Without caution, nurse temps' savings can explode into costly damages
With their use on the rise, take steps to ensure their competence
Temporary nurses are being used in health care facilities across the country in ever-increasing numbers. But just because their presence is becoming a permanent fixture in hospitals and other health care facilities does not mean you should be complacent about their use, risk managers warn.
While most temporary nurse agencies and registries have outstanding records for providing top-notch health care professionals, hospitals can put themselves at risk if they do not take the proper steps to make sure the nurses are suited for the work for which they are hired.
Take, for example, the death of a patient last winter at Brigham and Women's Hospital in Boston. The patient allegedly received an accidental overdose of potassium chloride while under the care of a temporary nurse in the intensive care unit, according to published news reports.
Did hospital fail to check the nurse's credentials?
Although the risk manager at Brigham and Women's Hospital declined to speak to Healthcare Risk Management about the incident, local newspapers reported that the temporary nurse was inexperienced in the ICU. Hospital staff may not have been aware of the temporary nurse's limited ICU experience when she was assigned to the unit because the credentials of agency nurses were not routinely checked, the local newspapers reported. At HRM press time, hospital officials had not publically addressed the allegations.
While incidents like this are a rarity, risk management experts say it is an excellent example of the risks a hospital can unwittingly expose itself to if it does not take the necessary steps to screen and properly place temporary nurses.
"You cannot bring them in without being able to demonstrate that you have done the same level of credentialing as you do for employees," says Sam Bishop, director of risk management for Promina Hospital Northwest in Atlanta. "If you haven't done that, as far as I am concerned, you are outside the standard of care and will have liability for any bad outcomes that the temporary nurse may impose on you."
But as the Brigham and Women's Hospital incident demonstrates, what should be done and what is done do not always mirror each other. If you use temporary nurses at your facility, take the following steps to enhance patient safety and minimize your institution's risk, experts advise:
1. Research the registry.
Before considering agencies, the risk manager should ensure that the human resources director or the nursing staff director checks the temporary agency's reputation. The number and types of restrictions on temporary agencies vary from state to state and usually are not specific to the nursing profession, making research through regulatory agencies somewhat futile, says Mark Kopson, JD, a partner in the Detroit health law firm Wachler & Kopson.
Instead, call other hospitals in your area that have hired from the registry to check on the caliber of their personnel. Questions to ask include whether the nurses looked presentable, whether they had adequate skills, and whether the agency was booking the nurses to work back-to-back shifts at different facilities.
2. Use requests for proposals (RFPs).
Once the hospital has determined which agency or agencies it plans to hire from, the risk manager should require the human resources department to submit a detailed RFP from the registry, Kopson suggests.
The RFP should clearly delineate the qualifications of the nurses the hospital is seeking to hire, Kopson says. "Do not take at face value the representations of the pool or agency."
3. Screen if you cannot credential.
As the Brigham and Women's case illustrates, knowing the background and skills of a temporary nurse before he or she is allowed to care for patients is essential. Relying on the agency's word is insufficient and risky.
"Test cases show that hospitals are held to the same standard of care for credentialing allied health care personnel as they are for employees," Bishop says.
While it is optimum to credential temporary nurses like any other credentialed member of the hospital, most facilities do not have the time or the means to repeat that process with temporary nurses. At a minimum, risk management experts recommend that the human resources department or nursing department require temporary nurses:
* complete an application for employment and clinical privileges;
* sign a statement that they will abide by hospitals bylaws and other rules and regulations;
* present their original license and bring photo identification such as a driver's license or state identification card for comparison;
* present any required certificates for other specialized training, such as CPR training.
The human resources staff also should conduct:
* a verification of the individual's education and work history;
* a check of personal and work references;
* review of evidence that the nurse has received any required vaccinations such as tetanus or tuberculosis;
* a check of state and local disciplinary agencies or nursing boards.
Going one step further
At Maricopa Medical Center in Phoenix, the hospital requires its temporary nurses to pass a 50-question exam on hospital procedures described in their orientation packet, on nursing skills, and on drug knowledge. The exam was designed by the hospital's nursing education staff and has been tested on the hospital's own nursing staff, says Tara Shepherd, RN, nursing systems support coordinator at Maricopa Medical Center.
The temporary nurses must answer 80% of the questions correctly or they are not allowed to work. "They are always free to take the test again, but it sends up red flags to us [if they cannot pass it the first time]," Shepherd says.
4. Do a skills check.
Temporary nurses also should be required to demonstrate the same set of core nursing skills that employed nurses do, Bishop says. Typically, hospitals have tests prepared for nurse applicants that also can be used for temporary nurses.
In addition to making good risk management sense, a skills check of temporary personnel is required under the human resources standards of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, says Ann Kobs, MS, associate director for the Joint Commission's department of standards.
The Joint Commission does not look at the actual process for testing the skills, however. It only requires that the check is completed before the temporary employee is allowed onto patient floors, Kobs says.
5. Require insurance.
All temporary nurses and the agencies for which they work should have separate professional liability insurance, risk management experts say.
The insurance requirement should be included in the original RFP to the agency and then in the hospital's contract with the agency or registry. The contract should state that the temporary nurse is insured. Do not accept a promise to get insurance, Kopson warns.
Risk managers also should check with their hospital's legal counsel to determine the minimum parameters of the temporary nurses' insurance, such as the rating of the insurer, and whether the institution should be named as an additional insured, Kopson says.
When the temporary nurse reports to the hospital for the first time, the risk manager should require presentation of the actual certificate of insurance, he says.
6. Use indemnifications.
Promina Hospital Northwest requires indemnification from the temporary nursing agencies it uses, Bishop says. The hospital also will provide a cross-indemnification for the agency. An indemnification is a contractual provision that allows a party such as a hospital another way to sue in the event that the requirements of the contract are not met.
The indemnification provision is inserted into the contract between the hospital and the temporary nursing agency and covers the acts, omissions, and commissions of the temporary nurse in favor of the hospital and the acts, omissions, and commissions of the hospital and its employees in favor of the temporary nurse and the agency.
7. Proctor temporary nurses.
Hospitals can be held liable for breaching a standard of care for failing to properly orient staff, including temporary staff. Because most facilities are unable to hold special orientation sessions for temporary staff because of the time constraints when they are needed, risk managers should ensure that new temporary nurses are proctored by a designated staff nurse to ensure that the temporary meets the unit's standards.
At Maricopa Medical Center, all new temporary nurses' first shift is an orientation shift where they are precepted, or closely monitored, the entire time, Shepherd says. This not only gives the hospital a chance to watch the new temporary nurses, it also allows those nurses to learn the finer points of paging, protocols for drug therapies, and other procedures, Shepherd says.
"We don't just throw them out to the wolves," she says.
8. Limit shifts.
The shifts of temporary nurses should be limited until the hospital is comfortable with their skills. Once the temporary nurses have shown themselves to have the appropriate training, risk management experts say it is important not to overuse them. They shouldn't work any more shifts than employed nurses.
9. Require rest.
Many hospitals that use temporary nurses have reported receiving nurses who have come straight off of a shift from another hospital. Risk managers should prohibit this practice and make sure the prohibition is written into the contract with the agency or registry, Kopson says.
10. Conduct evaluations.
At Maricopa Medical Center, members of the hospital nursing staff evaluate the temporary nurses in their respective units after they have worked at the hospital three or four times. The evaluations are combined with a profile the hospital creates of each temporary nurse it hires. The profile contains basic credentialing information and is updated every few months, Shepherd says.
RN evaluation is critical
"We [evaluate them] because it is prudent," says Shepherd. "If we are going to be responsible for our patients, then we need to be able to provide high-quality care. This is one mechanism to do that. We are not asking them to do anything that our staff would not have to do, and it helps us identify people who might not be appropriate for the hospital. Otherwise we are taking a risk if we don't evaluate them."
11. Report problems.
It is important to keep open lines of communication with the registry to report problems. At Maricopa Medical Center, Shepherd is the designated liaison for the hospital and its temporary staffing agencies. The agencies also want to keep a good reputation and usually are grateful to hear of any problems with their temporary nurses so they can correct them or terminate them from their registry. *
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