by	Linda J. Shinn, MBA, RN, CAE D. Kathleen Milholland, PhD, RN Karen A. Ballard, MA, RN E. Joyce Gould, MS, RN Barbara A. Brunt, MA, RNC Helen A. Schaag, MSN, MA, RN

To obtain the print publication that this CE is based upon, see Take Control: A Guide to Risk Management which can be purchased online.

Table of Contents

• Abstract and Objectives

• Information Systems Technologies: Rewards and Risks
  • Introduction
  • Information Technologies
  • Supporting Technologies
  • The Internet - A Special Information Technology
  • Risks
  • Rewards
  • Summary
  • References

• RNs, Risk, and UAP
  • References
  • Figure 1

• The Importance of Lifelong Learning in Managing Risks
  • Professional Nursing Development
  • Importance of Staff Development as a Risk Management Tool
  • Competence Issues
  • Mandatory Continuing Education
  • Relevance of Continuing Education to Voluntary Certification
  • Summary
  • References

• The Role of the Nurse Manager in Maintaining Quality and Managing Risk
  • Delegation
  • Staffing
  • Staff Competencies
  • Documentation
  • The Nurse Manager
  • Summary
  • References

• Attachment 1 Common Terms

• Attachment 2 How to Understand

• Attchement 3 ANA Reference Publications

• Attachment 4 SNA and State Licensing Boards

Abstract and Objectives

Abstract
In 1998, the independent study text "Take Control: A Guide to Risk Management" was published and co-provided by Seabury & Smith (formerly Maginnis & Associates), the Chicago Insurance Company and the Illinois Nurses Association. It was distributed by the American Nurses Association's Constituent Member Associations. The objectives of this text were to: identify key issues of concern in risk management and describe strategies nurses can use to manage risk.

Seabury and Smith Corporation has now asked ANA to transform this text into "The Nursing Risk Management Series" of three different independent study modules (ISMs) for placement on ANA's Nursingworld.org Web Site. The information and knowledge gained should assist nurses in all clinical practice areas to take control and manage the risks within their individual workplace and nursing practice.

Each module contains the abstract, specific objectives, text, reference list through 1998, an updated reference list through June 2001, the nursing post test and its feedback section. The registrant who successfully completes each ISM will earn ANA's nursing continuing education contact hour certificate. These independent study modules are: I: "An Overview of Risk Management" (1.4 contact hours); II: "The Rewards and Risks of the functional Aspects of Nursing Education, Information systems and Management" (2.8 contact hours) and III. "Ethical Issues and Specific Risk Hazards Faced by Nurses in Their Practice." (1.4 contact hours).

Objectives:

1. Describe the influence of technology on risk management.
2. Discuss the potential impact of Unlicenced Assistive Personnel (UAP) on an RN's risk.
3. Explain the effect of lifelong learning on managing risk.
4. Analyze the role and responsibility of the nurse manager in managing risk.

Information Systems
Technologies: Rewards and Risks

Registered nurses (RNs) are the primary information managers in clinical practice settings. RNs collect data, transform data to information, integrate information from multiple diverse sources, analyze information, make databased nursing care decisions, and communicate information .to others as appropriate (Zielstorff, Hudgings & Grobe, 1991). The skill employed and the activities undertaken by RNs information management make RNs the consummate knowledge workers of the 21st century. Along with cognitive nursing skills, RNs have employed information technologies of various complexities to meet the ever increasing demands for information and information management.

The purpose of this chapter is to inform RNs and other nursing personnel about current information technologies and potential risks associated with these technologies. The focus is on clinical nursing practice, since that is the domain of nursing in which the majority of RNs practice. First, current healthcare information technologies are described. Then, a discussion of the professional and legal risks associated with these technologies follows. Strategies that the individual RN might employ to reduce these risks are incorporated into the discussion as appropriate.

In this chapter, the concepts discussed are assumed to address the entire spectrum of nursing practice settings and the length of the healthcare continuum. Client is the term used to denote a recipient of RN services and may encompass an individual, a group of related or unrelated individuals, and communities (of any size).

This section begins with a discussion of the core source of client-specific health care: the client health record. A discussion of the two predominate information technologies which support this core source is provided. Then, the myriad supporting information technologies are described. Included in the discussions, as appropriate, are critical issues generated by these technologies.

The Client's Health Record

The most common information technology used in health care is the paper-based health record, which combines paper and writing instruments. The writing instruments may be manual (pen), mechanical (typewriter) or computerized (laboratory printouts). All written information about the client during an episode of health care is supposed to be captured in this document. (Images such as radiographs, sonograms, magnetic resonance imaging, etc. are stored separately from this record.) According to the Institute of Medicine, nearly every person in the United States who has had an encounter with the healthcare system has a paper-based health record (Dick & Steen, 1991 ). Most people have multiple health records kept by each practitioner they have visited. Even within one institution, a client may have more than one health record.

Although the paper-based health record has been in use for over a century, there has been growing criticism of its weaknesses and its inability to keep up with the rapidly increasing quantities of healthcare information generated and demanded by modem health care. The traditional organization of the paper record by sources and data chronology impedes the rapid retrieval and integration of data. Because all the client data are stored in a single document, only one person may have access to these data. Often, to counter this, different practitioners will remove the sections of the health record for which they have responsibility. This practice increases the difficulty in finding all of the pertinent information and integrating it into a comprehensive picture of the client's current status. As early as 1968, Dr. Lawrence Weed was identifying additional problems with the traditional health record such as illegibility, inaccuracy, duplication of data, gaps in information, and the misplacement or complete loss of information.

The electronic health record (EHR) is the solution most advocated for the problems of the paper-based health record and the information-intensive healthcare environment of today. The EHR is known by other terms such as computer-based patient record (CPR) and electronic medical record (EMR). Because it is computer-based, the EHR cannot be seen or touched. What is seen are displays on computer terminals and paper printouts ("hard copy"). An EHR is electronically maintained information about an individual's lifetime status and health care. Information in the EHR is characterized by content, representation, and time span (CPRI, 1996).

To provide the complete functionality that will result in the full range of possible benefits from the EHR, a supporting information system is essential. This may be known as an electronic health record system (EHRS), a clinical information system (CIS), a computer-based information system (CBIS), or some other variant. When the client-care information components of this information system are combined with administrative, financial, laboratory, and other information systems, the result is a healthcare information system (HIS). The EHRS supports the capture, storage, processing, communication, security, and presentation of electronic-based patient record information. It is the system that makes the EHR more than a static repository of data and information.

Hardware information technologies to support clinical nursing practice may be divided into mobile and stationm devices. Stationary devices include the ubiquitous portable computers (PC) and "dumb" terminals seen at nursing stations, the point-of-care, and other locations throughout a healthcare facility or office practice setting. Telephones and facsimile machines are another form of hardware information technology that supports the EHR and EHRS. Portable computers, often referred to as "workstations," are becoming the norm. These systems provide large screens, keyboards, and mouse/pointer devices for ease of use. Graphical, tabular, and text displays are available (Milholland, 1996).

Mobile technologies are becoming increasingly popular and available. They are intended for use in both institutional and home health settings, but the current emphasis is on their application for home health nurses. Regardless of where they are used, mobile devices add a level of freedom to the staff nurse who does not have to seek out a computer or paper chart for retrieving or recording patient information. Laptop/notebook computers are a common mobile information device, and they offer a large screen, a full keyboard and mouse/pointer capabilities but impose a weight and size burden. Hand-held devices most often are used for pen-based computing: a stylus is used to enter and retrieve information (there is no physical keyboard). Bar-code scanning is another feature of handheld devices which can be useful in tracking use of supplies and administration of medications (Milholland, 1996).

There are two main approaches to moving the information from the mobile computer to a more permanent system: wireless or phone-based. The wireless approach requires special transceivers mounted throughout the buildings where these devices are used. Usually, these transceivers automatically collect the data and information from the wireless device and transmit it to a receiving station which integrates the data into the enterprise's healthcare information system. Phone-based systems use a modem and a telephone line. (A modem is a special device which allows computers to use the telephone for communication.) This design is most often found in home health nursing, rather than in institutional settings. The nurse may phone in the information from the client's home or may wait until all home visits are completed before "downloading" the visit records from that day to the agency's computer. In the same vein, the nurse can have the health records for the next day's clients "uploaded" to the computer during the night so the information is available in the morning for review and planning (Milholland, 1996).

A recent innovation in wireless mobile information technology for institutional based healthcare practitioners is the portable phone. These cellular phones use a dedicated, transceiver-based system and replace personal beepers and overhead paging systems. Calls can be made or received from wherever the nurse is located.

Most everyone is familiar with Internet and the World Wide Web (WWW), that vast web of interconnected computers and software that enables people around the globe to communicate as if they were in the same room together. Healthcare practitioners, providers, and payers are viewing the Internet as a potentially powerful information technology for increasing access to healthcare, empowering consumers, educating practitioners, and transmitting healthcare information rapidly and cheaply. Some of the healthcare activities already occurring on the Internet are: transmitting requests for medications directly from the client's home to the prescriber's office, on-line hospital registration, development of "Home Pages" to provide clients with information about examination procedures, dissemination of clinical practice guidelines to practitioner's offices, and provision of continuing education programs (Milholland, 1996).

Regardless of the information technology used to create and support the EHR, there are numerous potential benefits (rewards), including reduction of administrative costs, enhancement of healthcare research, and improvement of client care. These benefits will be seen more and more as adoption of this information technology expands (Milholland & Heller, 1996).

Administrative benefits are accomplished via:

• reduced redundant data entry,
• electronic claims submission,
• improved risk management,
• reduced malpractice premiums,
• reduced record storage space,
• faster data retrieval time,
• improved provider productivity,
• provision of financial decision-support,
• closer connections between provider and client.

Healthcare research benefits from the use of EHRS, also. Because a EHR contains information from individual practitioner-client encounters, from entire treatment or illness episodes, and about a client's lifetime health status, there is a wealth of information available for study. Individual clients, groups of clients, individual practitioners, and groups of practitioners may be studied with greater ease because of the capacity and capabilities of EHRS.

The most important benefits of the EHR and EHRS for the client are:

• improved quality of care,
• improved access for practitioners to healthcare knowledge and decision support,
• elimination of duplicate tests and diagnostic activities,
• reduced delays in obtaining results of tests,
• enhanced clinical decision making,
• increased focus on wellness, health promotion, and disease prevention,
• linkage of protocols, client information, and healthcare knowledge,
• improved communication among practitioners,
• improved organization of client data, and timely data capture. (Milholland & Heller,1996).

Healthcare information technologies clearly have the potential for many rewards to practitioners and clients. However, along with the rewards of technologies come the risks. In this section, some of the potential risks of information technologies to RNs and their clients will be discussed. Possible strategies and/or actions to minimize these risks also will be presented. It is interesting to note that the major healthcare information publications do not address the professional or legal risks of these technologies. Problems with implementation and adoption of the systems are frequent topics, but not the risks. Yet every new technology inevitably has unexpected consequences and risks. More detailed analysis than what is in this chapter is needed. In the meantime, this chapter will help RNs to be prepared and pro-active.

For this section, risks are categorized as professional or legal. Professional risks are those that affect the profession of nursing and the individual RN's career. Legal risks concern the individual RN's license to practice and his/her vulnerability to legal action. It must be noted that the strategies to reduce the risks presented here may not be possible for an individual nurse to accomplish. However, if individual nurses work together as colleagues there is great power in numbers, persistence, and strong beliefs.

Professional Risks

The professional risks discussed in this section include: 1) the absence of nursing terms in electronic data sets, 2) the substitution of information technology for RNs, 3) documentation, 4) focusing on the technology instead of the client, 5) the potential for negative evaluation of nursing practice, and 6) physical safety of the nurse and the client. Space does not permit a comprehensive treatment of all potential professional risks, but these are key risks about which every RN needs to be aware.

Absence of nursing terms in electronic data sets.

The electronic health record and the systems which support it are focused on clinical client data. The data sets which are incorporated into the EHS are becoming increasingly multidisciplinary in nature'. Registered nurses must make sure that they are involved in the development of the data sets employed by the systems where they practice because without such involvement there is grave danger that the terms will not reflect nursing practice. The trend towards increasing multidisciplinary practice is a positive one. However, it often means that the work by nursing to identify and develop terminologies that encompass the nursing process is viewed as separatist or elitist. It is not. Nursing-focused information systems exist within the context of the total electronic health record system. The nursing profession supports multidisciplinary data collection and information management. However, it is absolutely essential that the data sets incorporate nursing terminology. Without the presence of this terminology, nurses will not be able to document the cognitive aspects of their practice (i.e., the intellectual processing of data into information and subsequent decision-making) and the outcomes of their work. Nurses and nursing practice will remain invisible to healthcare executives, to the public, and to policy makers.

The Nursing Minimum Data Set (Werley & Lang, 1988) has formed the basis for nursing data sets and nursing practice classification systems. The American Nurses Association has established a process for recognizing nursing classification systems that meet specific criteria for being useful to clinical practice. To date, there are four ANA-recognized nomenclatures: North American Nursing Diagnosis Association taxonomy of nursing diagnoses (NANDA, 1992); the Nursing Interventions Classification (McCloskey & Bulechek, 1992); the Omaha System (Martin & Sheet, 1992); and the Home Health Care Classification System (Saba, 1992). Knowledge of these nationally recognized nursing practice classification systems enables the practicing RN to advocate strongly for inclusion of nursing terms in the EHR. Other disciplines are not prevented from using these terms, nor is nursing prevented from using the terms of other disciplines. The power of the computer makes it very easy to establish common terms, add in terms that reflect a specific discipline, and conduct linkages to classification schemes behind the scenes. That is, the practitioner works only with the terms that are familiar and appropriate to his or her practice. Making sure the terms used are linked appropriately to nursing and other classification schemes is done by the computer, not the practitioner.

Substitution.

There is a growing concern among practicing RNs that the rapid adoption of healthcare information technologies will lead to the substitution of the technology for the human aspects of nursing. This concern is especially strong in the growing use of telecommunications technology for connection with geographically remote clients (telehealth). Many home healthcare services are using telecommunications to monitor the health status of their clients, thus decreasing the number of personal home visits by RNs. (It is interesting to note that this concern also is expressed by non-nurse healthcare practitioners.) The ANA and other nursing organizations strongly advocate that information technology is a tool to facilitate health care, not a substitute for in-person contact with the registered nurse. RNs participating in telehealth activities must be alert to and resist efforts to overuse the technology and under use the nurse. This issue is linked with the previously noted issue of the need for nursing terms to be included in EHRs. By having the data that demonstrate the improved outcomes when registered nurses regularly visit the client in the client's home setting, RNs are better prepared to counter the wholesale substitution of technology for professional practice.

1. A data set is a collection of terms or data elements organized to capture specific information.

Documentation.

For years, nurses, nurse executives, health policy analysts, health economists, advocates of the EHR, and many others have decried the vast percentage of professional nursing practice that is dedicated to documentation. Nursing documentation has been stigmatized as burdensome, excessive, and of little use or interest to others. It is not surprising that practicing RNs view documentation as a low priority item. As noted earlier, the adoption of an EHRS potentially will reduce much of the documentation burden. However, RNs must be careful that they do not give away the important aspects of nursing documentation in the rush to embrace EHRS benefits. As noted in the discussion of data sets, it is the documentation of nursing practice using nursing terms that will enable nursing to demonstrate its contributions to the quality of healthcare provided and to client and fiscal outcomes. As outcome-based measures of performance become increasingly adopted in healthcare, accurate and comprehensive documentation of nursing practice will be essential to maintaining and increasing nursing's influences within institutions and in health policy decisions. Thus, nurses need to resist the elimination of comprehensive nursing documentation for a short-term gain, but a long term loss. Documentation must be seen as a critical component of nursing practice, not an afterthought.

Focus on the technology and not the client.

Whenever new technologies are introduced, there is a very human tendency to divert one's focus to the technology. In nursing practice, this is a professional risk as it means less attention to the client with whom the nurse has a therapeutic relationship. That therapeutic relationship and the effectiveness of the nurse's practice may be diminished if the nurse cannot integrate the information technology into his/her practice in a seamless fashion. To counter this risk, each RN must be sensitive to its possibility, be on the alert for the diversion of focus, and work with the technology so that one is very comfortable with it. A high degree of comfort will lessen the amount of attention that must be given to the technology and will keep it as a tool to facilitate the practice of nursing.

Potential for negative evaluation of nursing practice.

Having practitioner and client data readily available for analyzing performance via client and fiscal outcomes means that nurses and nursing service units may be assessed as not performing up to expectations. This can be very scary to RNs, especially if such assessments are used in a punitive fashion. Enlightened organizations will use performance assessments to analyze what components of the healthcare organization are contributing to the performance problems and will work to resolve them (i.e., no blaming). This is the perspective that is supported by the federal government and by leaders in quality improvement methods. However, not all organizations are enlightened, and the fear felt by many RNs is valid. Nurses need to know what the performance expectations are for individual practitioners, nursing service units, and their organization as a whole. They need to demand this information for their own survival. Once this information is available, nurses might use it to do self-appraisals and to assess their nursing unit's performance and identify structure and process problems affecting that performance. Then, they can be proactive in seeking resolution of the problems and in developing strategies to meet performance expectations. Nurses also need to evaluate the performance expectations within the context of nursing's Code for Nurses (American Nurses Association, 1985), the Standards of Clinical Nursing Practice (ANA, 1992) and their scope of practice as delineated in their state nurse practice act. If the performance expectations are in conflict with these measures of nursing practice, nurses need to work with their organization to bring the performance expectations in line.

Physical safety.

Healthcare information technologies use many different devices in the collection and processing of data and information. Many of these devices are placed in institutional spaces which were not designed for computers or other electronic information devices. Often, the result is increasingly cluttered client care areas and awkward positioning of the devices for use by practitioners. Nurses may be forced into uncomfortable body positions for varying amounts of time. Back injuries from awkward placement of devices, neck strain from observing wall mounted display units, and hand and wrist problems from extended keyboard use are some of the potential physical risks. Further, the electronic nature of the devices poses potential safety risks to clients and to practitioners in the form of electric shocks and interference with implanted or external client care devices (e.g., pacemakers). Here, nurses need to be advocates for themselves and for their clients in seeking proper placement of electronic information devices and in obtaining information that the devices have been tested successfully for safety in a healthcare setting.

Legal Risks.

The legal risks discussed here are not a comprehensive discourse, but are significant issues about which RNs must be aware. These include documentation, over dependence on information technology, failure to use available information technology, and protection of privacy and confidentiality. As these technologies become more widely adopted, there will be increasing knowledge about the legal risks associated with them and pro-active preventive strategies for registered nurses.

Documentation.

Earlier, the information technology documentation-related risks to the nursing profession were discussed. There also are potential legal risks to the adoption of new documentation methods. Again, the comprehensiveness of nursing documentation and its relevance to the client's health are critical. If the terms that are incorporated into the EHR are not appropriate for describing what the nurse does and how the client responds, then there is an absence of evidence that what should have been done was done. This goes back to the old adage: "if it isn't written down, it wasn't done." With the trends to reduce the quantity of nursing documentation and the emergence of methods such as "charting by exception," nurses face increased risk of not having the evidence they might need to defend themselves in the event of legal actions. Complete and comprehensive written policies and procedures regarding new documentation models must be established before implementing a new charting method. One protection for RNs is to know and scrupulously follow those policies and procedures. Another is to inquire about the legal status of any new documentation model. Still another might be to point out the loss of client information that might explain variances in outcomes and costs if a new method is adopted.

Over-dependency on information technology.

Computers and the amazing things they can do lead many people to believe that information produced from a computer is always accurate and that computer-generated recommendations are far superior to human-generated decisions. This leads to over-dependency on the EHRS for clinical decision making. Information from the EHRS may not be critically analyzed or placed in the proper context. As a result, incorrect care decisions may be made. At a minimum, these decisions will delay the correct care and, at worse, they may directly cause harm to the client. In these instances, the nurse may be held liable for the harm. RNs must remember that computers are made and programmed by humans and that the data entry into the EHR is done primarily by humans. Computer error and human error are a constant possibility. No matter how sophisticated the information technology, the healthcare practitioner ultimately is responsible for final analysis of the information and for the clinical practice decisions made on the basis of the available information.

Failure to make use of information technology when available.

Just as there can be legal risk to over-dependence or faith in computer-based information technology, there can be similar risk when a practitioner fails to make use of available information technology. This is especially true when making practice decisions. For example, if nursing decision-support software is available, a nurse does not use it, and an incorrect diagnosis or intervention plan is made, there is potential liability. When there is access to scientific knowledge bases that would improve the accuracy of the practitioner's clinical decisions and the RN does not access those knowledge bases, there is greater legal risk in the event of an incorrect and harmful decision.

There is a fine balance between over-dependency on and non-use of available information technologies. As always, the RN is accountable for his or her decisions and actions and must make the determination of when to use the technology and when not to use it.

Privacy and confidentiality.

This is both a professional and a legal issue. RNs are ethically bound to protect the privacy and confidentiality of client information (ANA, 1985). However, the ubiquitous presence of information technology in health care increases the possibilities that client privacy and confidentiality may be breached and thus increases the legal risk to RNs. Computer systems actually are more secure than the paper health record, despite the attention given in the news media to computer system security breakdowns. Ibis does not mean they are impermeable, however; every institution which stores client information in a computer system has an obligation to use the best safeguards available to prevent unauthorized access from outside the institution. But inside a healthcare setting, it is the people who have to ensure that client and practitioner information is protected. This can be as simple as safeguarding assigned passwords (e.g., don't share it with anyone!). Each RN needs to sign off from the computer when done. This will prevent unauthorized access and the linkage of a practitioner's name with whatever an unauthorized user might do. Nurses must remember that the EHR is not the only information technology in use, as well. Telephones and facsimiles are used almost constantly to communicate client information. Thus, the person transmitting this information must make sure that the connection has been made with the right person or office and that transmitted materials are not left lying around. Non-professional staff need to be educated about the privacy and confidentiality aspects of using information devices.

Electronic health records (EHR) and electronic health record systems (EHRS) are increasingly present in nursing practice settings. These information technologies come in many shapes and sizes and may be stationary or mobile. Their adoption by nurses and other healthcare practitioners portend great changes in the nature, structures, and processes of healthcare delivery. Along with these changes comes the potential for great rewards that improve nursing practice, nursing administration, healthcare research, and client outcomes. Most of these rewards are still potential rewards, as the dissemination of EHRs and EHRS has moved slowly. Nonetheless, the rewards can be expected. Of course, there are concomitant professional and legal risks to the introduction of new technologies and practices. Nurses must be aware of these risks and be pro-active in devising solutions to minimize or prevent their occurrence. Cooperation will enable nurses to take advantage of their proportionally greater presence in healthcare settings, their positive status with the public, and their historic advocacy for the client to enact the solutions they devise.

American Nurses Association. (1985). The code for nurses with interpretive statements. Kansas City, MO: American Nurses Association.

American Nurses Association. (1992). Standards of clinical nursing practice. Washington, DC: American Nurses Publishing.

Computer-based Patient Record Institute. (CPRI). (1996). Computer-based patient record system. Description of functionality. Schaumburg, 10L: Computer-based Patient Record Institute.

Dick, R., & Steen, E. (Eds.). (1991). The computer-based patient record. An essential technology for health care. Washington, DC: National Academy Press.

Martin, K., & Sheet, N. (1992). The Omaha System: Applications for community health nursing. Philadelphia: W.B. Saunders.

Milholland, D.K. (1996). Information technologies for clinical nursing practice. Emerging hardware/software support for staff nurses. The American Nurse, 96 (28), 2-3.

Milholland, D.K., & Heller, B.R. (1996). The computerbased patient record. In R. Mills, C. Romano, & B.R. Heller, (Eds.), Information management in nursing and health care (pp. 138 - 143). Springhouse, Pa.: Springhouse Corporation.

McCloskey, J., & Bulechek, G. (Eds.), (1992). Nursing Interventions Classification (NIC): Iowa Interventions Project. St. Louis: Mosby.

North American Nursing Diagnosis Association. (1992). NANDA Nursing diagnosis: Definition and classifications. St. Louis: Mosby.

Saba, V.K. (1992). The classification of home health care nursing diagnoses and interventions. Caring Magazine, 11(3), 50-57.

Weed, L.L. (1968). Medical records that guide and teach. New England Journal of Medicine, 12, 593-600, 652-657.

Werley, H., & Lang, N. 1988. Identification of the nursing minimum data set. New York: Springer.

Zielstorff, R.D., Hudgings, C.J., & Grobe, S.J. (1991). Next-generation nursing information systems. Essential characteristics for professional practice. Washington, DC: American Nurses Publishing.

D. Kathleen Milholland, Ph.D., RN, was previously a Senior Policy Fellow, Nursing Practice Health Policy, Department Of Nursing Practice, American Nurses Association. Washington, D. C. (This chapter is an original work. The opinions and ideas expressed herein are not necessarily those of the American Nurses Association.)

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Cochran, M. (May 1999). The real meaning of patient-nurse confidentiality. Critical Care Nursing Quarterly, 22(1), 42-51.

Habel, M. (January 31, 2000). Continuing education. Documenting patient care, part II: limit liability, trends and computer charting. Nurseweek, 13(3), 14-16.

Korn, K. (April 1999). Computer comments. Professional liability and risk management information on the internet. Journal of The American Academy of Nurse Practitioners, 11(4), 165=166.

Tidd, C, Reilly, B. (August 1999). Compliance, control & computers. Caring, 18 (8), 28-31-34-35.

RNs, Risk, and UAP

In the delivery of nursing care to patients, there have always been assistants to the nurse. It is probably impossible to deliver nursing care without the proverbial "extra pair of hands." These assistants or unlicensed assistive personnel (UAP) are "individuals who are trained to function in an assistive role to the registered professional nurse in the provision of patient/client care activities as delegated by and under the supervision of the registered professional nurse" (ANA, 1996). They work in a variety of settings including hospitals, clinics, nursing homes, home care agencies, hospices, and private practices and can be identified as nursing assistants, nurses' aides, patient care technicians, nurse extenders, nursing associates, certified nursing assistants, or home health aides; (The latter two titles are in federal statute.)

There is nothing intrinsically wrong with nurses needing assistance in delivering care. The difficulty for registered professional nurses and licensed practical nurses arises when certain tasks are included in the job descriptions of unlicensed assistive personnel that many nurses believe constitute the legally-protected scope of the practice of nursing. Nurses fear that there may be adverse consequences for their patients and themselves if they permit a UAP to do the identified task or teach a UAP to perform particular aspects of patient care. Nurses also fear the consequences of failing to supervise the UAP in delivering care and in ensuring that there is a positive outcome for the patient. Nurses also express concern about possible professional disciplinary and malpractice charges arising from working with UAP.

There are many changes occurring in health care: managed care is increasingly more powerful; mergers and networks are changing the face of the industry; federal, state and local governments and private payors are increasingly reluctant to provide the money to support healthcare; and technology is rapidly changing diagnostic procedures and therapies. The settings in which healthcare is delivered are being modified as hospitals become intensive care centers for sicker and more acute patients, and ambulatory, home care, and long term care settings are caring for patients that a few years ago would have been in a traditional tertiary care center. The patient has not disappeared, just moved to another locale. There is still a patient needing care, and because of the multiple factors of time, acuity, and complex need, the patient may more than ever before require professional nursing care.

In response to these various economic, governmental, and business pressures, the healthcare industry has sought to restructure its facilities, downsize its work force, and reengineer the workforce by increasing the utilization of unlicensed assistive personnel and refocusing the role of nurses to supervise the tasks and care provided by these workers. This increased use of UAP to perform nursing duties is occurring in many instances without evidence of the need for changing the care delivery model or research to evaluate the possible outcomes of such changes. In its recent study on staffing in acute care facilities, the Institute of Medicine (IOM) was particularly concerned about the possibility that healthcare facilities were creating an industry-wide experiment (IOM, 1996). Where studies can be identified, they tend to be anecdotal in nature and frequently limited to a single institution or are drawn from a very small sample. The main factors examined are nurse satisfaction with the UAP role, the outcomes and quality of care, productivity and costs, and patient satisfaction. While VAP were originally added to nursing staffs to complement the nursing care delivered by licensed nurses and to perform non-nursing functions, in the most recent studies it is clear that the UAP are being used to substitute for the nurse (Krapohl & Larson, 1996) and it is this shift that so concerns the IOM and many nurses.

Nurses are very familiar with working with others in delivering care. Whether involved in a collaborative practice model or in more traditional care teams, nurses have a long history of delivering care to a variety of patient populations in conjunction with others. When using UAP in today's environment, the focus should be on clarifying that UAP can only be used in roles that support the RN's or LPN's practice and that in no circumstances can a UAP substitute for a licensed nurse or provide total patient care. "Nursing is a knowledge-based process discipline and cannot be reduced solely to a list of tasks; the licensed nurses' specialized education, professional judgment and discretion are essential for quality nursing care" (National Council of State Boards of Nursing 1995, p. 2). The American Nurses Association recognizes that "unlicensed assistive personnel provide support services to the RN which are required for the registered nurse to provide nursing care in the healthcare settings of today. Any nursing intervention that requires independent, specialized, nursing knowledge, skill or judgment cannot be delegated" (ANA, 1992).

It is imperative that one understand the authorization for the practice of nursing and the legal and professional responsibility for that practice. In all of the states in this country, the practice of nursing, as well as many other healthcare professions, is addressed in state statute and in a variety of rules, regulations and legal interpretations. There is no single model for a nurse practice act and this sometimes adds to the confusion across the country as to what nursing care must be done by licensed nurses and what tasks can be performed by unlicensed workers. Generally, states have specific definitions regarding the practice of a registered professional nurse (RN), a licensed practical/vocational nurse (LPN/LVN) and, in some states, advanced practice nurses (e.g. nurse practitioners, clinical nurse specialists, nurse midwives, nurse anesthetists). RNs in all states are independent practitioners of nursing and are not required to be supervised in the care that they render, while licensed practical nurses are dependent practitioners and by law are required to be supervised in most cases by RNs, physicians, or other categories of independent healthcare practitioners. It is a professional responsibility to be knowledgeable of one's nurse practice act; ignorance of the law is no defense in any disciplinary action (Green, Caddy, Waddell & Fitzpatrick, 1995).

It is clear that the states license nurses and other healthcare practitioners for two main reasons: to protect the public from harm and to permit the practitioner to practice within a legally-defined and protected scope of practice. The states have various administrative bodies such as boards of nursing to oversee the practice of its licensed practitioners. These state agencies regulate the practice of nursing and interpret the various statutes, rules, and regulations of the state regarding legally-protected scope of practice. In discharging the state's responsibility to protect the public from harm, the state's licensing authority determines what level of licensed practitioner or unlicensed person can perform a particular task.

In an attempt to clarify the relationship between nurses and unlicensed assistive personnel, considerable attention has been placed on understanding the processes of delegation, assignment, and supervision. Although these processes have similar meanings in most states, at least two states, California and New York, have either different definitions or particular prohibitions. Nurses practicing in these two states should familiarize themselves with the differences. There is nothing magical with the concept of delegation and it should not be considered universal protection against risk of malpractice and/or professional discipline. Registered nurses would be better served to remember that they are always responsible for permitting only individuals that they know are prepared by licensure, education, training, or competency to provide care to patients.

When planning care, an RN must match the right practitioner or worker with the patient and the patient's need. Ethically and legally, if an RN lets another RN or LPN care for a patient whose needs exceed the RN's or LPN's competencies, the first RN is just as guilty of unsafe practice as an RN who permits a UAP to perform a task that only a licensed person should perform. The National Council of State Boards for Nursing has recognized this responsibility in its Five Rights of Delegation:

• Right Task: The task is appropriate for delegation;

• Right Circumstances: The appropriateness of the patient setting, available resources, and other relevant factors are considered;

• Right Person: The right person is delegating the right task to the right person to be performed on the right person;

• Right Direction/Communication: A clear, concise description of the task, including its objective, limits and expectations is given; and

• Right Supervision: Appropriate monitoring, evaluation, intervention, and feedback are provided (NCSBN, 1995).

Both the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN) have attempted to provide additional direction in this arena by addressing the processes of delegation, assignment, and supervision. To NCSBN, "supervision is the provision of guidance/direction, evaluation and follow-up by the licensed nurse for the accomplishment of a nursing task delegated to unlicensed assistive personnel" (1995, p. 2). ANA provides a broad definition of supervision as "the active process of directing, guiding and influencing the outcome of an individual's performance of an activity or task" (1996, p. 13) and describes it as either on-site ( the delegator is physically present and available) or off-site (guidance is delivered through written, verbal, or electronic communication) (1996). Such clinical supervision is the 44 active process of directing, guiding and influencing the outcomes of an individual's performance of an activity or task" (ANA 1996, p. 13) and should not be confused with the definition of supervision in labor law that relates to individuals eligible for representation for purposes of collective bargaining.

NCSBN identifies delegation as the act of "transferring to a competent individual the authority to perform a selected nursing task in a selected situation in which the nurse retains accountability for the delegation" (NCSBN, 1995). The Council further cautions that inappropriate delegation or unauthorized practice of nursing tasks by a UAP may lead to legal action against the licensed nurse and/or UAP (NCSBN, 1995). ANA states that "delegation is the transfer of responsibility for the performance of a task from one person to another. The delegation of an activity passes on the responsibility for task performance but not the accountability for the process or the outcome of the task" (1996, p. 15). ANA further addresses what it categorizes as direct delegation (a specific, usually verbal, direction from the delegator for another person to perform a task/activity in a specific nursing care situation) and indirect delegation that involves using a list of tasks/activities that have been approved by the healthcare facility (ANA 1996). Since what types of tasks can be delegated differ across the states, nurses must be knowledgeable of their particular states' permitted and prohibited tasks.

In discussing assignment, ANA describes this activity as the shift of an activity or task from one person to another, and this shift includes both the responsibility and the accountability for the performance of the task/activity (ANA 1996). Assignment occurs between individuals of equal or similar skill, education, knowledge, and competency and involves tasks/activities within the person's scope of practice (RN:RN; LPN:LPN). Licensed healthcare practitioners whose legal scope of practice overlap may assign those tasks or activities that are shared (RN: LPN; RN:RT; RN:PT). As previously mentioned, these definitions of delegation and assignment are not applicable in California where differing definitions are in statute or in New York where a prohibition against delegation of nursing care is found in the unprofessional conduct regulations.

In addition to ANA's and NCSBN's statements, the specialty nursing organizations have rendered a variety of opinions on the use of unlicensed assistive personnel and the role of the professional nurse. Some of these statements include:

• American Association of Critical Care Nurses: AACN has established a competency-based curriculum for UAP and stresses that the RN must oversee the knowledge, skills, competency, and outcome-based evaluation of the program.

• American Association of Spinal Cord Injury Nurses: AASCIN has stated that the RN is responsible for practicing within the boundaries of the state's practice act and cannot delegate professional duties. Budgetary and resource considerations are not valid reasons for wrongful delegation. A UAP who does legally permissible nursing tasks should be under the direct supervision of the RN who has the authority to evaluate the UAP.

• American Nephrology Nurses Association: ANNA states that UAP must function under the state's nurse practice act, preferably with language specifically referring to the use of UAP in dialysis settings. It opposes the licensure of UAP, but supports certification of UAP in dialysis as a means of documenting a core competency level of knowledge. In the care of nephrology patients, only selected tasks should be delegated to LPNs and UAP.

• Association of Operating Room Nurses: AORN supports the delegation of nursing tasks as provided for in law and as implemented through guidelines developed by the profession. It opposes licensure or registration of surgical technologists.

• Emergency Nurses Association: ENA states that UAP in the emergency care setting must be appropriately trained, oriented and directly supervised by and responsible to professional emergency nurses.

• Intravenous Nurses Society: INA states that UAP may assist RNs in preparing equipment and recording statistics but should not be used in the role of delivering intravenous therapy.

• Tri-Council for Nursing (American Nurses Association, the National League for Nursing, Association of Nurse Executives, American Association of Colleges of Nursing): This Council has stressed the importance of using UAP in a manner that ensures appropriate delegation and assignment of nursing functions and adequate direction and supervision of individuals to whom nursing activities are delegated. The RN retains responsibility for the services provided by the personnel to whom these activities have been delegated or assigned, and RNs and LPNs are accountable for their respective individual nursing activities (ANA 1997).

While it is instructive and helpful to understand the distinction regarding delegation and assignment and the need for supervision and retention of responsibility for outcomes, what is most important is to understand that the practice of nursing is a complete and legally- protected scope of practice, and it is and always will be more than a lists of tasks. It is damaging fiction to think that one can establish lists of tasks for licensed nurses and UAP that in all circumstances will be a universal guide that will protect patients from harm and nurses from the risks of inappropriate delegation and assignment or failure to supervise. It is better to develop a clear understanding of what constitutes the legally protected practice of nursing and to never permit UAP to perform tasks that require the knowledge and judgment of nurses. Licensed nurses can acquire such knowledge by:

• becoming very familiar with the Nurse Practice Act of the state in which they practice and staying up-to-date regarding any changes in the practice act;

• learning the rules and regulations that are associated with the Nurse Practice Act, especially those addressing unprofessional conduct and illegal acts; learning the laws and regulations (federal, state, and local) that govern practice in the healthcare setting in which one practices;

• becoming familiar with institutional workplace policies and all applicable position descriptions;

• knowing the collective bargaining agreement if a union represents any of the employees and any relevant provisions regarding the protected worker and the delivery of patient care;

• understanding the expected and actual competencies of all members of the health care team (RNs, LPNs, OTs, RTs, PTs, SWs, UAP);

• maintaining knowledge of the generic and specialty professional standards of clinical nursing practice, the Code for Nurses, Nursing: A Social Policy Statement, and other applicable professional nursing publications;

• requesting an opinion from the board of nursing and sharing this information with colleagues when unsure about any particular practice; and

• seeking assistance in clarifying practice issues from the state nurses association.

The Code for Nurses stresses that professional nurses are accountable for the delivery of safe, competent care to those patients entrusted to them; this obligation is founded on the ethical principles of fidelity and respect for persons. The Code for Nurses reminds nurses that they have a professional responsibility to the public and the profession at large to ensure that safe and competent care is provided to patients, that the standards of the profession are maintained, and that the essential elements of professional nursing are not delegated to others (Code, 1985; NYSNA, 1996). Most importantly, RNs and LPNs must be aware of their individual strengths and weaknesses and when it would be appropriate and necessary to protect the patient by refusing an assignment because they lack the knowledge or skill. Likewise, RNs and LPNs must request or seek additional education and/or training to maintain competency. They should also request an orientation to working with UAP that includes learning the correct process in identifying tasks and providing supervision.

UAP do not have a scope of practice; they can assist nurses by performing health-related activities that are outside the legally- protected scope of nursing practice. Health-related activities do not require nursing skill or judgment and produce predictable results. Furthermore, health-related activities adhere to standardized procedures and can easily be assigned by either verbal direction or the use of an approved list of tasks. Such activities can include the following: activities of daily living (feeding, drinking, ambulating, turning, grooming, toileting, dressing); collecting data (vital signs, weights); collecting simple specimens (stool, urine); transporting patients; restocking supplies; clerical duties; housekeeping tasks and even some more advanced tasks such as obtaining EKGs and blood specimens.

Activities that are clearly within the legally-protected scope of nursing practice must be provided by RNs and LPNs. For example, UAP cannot be asked to perform any activities on patients whose status is unstable; activities which require assessment, problem solving, judgment, or evaluation; or activities for which the outcome is unpredictable. Generally, nursing care involving sterile technique, intravenous therapy, medication administration, and invasive. procedures are within the protected scope of nursing practice. Some states have specific laws, rules, or regulations permitting some nursing activities to be performed by unlicensed assistive personnel under special circumstances. Remember to assess the following six risk factors before permitting a UAP to perform an activity or task:

• What is the potential for harm?
• What is the condition or stability status of the patient?
• What is the complexity of the activity/task?
• Is there a potential for problem solving or innovation?
• Can the predictability of the outcome be determined?
• What level of interaction with the patient is needed for a positive outcome? (AACN, 1990)

During the process of assessing the risk factors associated with permitting unlicensed assistive personnel to perform a task, the licensed nurse (RN or LPN) is responsible and accountable for the following:

• knowing which health-related activities can be assigned to the UAP;
• completing all assessments and clinical decision making related to the patient and determining what tasks can safely be performed by assistive personnel;
• communicating the identified health-related activity appropriately to the UAP;
• providing appropriate supervision for the UAP's performance;
• determining that the outcomes of care are appropriate.

Since the UAP is hired by a health care facility, the particular facility is responsible for the following:

• developing appropriate and legally-acceptable job descriptions;
• hiring capable people for the UAP role;
• providing appropriate education and training for the UAP; conducting staff education for RNs and LPNs in working with the UAP;
• communicating information about the UAP's stage of learning and level of competency to the nurse who is responsible for supervising the UAP;
• determining the competency of the UAP;
• when necessary, terminating the UAP for substandard performance (Saskatchewan, 1992).

Most recently, there has been considerable debate about what additional activities are necessary to ensure the safe use of UAP. This debate has included proposals for standardized curricula, mandatory or voluntary certification, licensure, or registration. Currently, federal law and regulations have specific standards for certified nursing home assistants and home health aides. Some states have similar types of requirements for assistants in acute care facilities.

The problem with establishing any formal educational curriculum for the UAP, is that such an action would infer that there is a scope of activity (practice) that could be isolated and taught to the UAP. Nursing administrators should be free to determine how to use the UAP to legally assist in the delivery of care in a particular setting, making the training specific to the patient care setting. It is granted that certain settings (nursing homes and home care) already have some standardized educational requirements. Examples of some basic curriculum components that could be included in setting specific training for the UAP are: basic human needs (fluids, food, elimination, rest and sleep, physical protection, effective communication); activities of daily living (dressing and undressing, feeding, personal hygiene and grooming, toileting, locomotion, housekeeping); and psychosocial. and cultural information. These types of activities, when made specific to the needs of the patient in a specific setting will provide the nurse with the "extra pair of hands" needed to assist in caring for patients. It would also be helpful if the profession of nursing established a minimal level of formal education and basic abilities required of individuals applying for UAP positions.

To assure that there is safe use of the UAP in all patient care settings, it would be helpful to have:

• clear prohibitions in each state's laws against unlicensed assistive personnel performing care within the legally-protected scope of nursing practice;

• guidance from professional nursing organizations to support nurses in understanding how to provide nursing care with assistance from other licensed practitioners (e.g., LPNs, RTs, PTs, OTs) and UAP;

• authoritative interpretations issued by each state's board of nursing on the legally-protected scope of nursing practice within its state; and

• the development of meaningful discipline for the illegal practice of nursing by unlicensed individuals. Such discipline should be controlled by the same state agency that is responsible for the discipline of registered professional nurses and licensed practical nurses.

Increasingly, the consumer of healthcare (the patient) is becoming interested in who is providing care. Some of this interest is directly related to the ANA's Every Patient Deserves a Nurse campaign, promotion of a Patient Safety Act in the U.S. Congress, and efforts by various state nurse associations to address similar campaigns and legislative initiatives at the state level. There have also been some interesting surveys (Figure 1) that relate to consumers' and nurses' perspectives of the quality of care that is being delivered and received. In a American Hospital Association survey (1997) respondents identified the following: the quality of care has been declining; nursing is a main indicator of quality in hospital care; skilled nurses are being systematically replaced by poorly- trained and poorly-paid aides; the profit motive is behind the reduction in nursing care; and insurance companies or hospital corporations are responsible for hospitals' cutting staff at the expense of patients.

Professional nurses must ensure that patients are provi ded safe, high-quality nursing care and are not placed in harm's way. Nurses who are familiar with their state's nurse practice act, all applicable state rules and regulations, the standards of practice, and ethics of the profession and institutional policies will be well positioned to appropriately use unlicensed assistive personnel in delivering care to the patient. A clear understanding of what constitutes nursing's legally-protected scope of practice is the best protection against the inappropriate delegation of nursing care and in reducing one's exposure to malpractice or professional discipline.

References

American Association of Critical Care Nurses. (1990). Delegation of nursing and non-nursing activities in critical care: framework for decision making. Laguna Niguel, CA: Author.

American Hospital Association. (1997). Reality check. Public perceptions of health care and hospitals. [Video]. Chicago, IL: Author.

American Nurses Association. (1985). Code for nurses with interpretative statements. Kansas City, MO: Author.

American Nurses Association. (1992). Registered nurse utilization of unlicensed assistive personnel. Washington, DC: Author.

American Nurses Association. (1996).Registered professional nurses and unlicensed assistive personnel(2nd ed.). Washington, DC: American Nurses Publishing.

American Nurses Association. (1997). Summary of position descriptions related to unlicensed assistive personnel - NOLF Organizations. (Available from the American Nurses Association, 600 Maryland Avenue, SW, Suite 100 West, Washington, DC, 20024).

Green, A., Cady, C., Waddell, L., & Fitzpatrick, 0. (1995). Are you at risk for disciplinary action? American Journal of Nursing, 95 41-45.

Institute of Medicine. (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Washington, DC: National Academy Press.

Krapohl, G., & Larson, E. (1996). The impact of unlicensed assistive personnel on nursing care delivery. Nursing Economic$, 14 99-122.

National Council of State Boards of Nursing (NCSBN). (1995). Delegation: Concepts and decision-making process. Chicago, IL: Author.

New York State Nurses Association. (1996). Ethical guidelines for the utilization of unlicensed assistive personnel. Latham, NY: Author.

Saskatchewan Registered Nurses' Association. (1992). The registered nurse's scope of practice: Guidelines for decision-making and delegation. Regina, SK: Author.

Karen A. Ballard, MA, RN, was the Director, Nursing Practice and Services Program and now the Director of Practice and Governmental Affairs of the New York State Nurses Association, Latham, New York.

E. Joyce Gould, MS, RN, was the Director, Legislative Program, New York State Nurses Association, Latham, New York.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Higgenbotham, E.L. (July 2000). Advice of counsel, your responsibility when an assistant gives an injection. RN, 63 (7), 73-74.

Laben, J.K., Banks, J.G. (November 1999). Litigation against nursing homes for falls: suggested strategies for prevention. Journal of Nursing Law, 6 (3), 21-28.

Mahlmeister, L. (May June 1999). Professional accountability and legal liability for the team leader and charge nurse. Journal of Obstetric Gynecologic & Neonatal Nursing, 28 (3), 300-9.

Murphy, E.K. (January 1999). OR nursing law. RN liability exposure for delegated acts. AORN Journal 69 (1), 277-279.

FIGURE 1

Annotated List of Current Surveys Related to Consumers' and Nurses' Perspectives on Quality of Care Issues Mark A. Genovese and Warren G. Hawkes

Concern is growing about the quality of health care in the United States, according to several recent public-opinion surveys. They indicate that the public believes nursing plays an important role in the delivery of quality care. Market driven restructuring, however, has led to nursing staff cutbacks and a shortage of RNs at the patients' bedside. As a result, patients believe the quality of care they receive is declining and that consumers have lost control of the health care system. Furthermore, several studies indicate that nurses themselves share these beliefs. Below is a sample of some recent surveys on quality of care issues:

Reality check: Public perceptions of health care and hospitals (1997). [Video]. Chicago, IL: American Hospital Association.

Nothing is more important to the future of the nation's hospitals than trust, but according to this report, it seems this trust is being lost. The survey found that many patients see themselves as increasingly unable to control their own medical care and are daunted by the prospect of navigating a system they no longer understand. Researchers contacted 23,000 patients in 31 focus groups in 12 states and conducted telephone interviews with 1,000 registered voters. According to the survey, respondents:

• Feel the quality of care has declined during the past few years.
• Point to nursing as an indicator of quality in hospital care.
• Hold a strong belief that skilled nurses are being systematically replaced by poorly trained and poorly paid aides.
• Believe the profit motive is behind the reduction in nursing care.
• Blame insurance companies or hospital corporations for cutting staff at the expense of patients.

How Americans perceive the health care system. (1997).
Washington, DC: National Coalition on Health Care.

This nationwide poll of 1,011 American households found a "disturbing lack of confidence" among consumers with the state and direction of health care and concern about health care quality, cost, and coverage. It indicated consumers feel they are paying more and getting less while providers are profiting. The survey also found:

• 87% say the quality of care needs to be improved.
• 80% blame the profit motive for compromising quality.
• 72% want the government to play a role in cost containment and quality assurance.
• 80% of respondents believe something is seriously wrong with the health care system.
• Only 15% said they have "complete confidence" in hospital care.
• Only 44% expressed confidence that the health care system will take care of them.

Eye on patients: A report to the American public. (1997). Boston, MA: Picker Institute.

This survey of 23,763 hospital patients and 13,363 patients in clinics and doctors' offices throughout the nation in 1996, said consumers find the health care system "confusing, expensive, unreliable, and often impersonal." It said patients were concerned they did not have a role in making decisions about their own care, and that insurance companies were making more and more of such determinations. Other significant findings:

• 36% of hospital patients said they did not have enough say about their treatment.
• 21% of clinic patients said they were not as involved in decisions as they wanted to be.
• 33% of hospital patients said they feel poorly prepared to go home.
• 30% of hospital patients said they were not told about danger signals to watch for after they went home.

One million patients have spoken: Who will listen? (1997) South Bend, IN: Press, Ganey Associates.

Interpersonal issues such as attitude, interactive skills, and caring behavior were the factors most closely associated with the patient's overall satisfaction with a hospital and the likelihood of recommending it to others. Compiling data from 545 hospitals in 44 states, Press, Ganey received responses from more than one million patients between December 1995 and November 1996. The issues most closely correlated with likelihood of recommending a hospital were related to nursing: