Reinforcing the Value and Roles of Nurses in Diagnostic Safety: Pragmatic Recommendations for Nurse Leaders and Educators

The recognition of nurses for their roles in diagnosis is critical to achieving diagnostic safety improvements and advancements. Contemporary recommendations from the diagnostic safety literature^6-16 highlight actions nurse leaders and educators can take to improve diagnostic safety within four general domains:

1. Cultivating diagnostic safety culture.
2. Improving surveillance and reducing operational barriers to nurse participation in the diagnostic process.
3. Enhancing nurse, patient, and healthcare teamwork and communication.
4. 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.

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

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.

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