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Break Room: What to Tell the Nurse
Deborah L. Wilson, MSN RN CRRN Sarah Zegarowski, MSN RN CRRN

Patient safety is everyone's goal. Accomplishing compliance with a National Patient Safety Goal is especially challenging when it involves a change in patient condition. Early recognition of these changes and the response of healthcare providers are critical in improving patient outcomes. Although nursing assistants (NAs) are already at the bedside and able to recognize patient changes and have been asked to "tell the nurse" about changes; we have neglected to inform the NAs exactly what nurses need to know. Through our Proactive Risk-Assessment Task Force, NAs were identified as key building blocks in the care process. We developed a low-cost, easy-to-implement tool for NAs to use, which has had beneficial effects for nurses and patients.

In October 2008 a Proactive Risk Assessment Interdisciplinary Team at Shaughnessy Kaplan Rehabilitation Hospital (SKRH) in Salem, MA, was assembled to assess compliance with National Patient Safety Goal (NPSG) 16: "Improve recognition and response to changes in a patient's condition" (The Joint Commission, 2008). The team consisted of staff nurses, respiratory therapists, physicians, quality management, nursing education, and nursing leadership. Weekly meetings were scheduled for 1 hour during a 3-month period to assess current processes at SKRH and implement an action plan.

Using the Health Care Failure Mode and Effect Analysis™ (HFMEA) the team graphically described the step and substep processes that were used at SKRH for recognizing and responding to changes in patients' conditions (DeRosier, 2002). Failure modes were identified for all subprocess steps. The process revealed that some NAs did not know what to report (such as a change in patient's behavior). On the other hand, nurses might ignore the NA and therefore not respond accordingly. The team outlined an action plan for the failure modes that were determined to be frequent and high-risk events with potential adverse outcomes.

Brainstorming sessions to generate an action plan resulted in a low-tech solution with a big impact: A "what to tell the nurse" job aid/tickler. Interestingly, our sister facility, North Shore Medical Center, had also identified that NAs were not consistently reporting abnormal patient information. Together, we created a list of routine patient data that must be reported when out of range. These data included vital signs, blood sugars, intake and output, bowel movement, dressings, pain, mental status, and skin. The information was put onto a laminated badge that was attached to the name badge for easy access and quick reference. A housewide education plan was rolled out. Badge content, the appropriate action, and follow-up were discussed with both nurses and NAs. Expectations were clearly stated. Job aid/tickler badges were distributed to the NAs.

The ticklers accomplished two things: first, they gave NAs the correct information to report to the nurse; and second, they empowered NAs to report. Having the same information reported to the nurse resulted in a uniform standard of care throughout the facility. There was permission and a mutual understanding that NAs would report all abnormal findings. Another positive outcome was that the timeliness of reporting improved. Previously, NAs would wait until they finished measuring all vital signs, all blood sugars, etc., before reporting to the nurse. With the implementation of the ticklers, NAs were compelled to immediately report any abnormalities. Immediate and accurate communication from NAs allowed nurses to intervene in a timely manner.

The expectation that NAs will "tell the nurse" promptly also creates the expectation that nurses will act immediately upon the information. The nurse is able to make an accurate assessment, apply critical-thinking skills, and intervene to prevent a crisis. Research supports the correlation between early intervention in response to clinical symptoms and a decrease in cardiopulmonary arrests. These expectations have also instilled a trust component in the nurse-NA relationship, as well as improved patient care. Patients benefit when there is clear communication and a trusting relationship between caregivers (Institute for Healthcare Improvement, 2007). For these reasons, both nurses and NAs have found the tickler badges to be a valuable and useful tool.

Initially, we thought the development of our Rescue Stat Protocol in response to National Patient Safety Goal 16 would be the key to our compliance. However, the "what to tell the nurse" tickler had a much broader application and benefit to patient care on a daily basis. From a small tool emerged big benefits. A common knowledge base was developed. Respectful communication, mutual trust, and collaboration were fostered. These concepts can be applied to other relationships across the organization, such as nurse-physician and nurse aide-nurse aide.


DeRosier, J., Stalhandske, E., Bagian, J., & Nudell, T. (2002). Using health care Failure Mode and Effect Analysis: The VA National Center for Patient Safety's prospective risk analysis system. Joint Commission Journal on Quality Improvement, 28(5), 248–267, 209.

Institute for Healthcare Improvement. (2007). Protecting 5 million lives campaign, getting started kit: Reduce surgical complications. Cambridge, MA: Author.

The Joint Commission. (2008). The Joint Commission Accreditation Program: Hospital National Patient Safety Goals. Oakbrook Terrace, IL: Author.