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The Incredibly Easy blog will expand on selected topics presented in the print journal.
Monday, December 09, 2013

With today’s economy, an increasing number of medical institutions realize that satisfied patients are the most productive fruit. Patient satisfaction affects pay-for-performance ratings on quality of care received, which is publically reportable. Since 1999, every federally-sponsored healthcare center is required to evaluate patient satisfaction.


The Centers for Medicare and Medicaid Services partnered with the Agency for Healthcare Research and Quality to develop the Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The goal of the HCAHPS survey is to provide patients’ perceptions of care received through voluntary collection. Patients are able to rate their care as always, usually, sometimes, and never response scores. Patients are also asked to rate the facility from 1 to 10 and then are asked to endorse the hospital as definitely no, probably no, probably yes, or definitely yes scaled questions. The results provide a methodology and reporting vehicle that enhances accountability. Organizations must aim to provide excellent care, an exceptional environment, and outstanding employees.


The impact of excellence on patients is initiated upon the entrance door of your institution. The moment the patient enters, his or her hospital experience starts. If the floors are shining and employees (with their ID at the shoulder) are smiling and projecting a welcoming persona, a positive experience begins to evolve. Every department, floor, wing, and employee is responsible for providing a positive patient experience and excellent care. This message must be stressed by every administrator, supervisor, and staff member regardless of the department or rank. Every employee can be a leader who can make positive change in an institution and deliver excellence to patients’ care. 


Nurses are the critical link to outcomes. When we care for our patients, we are able to gauge their perceptions of the care received and can positively impact their experience by correcting negative practice or improving care delivery. The HCAHPS survey connects care to patient experience and provides a comparison between hospitals from a patient perspective. The impact of nursing care on patient satisfaction and outcomes has long been established but hadn’t been linked to financial incentives—until now.


So what can you do to build a culture of excellence at your facility? Education, awareness, accountability, and persistence are keys to providing excellent care and sustaining a culture of excellence.



Increasing the knowledge base of employees can both resolve knowledge deficits and result in higher patient satisfaction scores. Education includes defined indicators, such as customer service, on time appointments in clinics, on time surgery starts, minimal wait to be seen in the ED, welcoming security officers, answering the phone by the second ring, providing pain medication within minutes of the patient’s request, or providing hot food for breakfast, lunch, and dinner. All of these points are critical indicators for any patient experience. The HCAHPS survey measures patients’ experiences as we provide care.


Education should always be presented in verbal, written, and electronic formats to staff members because each person may learn new concepts differently. There must be a path developed to educate all employees. To be able to complete the education for individuals who were sick, on vacation, or attending a conference on that day, staff meetings must have an agenda and minutes taken. Attendance sheets must be 100% complete. So if a staff member was unable to attend on the day that the education in-service was held, the employer can open the in-service book, read the agenda and minutes, and sign-in on the educational session held. The goal is to reach all staff members with knowledge sharing and the message communicated 100% of the time.



Every employee, regardless of department area or rank, must be aware of the indicators or goals that pertain to his or her area and the institution as a whole. So, if we strive for excellent customer service standards, then this must be posted in visual areas of the department, which can serve as a reminder for staff members that there’s a focus of care we’re striving for or a minimal achievement standard we’re measuring. Focused visual posting creates awareness of pride for the department and serves as a common goal. Place bullet point information on lockers and in staff-physician lounges, and discuss it at staff and department head meetings. If everyone is aware that the customer service standards need to be improved, then this becomes a common goal. For example, if the focus is on environmental cleanliness, then identify key points and expectations and create measuring tools and parameters. Employees need to know what their job roles and expectations are.



All members of the healthcare team are responsible for positive HCAHPS scores. Start thinking about shared governance and interdisciplinary team building, with common shared goals and expectations. Nurses are the most frequent healthcare providers with whom patients interact, and communication is a key indicator of positive patient satisfaction. Holding each other accountable can be rewarding, and it isn’t impossible for any organization. When communication is effective, clear, and concise, there’s an opportunity to develop the healthcare partnership and produce compassion, human-based connection, and respect.


Accountability is based on the W system:

Who: Who needs to say?

When: When do they need to say?

Why: Why do the need to say?

Where: Where do they need to say?

What: What do they need to say?


Create a tool that outlines this system. For example: Who cleans? What’s cleaned (closets, floors, stretchers, vents, corridors)? When are they cleaned? Why are they cleaned? Where are they cleaned? Each checkpoint must have a lead person who has been educated on this system of accountability.



Persistence deals with finding the ways to impact change. A path to excellence may have many twists and turns, but the destination must always be seen. It should involve not many departments, but ALL departments. Not some staff, but ALL staff. Being persistent in achieving goals is the actual road to excellence.


Sour apples

Let’s briefly talk about “sour apples” or those staff members who are negative. This is the staff member who never has anything positive to say. The idea to get these employees involved is an important accomplishment. Every negative comment is required to be followed by a solution. Ask your colleagues for their recommendations. Tell them you want their feedback for a possible answer to the problem. Every problem or complaint needs a potential improvement and solution plan. After you institute this rule, complaints will come with potential solutions and staff involvement will develop.


The road to excellence is an interdisciplinary process, involving all departments of patient care and every discipline. Building a culture of excellence isn’t an impossible task; rather, it’s a rewarding achievement that every nurse, department, and organization can attain. The stronger our understanding of excellence, the higher the awareness, and the more robust the persistence, the greater the achievement.



Agency for Healthcare Research and Quality. HCAHPS fact sheet. http://www.hcahpsonline.org/files/HCAHPS%20Fact%20Sheet%20May%202012.pdf


Agency for Healthcare Research and Quality. Theory and reality of value-based purchasing: lessons from the pioneer. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/meyer/index.html.


American Sentinel University. Effective nurse communication key to patient satisfaction in health care system. http://www.prweb.com/releases/Nursing/hcahps/prweb9760519.htm


Bombard CF, Jordan CE. HCAHPS is all about patient satisfaction. http://ce.nurse.com/content/ce559/hcahps-is-all-about-patient-satisfaction/.


Kutney-Lee A, McHugh MD, Sloane DM, et al. Nursing: a key to patient satisfaction. Health Aff (Millwood). 2009;28(4):669-677.


By Eleonora Shapiro, DNP

Vice President of Perioperative Services

Mount Sinai Hospital

New York, NY

Tuesday, August 06, 2013

A temporal artery thermometer (TAT) is a portable, noninvasive, painless device that measures temporal artery blood temperature by scanning the overlying skin surface with infrared technology. As the scanning wand is firmly swept against the skin surface, it accurately measures both the temporal arterial blood temperature and the skin surface temperature. This process is called arterial heat-loss balance. Each second the wand remains in contact with the skin, it records 1,000 temperatures per second. It combines the average of these recordings, and the TAT software processes the result on a digital LED display in the form of a number. TATs are very efficient, providing results within an average of 6 seconds.


TATs can be used on all age groups, from newborns to geriatric patient populations. Medical grade TATs cost an average of $500 dollars, but less expensive in-home alternatives are available at most pharmacies and large retail stores. Although they can be utilized on newborns, new research has shown that TATs are slightly less reliable in infants less than age 3 months when compared with rectal temperature measurement. According to the manufacturers, TATs recognize changes in temperature quicker than axillary, oral, or rectal methods. However, unlike rectal thermometers, TATs cause no physical discomfort and can be utilized on a sleeping child without waking him or her.

To obtain an accurate reading, ensure that your patient’s skin surface is dry and intact before scanning. If perspiration or tears are present on the skin surface, it will result in a false low reading. Also, if your patient has been exposed to cold external environments, wait at least 15 minutes to allow his or her skin surface to acclimate. This will prevent a false low reading. TATs are routinely utilized in EDs, by home healthcare nurses, in physicians’ offices, and on long-term care and hospice units. Growing in popularity, TATs are now found in approximately 60% of all healthcare facilities nationwide. The general consensus to date is that TATs are accurate and painless tools to obtain temperatures.


The TAT is a lightweight, wand-like device that fits easily in one hand. It has a curved scanning tip sensor that’s gently moved snugly against the skin to obtain an accurate temperature. Most TATs are made of medical-grade plastic or stainless steel. TATs use an infrared scanner to measure the temperature of the temporal artery. The temporal artery begins in the forehead and runs parallel to the front of the ear, where it branches into the superficial temporal artery behind the ear and the carotid artery in the neck. The TAT captures heat that’s naturally released from the skin over the temporal artery. Because arteries receive blood directly from the heart, this is a good option for detecting core temperature without being invasive.

In healthcare settings, thin, disposable, single use, latex-free scanning probe covers can be used. Utilizing disposable probe covers reduces the risk of hospital-acquired infections. Even when disposable probe covers are used, you should ensure that the TAT is thoroughly cleansed between patients to reduce the likelihood of cross contamination. When cleansing the TAT, follow your healthcare facility’s policy and the manufacturer’s cleaning instructions. Most TATs are maintained in an electrical docking station to keep the battery of the device powered at all times. Some versions of the TAT can also use either a replaceable or rechargeable 9 volt battery to provide power.


Follow these directions when using a TAT to take a patient’s temperature:

Provide privacy and explain to your patient and his or her caregiver (if necessary) that you need to assess his or her body temperature. Providing privacy will allow the patient or caregivers to ask any questions they have about the procedure.

If the patient is a child, allow him or her to see and touch the TAT. This will usually engage the child and reduce any anxiety he or she may be experiencing.

Inspect the patient’s forehead and neck to ensure that there’s no visible perspiration present. Perspiration can cause a false low result.

Wash your hands and don gloves.

Visually inspect the TAT device to ensure that it’s clean and in working order.

Apply a disposable probe cover to the scanning tip if your facility uses them.

The TAT can be used in either the sitting or lying position. However, ideally your patient will be in a sitting position to reduce your risk of a back strain injury.

Firmly press the “scan” button.

Apply the scanning tip sensor gently across your patient’s forehead, behind the ear, and down the neck in one slow, fluid movement, ensuring that the scanning sensor remains in contact with the skin for a minimum of 6 seconds to obtain an accurate reading.

A digital reading will appear with the temperature result on the display window.

Discard the disposable probe cover in the waste basket.

Cleanse the TAT scanning wand and sensor per your facility’s policy and the manufacturer’s instructions.

Place the TAT back in its proper storage place so that other nurses can access it if needed.

Discard your gloves and wash your hands.

Record the temperature result in your patient’s medical record.

If your patient’s temperature is low or elevated, inform the healthcare team immediately.

The TAT is a painless and cost-effective tool you can utilize to accurately and quickly (within 6 seconds) assess temperature in patients of all ages in outpatient or inpatient settings. Talk with your healthcare team to see if a TAT would be a beneficial addition to your work area


Carleton E, Fry B, Mulligan A, Bell A, Brossart C. Temporal artery thermometer use in the pre-hospital setting. CJEM. 2012;14(1):7-13.

Carrigan J. How do temporal artery thermometers measure up? http://www.nursinglibrary.org/vhl/handle/10755/162372.

Jefferies S, Weatherall M, Young P, Beasley R. A systematic review of the accuracy of peripheral thermometry in estimating core temperatures among febrile critically ill patients. Crit Care Resusc. 2011;13(3):194-199.

Penning C, van der Linden JH, Tibboel D, Evenhuis HM. Is the temporal artery thermometer a reliable instrument for detecting fever in children? J Clin Nurs. 2011;20(11-12):1632-1639.


By Denise Landon, BSN, RN, CMSC

Direct Care Nurse • VA Outpatient Clinic • Clarkesville, Tenn.


Melinda Dickens, LPN, SN

LPN • Alvin C. York VA Medical Center • Murfreesboro, Tenn.


Charlotte Davis, BSN, RN CCRN

CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.

Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.

Monday, May 06, 2013

When broaching the subject of honoring your patient’s final wishes regarding end-of-life care, choose your words carefully. Words are powerful things! They have the power to leave lasting wounds, without leaving any external sign of trauma. When families hear the words “withdrawal of care,” they often associate it directly with taking something “away” from their loved one, rather than actually honoring their loved one’s final wishes. In that moment, they’re already having their loved one “taken away” by disease, illness, or trauma for which they may have had little time to prepare. They often feel as if they’ve lost control and are helpless. They may feel that if they elect hospice, palliative care, or comfort care that they’re in essence “giving up” on their loved one. Consider telling the family about giving their loved one the final “gift.” The “gift” is a way of communicating an option that conveys the family’s control over a situation they likely is beyond their control.


In situations such as this, I’ve told many family members that the last gift they can give their loved one is “letting them go” in peace, surrounded by family and friends. This gift comes from the heart, from the memories the family recounts and in honor of what they know their loved one wants. It’s the kindest, most unselfish, and also the most gut-wrenchingly difficult gift they’ll ever give anyone. For some families, they’ll never reach a point where they can give this final gift to their loved one. And that’s 100% okay. Reinforce to the family that the nursing team will be there to support them no matter what their decision.


I’ve found that when emotions run high, if the family is given ample time to reflect on what I’ve said, they’re more inclined to adhere to the patient’s wishes. The gift of letting the patient go and honoring his or her last wishes regarding end-of-life care can bring emotional closure to families. I’ve found that by carefully proposing the option of the “gift,” rather than “withdrawal of care,” the emotional turmoil of all involved may be eased. No matter what the family’s decision, our job is to provide support to the patient and family during this difficult process.


By Charlotte Davis, BSN, RN, CCRN

CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.

Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.

Wednesday, April 03, 2013

If you suspect that your patient lacks sound decision-making capabilities, consult with the healthcare team to ensure a comprehensive exam is performed. Healthcare team members that should be included in this exam are psychiatrists, nurses, social workers, chaplain services, and primary care and consulting physicians. They’ll evaluate each patient’s case individually to explore the patient’s reasons for refusing life-sustaining treatment and to ensure that the patient fully understands that refusal of life-sustaining treatment will result in death.

If your patient is found to be not competent to make medical decisions, the healthcare team will assess him or her for potential reversible causes, such as profound dehydration, depression, pain, drug combination interactions, and adverse reactions to new medications. Treating these causes may restore competence.

Many healthcare facilities offer the assistance of an ethics committee to direct the healthcare team in situations where the critical or terminally ill patient is deemed incompetent and there are no available family members or surrogates to make decisions when prolonging treatment is futile.


Although patients usually choose family members to make healthcare decisions for them when they become incapacitated, they can delegate this responsibility to anyone. Many patients may have a living will or a durable power of attorney for healthcare document.

A living will is a legal document that an individual uses to make known his or her wishes regarding life-prolonging medical treatments. It can also be referred to as an advance directive, healthcare directive, or a physician's directive.

A durable power of attorney for healthcare is a legal document that identifies a specific person or persons to make medical decisions for an individual in the event he or she becomes incapacitated.

In the absence of a living will or durable power of attorney for healthcare, a surrogate medical decision maker is needed. Both the living will and durable power of attorney for healthcare can be revoked at any time by a competent patient.


Ask your patients upon admission and as needed if they have a designated surrogate assigned to make healthcare decisions in the event they become incapacitated or are unable to make their own healthcare decisions. In some situations, families may quarrel over who should be granted this decision-making power. You can often help by respectfully and gently reminding the family to concentrate on what the patient wants in the event of his or her incapacitation. This may prevent the family from displacing their anxiety, sadness, or unresolved emotional feelings onto each other or the healthcare team. If family, friends, or loved ones have unresolved emotions involving the patient, it can pose a significant problem when the competent patient elects to refuse life-sustaining treatment.

The primary focus should remain centered on honoring patients’ wishes regarding their health. However, you can offer the assistance of ancillary staff, such as chaplain services, to the patient’s loved ones to help them during this emotional time. With the support of ancillary staff and the healthcare team, the patient’s loved ones often realize that the last “gift” they can give the patient is the difficult and selfless gift of letting him or her go.

If the patient is an adult, surrogates are listed in the following order: spouse, majority decision of adult children, parents, majority decision of adult siblings, or the nearest adult relative.

If the patient is a child, the surrogate is the legal guardian of the child. When the decision to withhold life-sustaining treatment for a child is made by the parents, the healthcare team has the responsibility to seek guidance from their ethics committee and legal team if they feel the decision isn’t in the best interest of the child. This conveys the healthcare facility’s commitment to ensuring the right decision is being made for the patient who’s a minor. In the extremely rare circumstance that the parents’ or guardians’ medical decisions aren't legally deemed to be in the best interest of the child, courts may appoint an independent, impartial healthcare decision maker.


After your competent patient has made the decision to refuse life-sustaining treatment, you should assume a supportive role for the patient and his or her loved ones. The care plan focus should shift from acute care treatment to palliative care maintenance of the patient’s healthcare needs. Palliative care is a holistic specialty area of healthcare that focuses on optimizing the patient’s quality of life by alleviating the symptoms, pain, and stress commonly associated with serious illnesses.

With supportive care from the healthcare team, patients can continue leading an active life filled with activities that bring them joy, such as traveling, hobbies, attending social outings with friends, or spending quality time with their loved ones. Refusal of life-sustaining treatment isn’t about death; rather, it’s about how a patient chooses to embrace his or her life.


By Charlotte Davis, BSN, RN, CCRN

CCU/CVICU Direct Care Nurse • Heritage Medical Center • Shelbyville, Tenn.

Direct Care Nurse/Charge Nurse • Alvin C. York VA Medical Center • Murfreesboro, Tenn.


Andrea M. Stone, BSN, RN

MICU Direct Care Nurse • VA Medical Center • Nashville, Tenn.

Tuesday, February 05, 2013
According to the U.S. Bureau of Labor Statistics, the number of employed nurses is predicted to grow from 2.74 million in 2010 to 3.45 million in 2020 to accommodate our expanding aging population. These numbers will lead to a 26% increase, meaning that the demand for nursing jobs—especially for experienced RNs—will grow faster than any other job sector through 2020. There’s a dramatic trend to increase nurse autonomy by ramping up nursing education. For this to be successfully accomplished, nurses must become empowered positive change agents and embrace the demands of their evolving profession by seeking out opportunities to expand their education, insight, and experience.
To effectively make positive changes in your practice and workplace, you must be in a cohesive, supportive work environment. Lack of support from coworkers and leadership teams is directly linked to low job satisfaction and decreased retention rates. Organizational leaders, management teams, and coworkers can cultivate nursing empowerment by being receptive, trusting, and supportive of nurses’ concerns and suggestions for improvement.
A recent research study followed 27 organizational leaders and mid-level supervisors for 1 year after they attended a formal leadership program to fine tune their leadership skills. Four researchers independently collected the data to obtain accurate, qualitative results. This research concluded that when organizational leaders and mid-level supervisors recognized the importance of changing their leadership style to one that’s more supportive, it resulted in increased trust and staff empowerment.
The American Nurses Association recommends that nurses become empowered by increasing their education and participating in shared governance—the practice of shared decision making between organizational leaders and nursing staff to develop safe nurse-patient ratios and protocols, create educational programs, and increase the efficiency or layout of the work area to enhance nursing job satisfaction and patient safety. Nurses are valuable members of organizational leadership teams because they have insight into organizational delays and system failures. This insight can help leaders identify innovative solutions to correct these problems while improving patient safety, care delivery, and nursing job satisfaction and meeting national benchmark standards.
Another way to become empowered is through embracing evidence-based practice (EBP). Currently only 55% of all healthcare practices are evidence driven. The Institute of Medicine’s roundtable report predicts that by 2020, 90% of all healthcare practices will be evidence driven. As nursing job roles and practice begin to be guided toward evidence-based data outcomes, you must become comfortable incorporating EBP into your daily practice. Consider forming an EBP committee with your coworkers to discuss relevant research findings that can improve nursing practice, the work environment, and patient safety.
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Jansen M, Zygart-Stauffacher M. Advanced Practice Nursing: Core Concepts of Professional Role Development. 4th ed. New York, NY: Springer Publishing Co.; 2009.
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Wilkerson BL. Specialty nurse certification affects patient outcomes. Plast Surg Nurs. 2011;31(2):57-59.
Winter M. Empowered nurses key to health care reform. http://www.healthpolicysolutions.org/2012/10/03/empowered-nurses-key-to-health-care-reform/.
By Rita Jordan, MSN, RN
GEC Nurse Educator • Alvin C. York VA Medical Center • Murfreesboro, Tenn.
Charlotte Davis, BSN, RN, CCRN
Direct Care Nurse, CCU/CVICU • Heritage Medical Center • Shelbyville, Tenn.
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The mission of the peer-reviewed journal Nursing made Incredibly Easy! is to meet the ongoing educational needs of nurses in a refreshingly original, easily understood format.

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