Kelly T. Gleason, Cheryl R. Dennison Himmelfarb
The dismal state of diagnostic errors in the medical world has recently been highlighted by the National Academy of Medicine’s report, Improving Diagnosis Healthcare (The National Academies of Sciences, 2015). Each patient in the United States health care system faces a 5% chance of experiencing a diagnostic error every year. The first goal listed in the National Academy of Medicine’s report is “Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families.” The report specifically recommends interprofessional teamwork in the diagnostic process. Historically, medical diagnosis is considered solely a physician responsibility, and teamwork in diagnosis generally refers to physicians working together across specialties. There is a pressing need to adjust this antiquated view and enlist nurses to address diagnostic error. Interprofessional collaboration has been a key principle in successful efforts to reduce therapeutic errors(Goeschel & Pronovost, 2008) and, we believe, will be equally important to diagnostic safety efforts. While there are logistical, regulatory, and sociocultural barriers to engaging nurses and other allied health professionals on the diagnostic team that must be addressed, the potential benefits of engaging them are immense.(Newman-Toker, 2016) Achieving diagnostic safety is aligned with the core values of the nursing profession to provide safe, effective, and compassionate care. The purpose of this paper is to discuss necessary steps to address barriers to nurses effectively participating in the diagnostic process.
To change the view that nurses are not diagnostic team members, several steps must be taken:
1) Sociocultural barriers: Nurses and physicians working together requires learned skills, including an understanding of roles and responsibilities, effective communication, shared values, and teamwork. Collaboration in practice results in better patient outcomes and healthcare processes (Zwarenstein, Goldman, & Reeves, 2009), and will be key achieving diagnostic excellence. There is a need for a paradigm shift in which nurses and physicians work together for the benefit of patient outcomes. Sociocultural barriers can be overcome through interprofessional education, multidisciplinary rounds, and understanding other health professionals' roles and responsibilities. Interprofessional education is required by licensing bodies of health professions and includes focus on interprofessional communication, understanding the roles of each discipline and collaborating as teams. Application of interprofessional principles should specifically focus on training opportunities related to the diagnostic process and the role of teams in achieving diagnostic accuracy. Creating structured opportunities for nurse to share observations and conclusions with diagnostic team may be a place to begin engaging nurses. Multidisciplinary rounds are increasingly common; including a discussion regarding the diagnostic process in multidisciplinary rounds would give the nurses an opportunity to present their observations and conclusions. Understanding other health professionals' roles and responsibilities is key to valuing the voice each health professional brings to the table. Nurses, physical therapists, and pharmacists are just a few allied health professionals that are not traditionally thought of as being members of the diagnostic team, though each brings an important perspective and knowledge to the diagnostic process.
2) Logistical barriers: Logistical barriers exist in managing nurses' time in their already busy schedules to give them opportunities to present their observations and conclusions to providers. While providers and nurses may be open to nurses participating on the diagnostic team, the current routine in many hospitals has the diagnostic thought process taking part separate from the nurses. Logistical barriers can be overcome by working as a team to prioritize the diagnostic process in recognition that it is currently a major source of patient harm.
3) Regulatory barriers: Regulatory barriers exist in the variable scope of practice regulations across locations. For example, within the United States, differences exist across states in nurse scope of practice regulations. More effective and timely diagnoses can be enhanced if nurses practice to the full extent of their scope of practice. The Institute of Medicine’s report “The Future of Nursing: Leading Chance, Advancing Health” (2010) highlighted the need for nurses to practice to the full extent of their education and training. Nurses play a critical role in monitoring the patient’s condition, identifying and preventing diagnostic errors, care coordination, communication, and patient education. However, there is documented evidence that nurses are not currently practicing to their full scope of practice. Addressing regulatory barriers requires: 1) working with legislators to create universal scope of practice regulations that allow nurses to practice to the full extent of their training, education, and experience, and 2) nurses understanding scope of practice regulations in their specific area.
In conclusion, diagnostic errors are an urgent problem in health care. Achieving diagnostic excellence is impossible unless nurses contribute to the diagnostic process as an equal member of the healthcare team. Nurses have not traditionally been considered diagnosticians; we have a responsibility to own our role on the diagnostic team out of commitment to providing safe, effective, and compassionate care.
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