Institute for Quality in Laboratory Medicine Series - Controversies in Laboratory Medicine: Nursing and the Laboratory: Relationship Issues That Affect Quality Care

The Institute for Quality in Laboratory Medicine (IQLM) is a new organization formed to engage the healthcare community in improving the use of laboratory tests and services. This series, brought to you by the IQLM, is intended to highlight issues and topics within the field of laboratory diagnostics that may have 2 or more points of view.

The Institute is unique. It is the only organization bringing together clinicians, laboratory professionals, patients, manufacturers, payers, government, and accrediting bodies to work on advancing substantial improvements in quality, effectiveness, safety, and appropriateness for the broad universe of laboratory testing. We hope that you find this series, published in Medscape General Medicine, equally unique and forthcoming in its multiview perspective on laboratory issues that affect us all.

The third installment in the series – “Nursing and the Laboratory: Relationship Issues that Affect Quality Care” – was written by Anthony Kurec, MS, DLM (ASCP), Administrator, University Pathologists Laboratory at the State University of New York Upstate Medical University in Syracuse, New York, and Karen Wyche, RN, MSN, Nursing Department Head, Washington Hospital Center, Washington, DC.

Five Nursing Concerns as Viewed by the Laboratory

By Anthony Kurec, MS, DLM (ASCP)

The function of the laboratory is to analyze clinical laboratory specimens and transmit these data to the appropriate healthcare provider in a timely manner. Most often, this information is communicated between laboratory staff and nursing personnel. As in any relationship, various issues arise that can influence the success and efficiency of this process. It is because of these issues that this relationship sometimes breaks down.

In canvassing laboratory personnel about nursing-laboratory interactions, the consensus as perceived by some focuses on 5 general areas. These issues are as follows and are not in any particular order:

Quality Issues

“Nurses do not fully appreciate quality control concerns of the laboratory.” As all laboratorians know, ensuring that quality control (QC) values are within established target ranges is critical yet, from time to time, can serve as the bane of their existence. When QC values drop out of range, causing delays in laboratory result reporting, anxious nurses do not always understand the reason for the delay and may place the blame on personnel incompetence, laziness of the staff, or improper specimen handling. In some situations this may occur, but it is more likely due to equipment failure, workflow issues, or some other technical problem. When explaining technical problems to a nonlaboratorian, the eyes glaze over and a sense of “losing” them is obvious. Nurses do not really care about the “why;” they just want the results.

Besides technical problems within the laboratory, QC issues arise outside of our walls and on the nursing floors. This is especially true in the areas of point-of-care testing. It seems that laboratory QC protocols, which we rely upon so heavily, are not as prevalent for nursing. Reported examples of QC issues are: not running controls as frequently as required; running glucometer controls 4 or 5 times in the hope that one of the values fall within the established range; or not performing preventive maintenance of glucometers as scheduled. It is a mystery to some nurses as to why one needs to perform and record QC as often as we do. We often hear complaints – Why can't you use reagents that are 1 or 2 days out of date? Why shouldn't you use a glucometer that has not been recently calibrated? Why do you need to record blood-storage refrigerator temperatures every day?

Another problem often encountered is unlabeled or mislabeled patient specimens as collected by nurses. Compliance in following specimen collection protocols waxes and wanes with staff turnover; thus, there is a perpetual need for training. When a nurse asks a technologist to relabel a blood tube for them, the technologist's comfort goes beyond the level of trust. Accepting on faith that a specimen is from a particular person is not an innate characteristic for most laboratorians and is viewed by some as unscientific.

Laboratory Reports

“Nurses do not take the time to look up reports.” Many laboratory technologists feel that it is a waste of their time to answer phone calls regarding test results when there is computer access and/or hard copy reports available. Frequent phone calls cause interruptions in the workflow and may even require a dedicated full-time employee to manage the phone volume. This process becomes particularly annoying when one receives 3 or 4 phone calls on the same patient within a short time. It is very frustrating for laboratory personnel to receive phone calls stating “reports were never received” or are “not in the chart,” especially when it is clear that all reports are computer generated. While it is easy to show the time and date that a report was printed from the Laboratory Information System, proving that the report was misfiled, sitting on someone's desk to be reviewed, or assisting a caller who just can't be bothered to look it up is not so easy to do.

Salaries

“Nurses make more money than we do.” The national average salary for nurses is about $56,000 (Department of Labor), while for medical technologists it is around $42,000 (Department of Labor & American Society for Clinical Pathology Wage & Vacancy Survey of Medical Laboratories). The reasons for the difference vary, but mostly it is a result of supply and demand. While this is not a fault of nursing, salary discrepancy is one of those sensitive issues that triggers a feeling of resentment among laboratorians, especially when many RNs have only a 2-year degree compared with 4-year degree that is required for medical technologists. This can underscore a subtle, negative relationship between nursing and the laboratory.

Technical Concerns

“Nurses do not understand or appreciate technical or workflow complications of a busy laboratory.” This is one of those situations where “walking in my shoes for a day” would present a greater sensitivity to what the daily work obligations are for laboratory personnel. Moreover, I am sure that the converse is true for nursing. There are dozens of problems that have to be dealt with daily that lead to frustration and low morale: QC issues, instrument breakdowns, staffing shortages, budget cutbacks, getting lab results faster, and a constant demand to do more with less.

When there is an instrument malfunction and there are dozens of patient samples on the machine to be processed, it becomes a nightmare to ensure that samples are not accidentally mixed up, that the sample integrity is maintained, and/or that STAT samples are processed quickly. The technologist is responsible for ensuring this is managed correctly, for one mistake can adversely affect a large number of patients in a single run. Yet, if a nurse makes a single mistake, the impact is usually limited to a single patient. Thus, from a nursing perspective, the magnitude of a single laboratory error and the residual impact of patient care may not be fully appreciated.

Professionalism

“Laboratory personnel are not considered professionals.” Historically, laboratories have been located in the furthest outreaches of a hospital, such as the basement or some other isolated area. In addition, the public has little or no idea what laboratorians do. And to a large degree, neither do nurses or other healthcare providers. Yet, 70% of all medical decisions are based on laboratory results. The impact that the laboratory has on patient care is profound. Yet, there is a sense of “second-class” citizenship. This perceived stigma carried by some laboratorians is a result of various factors. Most patients have little or no contact with laboratory personnel, further cloaking the laboratory in mystery. In years past, the phlebotomist was the only laboratory person visible to patients and other hospital staff, thus portraying a limited perception of a technologist's responsibilities. In the last few years, many hospitals have redesigned staffing responsibilities, including moving phlebotomy to the nursing staff. So even the phlebotomist is now a rare sight for hospital staff and patients.

Conclusion

As noted in the beginning, these are the perceptions from various laboratorians as they relate to nursing and others outside the laboratory. Most of these issues are fixable and can be resolved through better communication and understanding. There is plenty of room on both sides to raise the sensitivity to each other's plight and to realize that all are busy, yet have different but equally important agendas that must be addressed. We hope that highlighting these perceptions will provide a greater awareness of each other's needs and responsibilities, for our ultimate goal is to establish a successful team process in support of good patient care.

Readers are encouraged to respond to George Lundberg, MD, Editor of MedGenMed, for the editor's eye only or for possible publication via email: glundberg@medscape.net

Five Nursing Concerns as Viewed by the Laboratory

By Karen L. Wyche, RN, MSN

The clinical laboratory plays an invaluable role in the overall medical management of our patients. This department does an extraordinary job of ensuring safe and accurate laboratory tests. However, there is always room for improvement. To maximize patient benefits and improve the quality of care received, the laboratory would benefit from evaluating the following irritants from a nursing perspective. Here are 5 areas identified for improvement: poor response time to the unit for specimen collection; competency/skill level of phlebotomy personnel; changes in policies and procedures without proper notification; poor turnaround time of STAT tests; and inability to coordinate multiple tests for the same patient.

Poor Response Time to the Unit for Specimen Collection

The majority of diagnostic determinations and subsequent interventions provided to our patients are dependent upon laboratory test results. Delayed specimen collection leads to delayed processing, which leads to delayed treatment. Having the latest and greatest technology in laboratory equipment is practically useless if we continue to have poor response time to the unit for specimen collection. For our patients to receive the best possible care and achieve optimal outcomes, specimens need to be collected sooner rather than later so that the proper treatment can be initiated.

Competency/Skill Level of Phlebotomy Personnel

Competency and skill (technique) need to be assessed continuously. Having blood drawn is no fun. The laboratory personnel have a responsibility to educate the patient by talking them through the process and to be proficient in obtaining the blood sample. When patients are subjected to multiple attempts as a result of poor skill on the part of the technician, it produces extreme apprehension in the patient and subjects the patient to additional pain and discomfort. Often it is the nurse who has to perform service recovery on behalf of the lab by providing the patient with an explanation and other additional comfort measures. In addition, how about adding a little compassion? In a healthcare environment where volumes are up and resources are limited, everyone is busy and works under extreme pressure to streamline processes by doing more in less time. However, these patients are often anxious and frightened. A little “tender loving care” would go a long away. All healthcare personnel have a responsibility to be compassionate and caring to patients, regardless of the setting, the type of position they have, or the job requirements. Along with performance improvement comes an equal responsibility to improve quality as well.

Changes in Policies or Procedures Without Proper Notification

Occasionally the clinical laboratory will have changes in policies and/or procedures that are not always communicated to the nursing units. For example, a specimen that previously did not require ice now needs to be sent on ice. However minute this may seem, when the specimen is sent without ice, the sample is discarded. This can be very frustrating and time consuming to the nursing staff when a specimen needs to be resent, not to mention embarrassing, as the nursing staff now has to explain to the patient what happened and inconvenience the patient by obtaining another sample.

Poor Turnaround Time (TAT) of STAT Test

STAT tests are usually ordered during a medical emergency or on a compromised patient. The purpose is to gather data that will guide the healthcare team in the decision-making process. Because these patients are medically unstable, it is essential that these data be obtained in a timely matter. Part of the problem with TAT is that the definition varies across the spectrum, creating inconsistencies. Some believe that TAT is measured from the time a request is received in the laboratory department, while others believe it is measured from the time the actual specimen is received in the laboratory department. Regardless of which side of the argument one may sit on, all would agree that it is imperative that the results are obtained as soon as possible to optimize the best possible outcome for the patients.

Inability to Coordinate Multiple Tests for the Same Patient

In this current era of technology, it is almost absurd that multiple tests for patients cannot be coordinated by day or by week. As a result, some tests are either delayed or omitted altogether. On the other hand, patients may receive multiple needle sticks for what could have been resolved with one. Unfortunately, organizations and departments get caught up in regulatory and compliance issues and subsequently lose the patient as the focus.

Conclusion

The clinical laboratory does function effectively and efficiently. However, as in any area, there are opportunities for improvement. As the above concerns were reviewed, almost all of them appear to be easily addressed and improved through better communication and collaboration between the clinical laboratory and the nursing units. Improving communication through mutual respect and understanding will foster the partnerships necessary to provide safe and high-quality patient care and optimize the patient experience.

Beyond the Complaints: Working Together to Improve Laboratory Testing and Services

IQLM

You both believe these concerns may be addressed through better communication between the laboratory and the nursing units. What is the first step you would advise others in how to open and improve these communications?

Kurec

Everyone is busy, which, in part, is one reason why there are issues. Too often, “I don't have the time to address this now,” gets in the way of fixing problems early on. Yet, at some point, the problem does have to be addressed, and it usually requires significantly more time, effort, and money to solve. The first piece of advice is to not ignore the problem and find the time to look into the issue.

If there are multiple concerns, then identify the player(s) and ask what the top 3 or 4 concerns are as perceived by each side. It is often surprising how much can be solved through an informal discussion. You can't fix what you don't know about. For more complex issues, a formal meeting may be required. The main thing is to recognize that there are problems, understand them, and then look for ways to resolve them in a mutually agreeable manner. Too often, we complain among ourselves but never bring these concerns to the right person's attention so they may be addressed.

Wyche

The first step that I would implement to open and improve communication between the laboratory and nursing would be to form a joint practice committee consisting of both nursing and laboratory personnel. This platform could address any areas of concerns using the problem-solving method.

IQLM

Laboratory professionals expressed concern over the perceived lack of recognition of their skills and expertise. How can nurses help the laboratory community receive the respect it deserves? What must the laboratory do to command that respect?

Kurec

One simple thing that nurses can do in support of the professional recognition of laboratory personnel is to appreciate that laboratorians are well educated and have been trained to understand the disease process and the appropriate testing that needs to be performed to achieve a diagnosis. It also would be helpful if nurses understood that the testing process can be complex and often is in high volume; thus, the technologist is not ignoring a nurse and his/her patient but rather trying to manage a number of tasks at the same time. What laboratorians should learn from nurses is that they too are under stress. They are in direct contact with an ill patient whose families are upset while dealing with their own nursing protocols, physician orders, and other daily activities that consume their time. A mutual appreciation of how each other's time is spent is a step in the right direction.

What laboratorians might do to command respect is to look at what nursing has done. Nursing is well organized, they have professional licensure, they speak with one voice, and are clearly and easily recognized by the public as healthcare providers. Laboratorians are licensed in only 12 states, have multiple professional organizations, and have little or no direct contact with the public. We have done a poor job in promoting ourselves to the public as well as with our healthcare peers. It is vital that we laboratorians take every opportunity to establish ourselves in leadership positions within the healthcare arena. Further, some feel that obtaining professional licensure for laboratory personnel will confirm the legitimacy of the profession and generate a sense of personal accountability and pride in the work we do.

Wyche

Nursing can help the laboratory community receive the respect it deserves by educating the nursing staff on the many roles and responsibilities of the laboratory department. Understanding the tremendous service this department provides will, we hope, produce greater appreciation and respect.

Respect can be easily attained by the laboratory by simply performing to the level of expectation and maintaining consistency in the level of service that is needed and required.

IQLM

In a previous article comparing concerns between pathologists and other clinicians (Medscape General Medicine, February 2006), it was suggested that there is an inappropriate ordering of STAT testing. How do you define STAT testing? When do you believe it is warranted to request a prompt turnaround on a laboratory test?

Kurec

For those who work in the laboratory, STAT covers a broad range of time intervals. Common situations where tests are ordered STAT include true emergencies where information is needed within 30 minutes or less, while in other situations STAT may mean: “I need the results before rounds,” “I need results today,” or “I forgot to order certain tests with the morning blood draw and so we need to get this done now.” In a busy laboratory, one can receive many STATs within a short period, so the issue becomes: which one is STAT-er?

When STATs are ordered, there are some who believe that these tests can be completed in just a couple of minutes, not realizing that there are some technical issues that cannot be avoided (ie, the blood sample has to clot – takes about 10 minutes or longer if on an anticoagulant; the tube has to be centrifuged to get the serum – another 15 minutes; etc.). In addition, there are numerous preanalytical procedures that have to be addressed (ensuring proper labeling of specimens; logging into the computer system; bar coding labels; needing an Advance Beneficiary Notice; etc.). The fact is that most laboratory tests could be done relatively quickly if that were the only sample to be processed. But with today's technology, specimens are batched to better utilize resources (reagents, throughput time, control runs, etc.). This technology provides for a high level of accuracy and speed, yet when 20, 30, or 100 samples have to be run, something has to go last. Even with large runs, results from the most common laboratory tests performed should be available within 1-2 hours. And since many laboratory instruments are interfaced with a laboratory information system, reporting becomes less of an issue.

The judicious use of the word STAT is too encouraged and should be reserved for true emergency use. If laboratory results are needed within a certain time frame, it should be noted that results are “needed by noon,” “needed before evening rounds,” or “needed today.”

Wyche

STAT testing is defined as any emergent test ordered requiring a turnaround time of 1 hour or less. STAT testing is warranted any time a patient becomes hemodynamically compromised. However, minimizing any inappropriate ordering of STAT testing can occur when routine laboratory ordering and results are not delayed in any manner.

IQLM

Name one way a laboratory may help the nursing unit stay updated on policies and procedures.

Kurec

There needs to be ongoing communication between nursing staff and the laboratory. Scheduling monthly or bimonthly meetings between stakeholders is one way to address ongoing and new issues. Providing names and phone numbers of supervisors for each section of the laboratory is helpful to nurses when there is a question. Conversely, sharing contact information regarding nursing staff would also be appropriate. For this to work properly, those involved would have to be committed and willing to serve as the resource person. Managing data and information is a growing responsibility of laboratory personnel. Thus, it is critical that we find ways to share patient information in a prompt and safe manner.

Wyche

The laboratory can help the nursing units stay updated on policies and procedures by producing a monthly newsletter. This newsletter would be the vehicle to communicate any new and/or changes in policies, procedures, or practice.

IQLM

Taking a “walk in my shoes” seems like a great suggestion for helping both nurses and laboratory professionals understand better each other's roles and skills. What suggestions do you have for creating a “Take My Nurse/Laboratory Professional to Work Day” within the confines of a busy hospital?

Kurec

One mechanism I have seen work is to invite nursing personnel to spend a day in the laboratory and vice versa. This presents the opportunity for each to see what the other has to deal with and raises their level of awareness. Excuses about not having the time to do this are probably legitimate. However, if one is committed to solving problems, then one will find the time. Sacrificing one day now could save many future hours of dealing with ongoing problems and goes a long way in strengthening relationships among professionals.

Wyche

Within the confines of a busy hospital, “Take My Nurse/Laboratory Professional to Work Day” presents quite a challenge. My suggestions would be to start with some “baby steps.” My first suggestion would be for the laboratory department to host an open house. This would allow the nursing staff an opportunity to explore their environment and see some of the many challenges they face. My second suggestions would be to shadow each other for approximately 2-4 hours. While this may not provide the same benefit of a full day, it will allow a snapshot that will hopefully provide better understanding of each other's roles and skills.

IQLM

Can we fix these concerns? Do you have other suggestions?

Kurec

Clear and frequent communication is key to solving many of the issues raised by laboratorians and nurses. The main goal for both is to provide the best patient care possible. Yet miscommunication, lack of understanding, or an indifferent attitude can cause errors and/or delays in providing that care. Fixable, yes, but it takes leadership from both sides to initiate the needed dialogs that will result in better patient care, improve staff morale, and reduce wasting of resources. Keeping an open channel of communication by sharing information can fix existing problems and prevent future ones.

Wyche

Yes, we can fix these concerns as we work together to improve communication and address the recommendations offered. The benefit is enhancing the delivery of safer, higher-quality patient care.