Both nurses and laboratorians get frustrated with each other’s behavior. Consider the following three fictional scenarios of nurses’ behavior that potentially could confound the lab and create conflict.
Scenario 1: A patient comes to the clinic for a lumbar puncture. Unrecognized by the nursing staff, the cerebrospinal fluid (CSF) specimen requirements state that no parafilm should be used after the specimen is collected. In addition, the specimen must be collected in a special container and the cap of the container must be screwed on properly to avoid loss of the specimen. Failure to follow instructions may necessitate another lumbar puncture for the patient.
Scenario 2: Nurses have been cutting off patients’ wristbands in the hospital and attaching them to the patients’ gowns or even to their beds. When the phlebotomist arrives to collect blood, she balks, since she is not certain that the patient is properly identified. She notifies her supervisor about the situation.
Scenario 3: Nurses are harried in the operating room. In particular, the nurse who is responsible for checking the identification of the blood bag for a patient who is about to receive a transfusion is fatigued at the end of a long shift. Unbeknown to the blood bank staff, nurses have been using shortcuts. In fact, they use processes and procedures that are at odds with the guidance of the blood bank pathologists in order to speed up blood administration.
In each of these scenarios, the laboratorians are horrified. How could a nurse not understand or not follow the procedures as outlined by the laboratory? What were they thinking? Our natural reaction is to admonish the nurses by sending them an e-mail and telling them to follow the correct procedure—or else!
But let’s step back from each of these scenarios, suspend judgment, and ask why the nurses may have done what they did. Let’s give them the benefit of the doubt that they are rational human beings who have their patients’ interests at heart in everything they do.
In the first scenario, the nurses may not appreciate the different specimen requirements for lumbar puncture specimens. Proactive laboratories will view the nurses assisting the physician as “step zero.” Even though specimen collection is out of the lab’s sight, laboratorians can help nurses by ensuring that they understand the significance of not properly collecting CSF specimens. Step zero is permission for us to go beyond our comfort zone—the zone of control within the walls of the laboratory—and move upstream to the zone of influence.
Laboratory-based processing and phlebotomy supervisors could consider assisting nurses to ensure that they collect lumbar puncture CSF specimens properly. We know doing so is in the best interests of our patients. After this initiative, there likely will be fewer comments from physicians and nurses that any problems with such specimens are due to “lab errors.”
In the second scenario, the laboratory supervisors and the director met with nurses, not to criticize them, but to understand why they were cutting off patients’ wrist bands. Surprisingly, they found the nurses had good reasons. For example, the nurses said that pediatric patients, edematous patients, and obese patients were uncomfortable wearing standard wrist bands, and so the nurses felt they were relieving patients’ suffering by removing the bands. And since they attached the cut-off wrist bands to patients’ gowns or bedding, they did not perceive the patients as being unidentified.
After collegial brainstorming, the nurses and laboratorians came up with two simple solutions. For pediatric patients, the team recommended softer pediatric wrist bands specifically designed for infants. For obese and edematous patients, the team recommended special expandable wrist bands. The incidence of nurses cutting off wrist bands plummeted to zero.
In the third scenario, blood bank pathologists met with operating room nurses and acknowledged the distractions, long hours, and difficult environment—while also guiding them to safe blood bank procedures. The nurses agreed that blood transfused a few minutes later was safer than giving patients the wrong blood, which could cause a fatality. The nurses appreciated the blood bank pathologist’s offer to speak to the surgeons or anesthesiologists about the safer procedures.
It is healthy for laboratorians to realize that just because a procedure is written in the laboratory, it will not always be followed as instructed. Laboratorians should meet with nursing staff in a non-judgmental setting to ask why the procedures are not being followed as written.
Us Versus Them?
Tony Kurec, MS, DLM (ASCP), and Karen L. Wyche, RN, MSN, wrote about the common misunderstandings that occur between laboratorians and nurses in a 2006 article for the Institute for Quality in Laboratory Medicine (1).
Kurec outlined 5 concerns laboratorians have about nurses:
- Nurses don’t fully appreciate quality control (QC) concerns of the lab—delays by the lab for QC reasons may be seen as “personnel incompetence, laziness of the staff, or improper specimen handling”
- Nurses call the lab instead of looking up reports, and generally call too frequently
- Salaries for nurses with a 2-year degree are higher than laboratorians’ with a 4-year degree, which can cause ill feelings
- Nurses don’t understand the technical or workflow challenges in the lab. For example, a nurse may not appreciate the multiplicative effect of an error, such as mislabeling
- Nurses may not consider laboratorians as fellow professionals
Wyche raised 5 concerns nurses have about the lab:
- Perceived poor response time to the unit for specimen collection
- Competency/skill level of phlebotomists
- Changes in policies and procedures without proper notification
- Poor turnaround time of STAT tests
- Inability to coordinate multiple tests for the same patient
Getting the Relationship Right
For our part, laboratorians should assume that most nurses come to work intent on doing a great job, and that some of their poor habits that confound the lab make sense in the context of nursing work. For example, most shortcuts seem reasonable when viewed through their lens: due to time constraints and patient considerations, nurses often borrow from one area of patient safety—which they perceive as lower risk—to add safety in another area.
Could it be that they think the lab is one place to borrow from, in order to give more to medication safety? Think about it from the nurse’s perspective: a medication mistake, like an insulin overdose or the wrong medication, could immediately harm the patient. On the other hand, lab results—except in critical care/urgent situations—usually have two safety guardrails: 1) redundant clinical information from other lab tests, physical, history, other studies; and 2) time to repeat an unexpected result in most cases.
This is why it is critical that nurses understand that certain lab requirements, such as following the protocols for identifying patients before giving blood or blood products, must be followed explicitly every time.
Laboratorians should consider working more closely with nursing colleagues to make our systems safer. Because laboratorians are adept at seeing the big picture, analyzing data, and seeing patterns and process flows, we complement our nursing colleagues, who see problems at the bedside. By strengthening the hand-offs between nursing and laboratorians, we understand and humanize each other. We begin to understand each other’s special challenges. Sometime in the future, almost all of us will end up on the other side of nursing and the laboratory as patients. Wouldn’t we all benefit from proactively dealing with these issues?
1. Kurec A, Wyche KL. Institute for Quality in Laboratory Medicine series-Controversies in laboratory medicine: Nursing and the laboratory: Relationship issues that affect quality care. MedGenMed 2006;8:52.
2. Dingley C, Daugherty K, Derieg MK, et al. Improving patient safety through provider communication strategy enhancements. http://www.ncbi.nlm.nih.gov/books/NBK43663/ (Accessed July 15, 2015).
3. O’Daniel M, Rosenstein AH. Professional communication and team collaboration. http://archive.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/ODanielM_TWC.pdf (Accessed July 15, 2015).
James S. Hernandez, MD, MS, is an associate professor of laboratory medicine and pathology, and medical director and chair of the division of laboratory medicine at Mayo Clinic in Scottsdale and Phoenix, Arizona. +Email: [email protected]
CLN's Patient Safety Focus is sponsored by ARUP Laboratories