The recognition of nurses for their roles in diagnosis is critical to achieving diagnostic safety improvements and advancements. Contemporary recommendations from the diagnostic safety literature6-16 highlight actions nurse leaders and educators can take to improve diagnostic safety within four general domains:
- Cultivating diagnostic safety culture.
- Improving surveillance and reducing operational barriers to nurse participation in the diagnostic process.
- Enhancing nurse, patient, and healthcare teamwork and communication.
- Building on nursing educational curriculums and interprofessional education (IPE) initiatives to provide further education and training.
Domain 1: Cultivating Diagnostic Safety Culture
Nurse leaders and educators are key to creating a common purpose and commitment to diagnostic improvement within their nursing and care teams.10,17 To create this commitment, all members of the interprofessional team must first identify and adopt a common language and conceptual model of the diagnostic process.9 Physicians and other providers may be unaccustomed to including nurses in existing discussions and reviews about diagnosis. Therefore, healthcare leaders should evaluate and ensure that the diagnostic process is consistently presented as a team effort in all employee onboarding, orientation, continuing education, programs, and conferences.
Leaders can evaluate and revise everyday language and terminology to better recognize and reflect nurses’ contributions to diagnosis in their current roles and responsibilities. For example, in settings such as primary care or the emergency department, replacing the term “triage” with “diagnostic triage” is one way to acknowledge how nurses who function in these roles contribute to the accuracy and timeliness of diagnosis.10 Similarly, referring to “point-of-care testing” as “diagnostic point-of-care testing” acknowledges how nurses’ responsibilities extend beyond simply performing and initiating this type of task but also are key to diagnosing and monitoring disease.
Nurse leaders can also encourage and support nurses’ participation in patient safety event reviews, diagnostic discussions with the medical or healthcare team, and existing diagnostic societies and groups (e.g., Society to Improve Diagnosis in Medicine [SIDM]). Engaging nurses in diagnosis also helps create a culture of diagnostic safety within the extended care team.
Nurses often serve as leaders of care teams composed of certified nursing assistants, medical assistants, environmental services workers, and other staff. Thus, they are well positioned to acknowledge and elevate the contributions and roles of other team members. For example, a nursing assistant who notices and immediately informs a nurse of a patient’s low urine output can be recognized for their “good catch” and timely contributions to a new diagnosis of renal failure. Healthcare leaders are well positioned to cultivate diagnostic safety culture by proactively recognizing and celebrating the contributions that team members make to diagnosis in daily huddles, interdisciplinary rounds, and other team, staff, or leadership meetings.
Action Steps To Consider:
- Provide a visualization of the Institute of Medicine’s diagnostic process conceptual model in the staff break room and discuss with nurses and care team members.
- Listen for and endorse examples of team members’ contributions to the diagnostic process in daily huddles or interdisciplinary rounds.
- Evaluate and replace everyday terms used to describe nurses’ roles to better acknowledge their contributions to diagnosis.
- Identify a diagnostic safety nurse champion and encourage their and other nurses’ participation with SIDM or other diagnostic societies and groups.
Domain 2: Improving Surveillance and Reducing Operational Barriers
System surveillance is the “purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision-making”18 and an important nursing intervention in diagnostic safety. Surveillance depends on nurses being able to leverage technologies, access data from multiple sources, and effectively collaborate with physicians and other healthcare team members as needed.19-22 Leaders are key to improving diagnostic safety efforts by supporting nurses’ use of the new technologies, processes, and clinical information systems that enhance surveillance.19 In addition, they can work to optimize organizational features known to affect nurse surveillance capacity, such as staffing and the nurse practice environment.23
Leaders can strengthen nurses’ roles in the diagnostic process by hardwiring workflows to protect existing time (or create additional opportunities) for nurses to meaningfully collaborate and share their observations with other team members, patients, and families.4,10,24 Other action steps leaders can take to improve surveillance include formalizing use of diagnostic checklists25; encouraging nurses and other team members to report diagnostic errors; and sharing system resources that improve diagnosis (e.g., obtaining second opinions, using health informatics tools, reviewing diagnostic performance data).10
Action Steps To Consider:
- Ensure that nurses are regularly invited to and actively participate in interdisciplinary rounds or conferences.
- Develop a quick reference (e.g., one-page handout or checklist) that identifies and shares available system resources for nurses to use in improving diagnosis.
- Encourage nurses to report any identified diagnostic errors through established safety reporting mechanisms and chain of command.
- Evaluate nurses’ current work environments and identify opportunities and barriers to improving nurse surveillance capacity.
- Create regular (e.g., biweekly or monthly) opportunities for nurses and other team members to debrief on surveillance events (e.g., communication delays, rapid response calls, transitions between care providers or settings, or “near-misses”). Discuss the associated tasks and thought processes taking place during those events.
Domain 3: Enhancing Teamwork and Communication Between Nurses, Patients, and the Healthcare Team
Communication breakdowns are a leading cause of diagnostic errors.26 Nurse leaders and educators can reinforce the importance of using communication tools, such as Situation-Background-Assessment-Recommendation (SBAR),27-30 to structure communication with physicians and other diagnostic team members and reduce adverse events. Nurse leaders and educators can work with nurses to evaluate current communication processes, identify communication standards for their workflow and setting, and promote nurses’ commitment and adherence to communication best practices.
For example, leaders in ambulatory care settings can map out a typical patient’s experience from check-in, checkout, and followup and identify barriers to information sharing between team members and opportunities to close communication gaps. Similarly, nurse educators can evaluate their team’s awareness of and adherence to communication best practices and work to identify individual nurses or staff members that may require further training or support.
Nurse leaders and educators can also introduce any of the free, publicly available, and downloadable programs and training materials developed by the Agency for Healthcare Research and Quality (AHRQ) to improve diagnostic communication between patients and the healthcare team. The TeamSTEPP® for Diagnosis Improvement program,31 for example, is an evidence-based program that can be taught in classroom settings or as individual self-paced learning modules. The program introduces diagnosis concepts and skills and can help raise diagnostic safety awareness among nurses and other healthcare members.
Action Steps To Consider:
- Reinforce the use of communication tools (e.g., SBAR) to nurses and other care team members in their daily practice.
- Establish 5 to 10 minutes in huddles or staff meetings for nurses to discuss their experiences and perspectives on teamwork and communication.
- Map out a typical patient’s experience throughout the clinic or unit and identify ways to close communication gaps and achieve communication best practices. For example, solicit nurses’ feedback on the use and effectiveness of text-paging or messaging platforms; establish communication standards about how nurses share and receive feedback on patient concerns with the primary care provider; and identify workflow opportunities for nurses and other team members to review patient cases and receive second opinions.
- Introduce the TeamSTEPPS® for Diagnosis Improvement program or Toolkit for Engaging Patients To Improve Diagnostic Safety, if applicable, to healthcare providers, leaders, and staff members.
In addition, the Toolkit for Engaging Patients To Improve Diagnostic Safety32 was designed to prepare patients, families, and providers to work together as partners to improve diagnostic safety. This toolkit consists of two strategies: the Be the Expert on You Note Sheet,33 which can be given to patients ahead of a clinic visit and helps prepare them to share their personal health story clearly and concisely; and 60 Seconds To Improve Diagnostic Safety, which includes training materials to support providers in deeply and reflectively listening to patients’ stories, uninterrupted.
Domain 4: Building on Nursing Education Curriculums and Interprofessional Education To Provide Additional Diagnostic Safety Training
Many prelicensure and graduate degree programs have undertaken collaborative approaches through interprofessional education (IPE) to develop healthcare students as future interprofessional team members and better address patients’ complex medical issues.34-36 With the release of the American Association of Colleges of Nursing 2021 Essentials, it is a requirement that essential core competencies in nursing curriculums include aspects of nurses contributing as team members to diagnoses and patient safety.37
To identify knowledge gaps and improvement opportunities, nurse leaders and educators can choose among several tools and instruments to evaluate nurses’ perceptions of teamwork (e.g., TeamSTEPPS Teamwork Perceptions Questionnaire38; TeamSTEPPS Team Assessment Tool for Improving Diagnosis39). Another option is to develop surveys to assess nurses’ awareness and knowledge of diagnostic safety. Educators can also choose among several learning strategies to introduce or emphasize diagnostic safety to practicing nurses in their specific environments, thus building on the themes of teamwork and diagnosis in nursing curriculums and IPE (Table 1).
Table 1. Recommended Diagnostic Safety Learning Strategies for Practicing Nurses
|Presents key concepts initially and can be useful for later reference materials
|Limited interaction with learners; may not convey nuances of diagnostic safety; quantity of information may be overwhelming.
|Provide graphic overview of diagnostic process; distribute education newsletters and fliers to nurses.
|Good for primary explanation and clarifying diagnostic concepts
|Teacher centered, not as learner centered.
|Present diagnostic safety content in staff meetings, programs, and conferences.
|Computer-assisted instruction (e-learning)
|Good for initial instruction and future reference
|Learners may experience computer or technical difficulties in accessing or completing material; inconclusive outcomes.40
|Develop self-learning modules about diagnostic safety.
|Test-based online learning
|Helps identify gaps in knowledge and determine ongoing educational needs; provides actionable data
|Questions may be difficult to create; learners may not enjoy the learning.
|Several online platforms are available to help educators create this type of tool.
|Small group teaching session
|Increases student engagement, improves knowledge retention, and promotes peer discussion
|Can be time consuming; team members may not all participate.
|Present diagnostic safety case, facilitate discussion, and encourage a structured approach to problem-solving.
|Useful in fostering teamwork and clinical reasoning; the closest to real-life experiences
|Learners may feel put on the spot or uncomfortable; resource intensive.
|Practice assessing deteriorating patient and communicating patient assessment findings to physician.
Action Steps To Consider:
- Assess nurses’ knowledge and perceptions of teamwork and diagnostic safety.
- Use assessment results to identify opportunities for improvement.
- Focus on key diagnostic safety concepts and interventions that are essential and feasible for nurses in your specific clinical setting.
- Select and implement the most effective learning strategy for your target learners.