Nurses Key to Care Coordination

It seems each new study that examines a particular facet of nursing also reinforces the notion that nurses are the backbone of healthcare delivery in the United States.

Nurses play the leading role in delivering and coordinating care for patients, safeguarding them against medical errors, and acting as the patients' advocate at a time when patients are struggling with anxiety, fear, pain, and confusion.

The role of nurse advocate and care coordinator will only grow in coming years as the practice of medicine gets more complex, and the medical care team approach becomes more entrenched. One could argue that experienced and well-trained nurses at the bedside are as big a factor in determining healthy patient outcomes as any other component in healthcare delivery. Someone will have to lead the care team, and nurses are the obvious choice.

The common sense findings in a Robert Wood Johnson Foundation study this month underscore the importance of nurses' critical thinking skills as the key component in reducing errors and improving outcomes.   

The study by the Interdisciplinary Nursing Quality Research Initiative (INQRI) appeared in the January issue of Qualitative Health Research. The study details 10 clinical reasoning practices and processes that 50 nurses at 10 hospitals have identified to prevent medication errors.

They are:

• Educating patients about their medication;
• Considering all factors related to the patient; 
• Advocating for patients with the pharmacy;
• Coordinating care with physicians;
• Independently reconciling medications with patients' records;
• Verifying medications and doses with colleagues;
• Coping with interruptions and distractions;
• Interpreting physicians' orders;
• Documenting near misses;
• Communicating openly with physicians, pharmacists and other team members.

This is not breaking news. Everything on that list would prompt a knowing nod from nurses.

However, these findings also give those who aren't nurses a better idea of the challenges that nurses face every day and the skills they need to do their job effectively. Imagine the sum total of these 10 focus points for each patient, multiply it by the number of patients under a nurse's care at just about any time and on no particular floor, and you might have a better idea of the pressures on time that are placed upon nurses on any given 8- or 12-hour shift.

Among the most serious problems nurses continually face are missing medications and the timeliness of medication delivery, the study found. Administering medication seems simple enough until the pressures and distractions that nurses routinely face are factored in.

For example, medication delivery schedules at hospital pharmacies may not jive with nurses' work schedules. Or, the patient may be scheduled for other tests that coincide or interfere with medication times. The INQRI study found that effective strategies to ensure medication compliance included repeated calls to the pharmacy to check on medications' status, marking drugs to be given immediately, and often picking up the medications themselves instead of waiting for delivery.   

The study made clear that the ability of nurses to effectively communicate with everyone in the care continuum—from the patient to the subspecialist—is particularly important.

Coauthor Linda Flynn, RN, professor and associate dean for graduate nursing education at Rutgers, said the study "identified communication with doctors, pharmacists and other nurses as an indispensable part of preventing medication errors and ensuring patient safety."

"That means that nurses also (should) take responsibility for developing good relationships with all members of the health care team, so that when they have to locate missing medication, double-check doses or ask questions about new medications, they get the answers they need when they need them," Flynn said.

The study recommends tapping into nurses' clinical reasoning as a foundation for reducing medication errors in the care team environment. Such a program would push nurses to move beyond the "five rights" of medication administration (1. Right patient, 2. Right Route, 3. Right Dose, 4. Right Time, 5. Right medication) and to use clinical reasoning to protect their patients from harm.

The study also calls for retooling provider education to promote the team care approach. That includes learning basic errors theory and team-centered clinical problem-solving exercises.

As the study makes clear, nurses will face a variety of new challenges in the coming years as they are asked to play a greater role in patient care coordination. Everyone else in the healthcare delivery system must understand that role and must be willing to provide nurses with the support and resources they need to do their many jobs.