesia nursing. (2) Identify two communication tools that support patient safety. (3) Describe methods that address interpersonal conflict. Accreditation American Society of Perianesthesia Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114. Registered nurse participants can receive .97 contact hours for this activity. Disclosure: All planners and authors of continuing nursing education activities are required to disclose any significant financial relationships with the manufacturer(s) of any commercial products, goods or services. Any conflicts of interest must be resolved prior to the development of the educational activity. Such disclosures are included below. Planner and Author Disclosure: The members of the planning committee for this continuing nursing education activity do not have any financial arrangements, interests or affiliations related to the subject matter of this continuing education activity to disclose. The author for this continuing nursing education activity does not have any financial arrangements, interests or affiliations related to the subject matter of this continuing nursing education activity to disclose. Verification of Participation: Verification of your participation in this educational activity is done by having you complete the registration form and submit the form along with the post test and evaluation form to the ASPAN national office. Requirements for Successful Completion: To receive contact hours for this continuing nursing education activity you must submit the posttest and evaluation form to the ASPAN national office and achieve a minimum grade of 80% on the posttest. Commercial Support: No commercial support has been received for this educational activity.
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Directions: The multiple-choice examination below is designed to test your understanding of Perianesthesia Nursing –Beyond the Critical Care Skills according to the objectives listed. To earn contact hours from the American Society of PeriAnesthesia Nurses (ASPAN) Continuing Education Provider Program: (1) read the article, (2) complete the posttest by indicating the answers
in the test grid provided, and (3) tear out the page (or photocopy) and submit postmarked before February 28, 2016, with check payable to ASPAN (ASPAN member, $12.00 per test; nonmember, $15.00 per test) and return to ASPAN, 90 Frontage Road, Cherry Hill, NJ 08034–1424. Notification of contact hours awarded will be sent to you in 4 to 6 weeks.
Posttest Questions 1. Communication skills for the perianesthesia nurse are: A. A required competency B. An important means to support patient safety C. Necessary when confirming patient consent, providing transfer of care report or patient health teaching D. All of the above 2. Gaps in providing a comprehensive report at transition of care may be due to: A. The skill of patient handover not being formally taught in a nursing school program B. The presence of a standard transfer of accountability form C. The process of transfer of care being simple and not cognitively taxing D. The process of transfer of care being learned on the job in a consistent manner 3. The SBAR communication tool refers to: A. Sensory, blood pressure, airway, recovery score B. Situation, baseline, assessment, recommendations C. Situation, background, assessment and recommendations D. None of the above 4. Human factors engineering: A. Examines the interface between machines and technology B. Is only relevant when designing medical devices and equipment C. Has little relevance to patient safety D. Examines how humans interface with technology, processes and protocols
5. In responding to a crisis, humans by nature can: A. Become distracted and overly focused on a technical problem B. Have difficulty making decisions despite their expertise C. Provide optimal care without a guiding algorithm D. a & b 6. Being a mentor involves: A. Being a role model in critical thinking and communication skills B. Pulling didactic learning into action C. a & b D. Focusing only on technical skills 7. Adverse events rates in hospitalized patients are: A. 1.5% B. 15% C. 25% D. 7.5% 8. Strategies to support patient safety include: A. Use of a punitive approach following adverse events B. c & d C. Including topics such as safety and workflow as agenda items at staff meetings D. Providing educational opportunities such as mock airway emergencies for staff to increase their familiarity with algorithms 9. To manage power struggles, using the following phrases can redirect attention to resolving a situation: A. You are not being helpful B. I need a little clarity C. b & d D. I’m concerned
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10. Another tool to support the use of assertive language is: A. DESC; describe, educate, summarize, collaborate B. DESC; describe, explain, suggest alternatives, state the potential consequences to the patient C. DESR; define, explain, summarize, recommendations D. SBSR; situation, background, suggest alternatives, reflect
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________________________________________________________________________________________ Please Print Name__________________________________Nursing License No./State____________________________ Address__________________________________________________________________________________ City_______________________________State_______________________Zip_________________________ ASPAN Member #__________________________________________________________________________ E-Mail____________________________________________________________________________________ EVALUATION: Perianesthesia Nursing–Beyond the Critical Care Skills
BEYOND CRITICAL CARE SKILLS
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Evaluation Form SD5strongly disagree; D5disagree; N5neutral; A5agree; SA5strongly agree 1. After completion of this educational activity, I am able to describe the skills around communication, mentorship, and crisis management within perianesthesia nursing. 2. After completion of this educational activity, I am able to identify two communication tools that support patient safety. 3. After completion of this educational activity, I am able to describe methods that address interpersonal conflict. 4. The program content was relevant to my nursing practice. 5. Learner paced was an appropriate format for the content. 6. This educational activity was free from commercial bias. 7. The planner and presenter disclosure information was included in this educational activity.
SD
D
N
A
SA
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
8. Identify the amount of time required to review the on demand video module, take the test and complete the evaluation form: a. Over 120 minutes b. 91-120 minutes c. 61-90 minutes d. 30-60 minutes e. Under 30 minutes 9. Will the knowledge gained through this educational activity change your practice?
a. Yes b. No 10. If you answered yes above – please explain: 11. Additional comments
Test answers must be submitted before February 28, 2016 to receive contact hours.
