Nurse On the Move: Lisa Gorski


ALisa-Gorski.jpgfter a short hiatus, Nurses On the Move is back and better than ever! I am excited to bring you our next nurse
leader, Lisa A. Gorski MS, RN, HHCNS-BC, CRNI, FAAN. With more than 30 years in the field, Gorski is an expert in both home healthcare and infusion nursing. As a clinical nurse specialist at Wheaton Franciscan Home Health & Hospice in Wisconsin, an editorial board member of Home Healthcare Now, an associate consultant for OASIS ANSWERS, Inc., and a published author, her knowledge of the nursing profession is truly impressive.

Through our phone interview, I spoke with Gorski about why she decided to enter into home healthcare, her time as president of the Infusion Nurses Society, and what advice she has for a nurse starting their career.

BONUS: The current issue of Home Healthcare Now is FREE until August 15th on NursingCenter.

Q:  Why did you choose nursing as a profession?
A:
I wanted to be a nurse since I was a young child. When I was 5 or 6 years old, I drew a picture and wrote a story about how I wanted to be a nurse and help people! That desire never waned. In high school, my intense interest in the sciences and a summer of volunteer work in a hospital as a ”candy striper” reinforced my goal to become a nurse. 

Q:  What attracted you to home healthcare?
A:
I knew that I wanted to work with patients on a longer term basis. I had several graduate school colleagues who worked in home healthcare, and at the time, changes in reimbursement led to shorter hospital length of stay and more transitioning to home care. I saw a potential future in home healthcare.  

The challenges and opportunities in this specialty were apparent to me, including working with families, as well as patients, and working with them over longer periods of time to keep them functioning well in their home.  There is a great need for employing effective patient education to help patients manage their own care. While the assessment and intervention skills that I gained in my acute care experience served me, I needed to develop a new body of knowledge. While I could manage blood sugar levels in a critically ill patient, working with home care patients to manage their diabetes was a different challenge that required not only the clinical focus on diabetes, but also a focus on living with a chronic illness. In graduate school, I studied the issues related to living with chronic illnesses. One of the books I read during graduate school still sits on my bookshelf and still provides me with perspective – Chronic Illness and the Quality of Life by Strauss and Glaser (1975).  

Q:  What’s the biggest challenge related to home healthcare and how do you combat it?
A:
One challenge is time management. Home care nurses travel and generally see five to six patients on the same day. Depending on the needs of the patients, there is also a considerable amount of time coordinating care and communicating with other involved healthcare professionals. As any home care nurse will tell you, there is a considerable burden of documentation. And you must be accountable to that patient and family. When you leave the home, you have to think about what happens or could happen when you leave – have you addressed critical issues to ensure that your patient will be safe when you are gone, as there is no one else there until you get back. Think about the patient with a running infusion of a chemotherapy drug. Does the patient understand what to do and who to call if an alarm occurs or if there is an adverse reaction; is the phone number to call for problems readily available?

On the bigger picture side, the pressures of ensuring positive patient outcomes with reimbursement restraints are challenging. An overarching goal of home care is to keep patients safe in their homes. The hospitalization rate for home health is a publically reported outcome, and hospitals are penalized when patients return back to the hospital within 30 days. As a nurse who has worked in home care for 30 years, the level of patient acuity has certainly increased. I believe the challenge for home care nurses is to become less focused on the tasks to be done, such as wound care or other treatments, and more focused on identifying the nursing diagnoses and managing the outcomes. Keeping patients at home requires that the nurse possess exceptional assessment skills, that risk factors for re-hospitalization are identified and mitigated, that ongoing monitoring identifies and reports  early/subtle changes in condition to allow early intervention, and that there is significant attention paid to medication management.

Q:  Why are you passionate about infusion nursing?
A:
I became a home care nurse during the mid-1980s during that period of great growth in the home care industry. Transitioning patients who required infusion therapy from the hospital to home was a growing trend.  

At that time, I managed many patients who required home infusion therapy from simple IV antibiotics to complex parenteral nutrition. My critical care skills combined with my growing experience in home care issues served me well in that area of practice. However, one of the issues that I identified was that exceptional IV therapy skills are not enough in home care. Because patients and families are involved in various aspects of self-care related to the IV infusion, the home care nurse’s skills in patient education are equally important. Patients are often anxious or may have functional limitations that impact the ability to learn and manage, and these must be addressed. My first published article  in Home Healthcare Nurse in 1987 addressed the patient education issue. I later wrote three books on the topic of home infusion therapy and am in the process of writing another.  

Q:  You served as the president of the Infusion Nurses Society (INS) from 2007 to 2008. How did that role impact your profession in nursing?
A:
After being involved in the INS for many years in a variety of local chapter and national positions, it was an honor to serve as president for that year. Subsequently, I continued to serve INS as the chairperson for the 2011 Infusion Nursing Standards of Practice and am currently serving again in that role for the standards that will be published in 2016. There is a rapidly growing research base for infusion therapy by investigators across the world. Working with my amazing infusion therapy colleagues to search and review the literature and to develop evidence-based recommendations and educate the infusion community has contributed to improved patient outcomes and reduction of preventable complications. My INS involvement has led to so many opportunities. I have had the pleasure of doing many presentations across the country and some international presentations. I regularly talk to or have email discussions with nurses, pharmacists, and physicians regarding infusion related issues and practices. I recently had the opportunity to present in Santiago, Chile and Buenos Aires, Argentina and will be doing presentations in China later this summer. Clearly, nurses not only in the U.S., but across the globe, are striving to provide the best practices for their patients. 
 
Q:  The nursing journal, Home Healthcare Now, was previously titled Home Healthcare Nurse. Why did this publication change its name?
A: Home healthcare nurses have always worked collaboratively with other disciplines, including physical, occupational, and speech therapists, social workers, and pharmacists to name a few. The collaborative relationship has always been strong in homecare – this was evident to me from the minute I became a home care nurse. The focus is on interprofessional care, and I think the new title reflects that. 





Q:  For a nurse starting out, what would be your number one piece of advice?
A:
Nurses today have so many opportunities in many different settings. When you leave a position, you want to feel as if you’ve mastered it. Really learn your first job and develop your skills, especially in working with other healthcare providers. Identify where your strengths lie and use them to determine where you want to go. Also, get involved in nursing organizations relevant to your practice. I am also a member of the National Association of Clinical Nurse Specialists and the American Nurses Association, which have provided me with more information and knowledge and more contact with colleagues who share similar interests and challenges. I recently attended the International Home Care Nurses Organization (IHCNO) where I was inspired by reports of research and home care practices in several countries. Involvement in practice beyond our daily organizational work keeps us fresh and motivated!

Q:  Finally, what do you envision for the future of nursing?
A:
It is really bright! There are so many opportunities for nurses in a variety of settings whether clinical or non-clinical. Nurses are shaping healthcare policy and are increasingly involved in politics. Our critical thinking, expertise, and leadership make an incredible impact in patient care. We are healthcare leaders. 

*Do you know an inspiring nurse to be featured for the next Nurse On the Move? Email your submissions to
ClinicalEditor@NursingCenter.com.

 


Keep a positive spin on the progress of full practice authority for NPs

US_Navy_100812-N-4044H-247_Suzanne_Harwood,_a_Latter-day_Saints_Charities_volunteer_nurse_practitioner,_embarked_aboard_the_Military_Sealift_Command_hospital_ship_USNS_Mercy_(T-AH_19).jpgThe scope of nurse practitioner (NP) practice is regulated by the state government. Currently, 21 states and Washington, D.C have passed legislation allowing nurse practitioners full practice authority. This permits NPs in these states to independently diagnose, make treatment decisions, order and interpret diagnostic tests, and prescribe medications without the oversight of a physician. Research unequivocally supports the safety, effectiveness and quality of the care provided by nurse practitioners as a safe alternate to physician care (Horrocks et al. 2002, Mundinger et al. 2000). Furthermore, this model for nurse practitioner care is endorsed by the groundbreaking 2010 Institute of Medicine report titled, The Future of Nursing: Leading Change, Advancing Health. This document comprehensively analyzed ways to expand access to quality care for persons in the United States and supports NPs practicing to the full extent of their license and education. This movement is gaining momentum as NPs have made great strides in lobbying for full practice authority.

A recent article in the New York Times,Doctoring without the Doctor” tells the story of a nurse practitioner in rural Nebraska who, upon graduation, was unable to practice in her field because she was unable to find a collaborating physician to work with for a reasonable cost and within a reasonable distance. The article goes on to describe the recent legislation in Nebraska, which, in April 2015, became the 20th state to pass legislation allowing nurse practitioners to practice without a collaborating physician. While the overall tone of the article was supportive and brought to light the issues of access to healthcare in rural America, the title insinuates an effort for NPs to take on duties and responsibilities that they were not trained to perform (i.e. providing the services of a doctor with no doctor). In reality, the legislation has little to do with the nurse practitioner practicing without “the Doctor;” the impetus for full practice authority lies in a goal to eliminate barriers to healthcare access rooted in old, outdated laws and regulatory barriers that prevent nurse practitioners from practicing to the full degree and providing the full scope of services for which we were educated for. Furthermore, nurse practitioners do not wish to eliminate collegial collaboration with physicians or any members of the healthcare team. We all understand that true quality care takes a team of healthcare providers from multiple disciplines. Nurse practitioners are not lobbying to “doctor” without a “doctor” as the title implies. In essence, the NP movement to expand legislation to support scope of practice will provide increased patient access to proven high quality care,expanding the healthcare work force to allow access to care in geographic regions where patients have limited access to quality care. 

As nurses, we must continue to support legislation and promote our profession, as well as continue to educate the public on misconceptions about the profession. There were over 400 comments in response to the New York Times article. Reading through them brings to light an abundance of support from the public and healthcare community, but, unfortunately, also highlights continued misconceptions of the public and healthcare providers on the role and scope of NP practice in the U.S., as well as misconceptions as to the goal of full practice authority. One comment from a physician is as follows, “I may be biased, but I am yet to encounter a nurse practitioner with the competence, (I believe) intelligence and with the sense of responsibility of my physician.” Another physician writes, “If NPs want independent practice, so be it. Just make them get their own malpractice insurance and not be tied in any way to any physician, supervising or not. Take full responsibility and liability for all their own medical decisions and see how it plays out. It's only fair.”(Tavernase, 2015). These type of comments shade the topic to appear as a turf battle, when in reality, the majority of NPs and physicians work together seamlessly in our healthcare system. 

aanp-logo.pngThe American Association of Nurse Practitioners (AANP) has been a main supporter of removing barriers to NP practice. In an issues brief they summarize the goals best as to “remove barriers and obsolete legislation and regulations that do not recognize NPs’ advanced education and clinical preparation to furnish the full range of services that they are licensed to provide.” 

Recently, the Pennsylvania Coalition of Nurse Practitioners (PCNP) organized a lobby day in support of a house and senate bill to support full practice authority. PCNP has dedicated significant time and effort to ensure PA laws are udated. To date, PA has yet to pass this legislation. What types of struggles have you encountered in your state for full practice authority? Do you have full practice authority in your state and if so, has there been any noticeable changes in your day to day practice? Have the physicians, patients, and other nurses in your life supported this work? Please share your thoughts in the comment below.
References: 
AANP Issues Brief: Remove Barriers to Nurse Practitioners’ Ability To Practice.Retrieved from: 
http://www.aanp.org/images/documents/federal-legislation/issuebriefs/Issue%20Brief%20-%20Removing%20Barriers.pdf

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011

Horrocks, S., Anderson, E. & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324, 819

Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A. M., Tsai, W., Cleary, P.D., Friedewald, W.T., Siu, A.L. &Shelanski, M.L. (2000). Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. The Journal of the American Medical Association. 283(1), 59-68

Tavernise, S. (2015). Doctoring, without the doctor. New York Times. May 25, 2015.Retreived from: http://www.nytimes.com/2015/05/26/health/rural-nebraska-offers-stark-view-of-nursing-autonomy-debate.html

Megan Doble, MSN, RN, CRNP

 


Maternal Health Around The World [Infographic]

The Maternal Mortality Rate (MMR) is an issue in many countries that are often regarded to have the most advanced healthcare systems. In fact, the rate at which mothers are dying as a result of pregnancy or childbirth in the United States continues to rise despite the U.S. spending more money than any other country in the world in regards to pregnancy hospitalization and childbirth.
 
Nursing@Georgetown prepared a useful infographic on the topic of Maternal Health around the World in hope to explore not only the cause of these deaths but also how they may be prevented in the future. The infographic dives into some of the most important statistics such as leading causes, MMR across the world, the midwifery model, and more.

 

Brought to you by Nursing@Georgetown: Nurse Midwife programs

 

Posted: 7/1/2015 1:23:03 PM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments
Tags: maternal death, MMR, women's health
Categories: Diseases & Conditions


Middle East Respiratory Syndrome (MERS)

mers-3-(1).PNGMiddle East Respiratory Syndrome (MERS) has been making headlines since 2012 when it was first discovered in Saudi Arabia. A recent outbreak of MERS has occurred in the Republic of Korea affecting 150 people and claiming the lives of over a dozen to date. Close to 3,000 people in South Korea are under quarantine. Two unrelated cases of MERS were diagnosed in the United States in 2014 and both patients have made a full recovery. 

While not considered a public health emergency by the World Health Organization, viruses can mutate and could cause a global pandemic. As a healthcare provider, it is important that you have an understanding of MERS and appropriate infection control practices in order to identify and prevent its further spread. As an educator, you play a critical role in informing patients about the signs and symptoms of MERS and strategies to avoid contracting this highly contagious disease.



What is MERS?

MERS is caused by a coronavirus (CoV), a group of viruses that are responsible for illnesses ranging from the common cold to Severe Acute Respiratory Syndrome (SARS). Almost 1,200 cases of human MERS-CoV infection have been reported and over 440 deaths (35% mortality rate) have been attributed to it. The origin of the virus is unknown but is suspected to have come from an animal source. MERS-CoV is thought to spread from an infected person’s respiratory secretions, such as through coughing. The incubation period for MERS (time from exposure to MERS-CoV to symptoms) is typically five to six days but can range from two to 14 days. There are no specific treatments for patients aside from supportive therapy to relieve the symptoms. Patients with mild to no symptoms have made a full recovery.

Symptoms include:

  • Fever, cough, shortness of breath, runny nose, severe acute respiratory disease
  • Chills, chest pain, body aches, sore throat, malaise, headache
  • Diarrhea, nausea, vomiting, abdominal pain

Severe complications include: 

  • Pneumonia
  • Kidney failure

Who’s susceptible or at high risk?

  • People with pre-existing medical conditions such as diabetes, kidney failure, chronic lung disease
  • People with weakened immune systems such as cancer patients receiving chemotherapy or organ transplant patients receiving immunosuppressive drugs
  • Elderly

Need-to-know information for nurses

  • If your patient exhibits fever and symptoms of respiratory illness, assess if he or she has
    • traveled to a country in or near the Arabian Peninsula within 14 days of symptoms onset.
    • been in contact with someone who has traveled to the Arabian Peninsula within 14 days of symptoms onset.
    • a history of being in a healthcare facility (as a patient, worker or visitor) in the Republic of Korea within 14 days of symptom onset.
    • been in close contact with a confirmed MERS patient while the patient was ill.
  • MERS is a reportable disease and local health departments should be notified of any suspected MERS cases.
  • Strict infection-control measures should be used while managing suspected and confirmed cases of MERS, including hand hygiene; contact, droplet and airborne precautions along with full personal protective equipment – gown, gloves, mask and eye protection (goggles or face shield).  MERS patients should be placed in a negative pressure room. 
mers-pt-ed.PNG
 
Please visit the Centers for Disease Control and Prevention (CDC) for complete recommendations and Interim Guidance for Healthcare Professionals in the detection, evaluation and care of MERS patients.
References:
Todd, B. (2014). EMERGING INFECTIONS: Middle East Respiratory Syndrome (MERS-CoV). AJN, American Journal of Nursing, 114 (1).
Centers for Disease Control and Preventions (2015, June 12). Middle East Respiratory Syndrome (MERS).
World Health Organization (2015, June 13). Middle East respiratory syndrome coronavirus (MERS-CoV).

Myrna B. Schnur, RN, MSN

 


Celebrate Nursing 2015: Part 2

I hope that 2015 has been a good year so far! It’s hard to believe it’s already June. Time to look ahead to nursing recognition weeks for the second half of the year!

June

Vascular Nursing Week June 7-13

National Time Out Day June 10 

38th Annual National Nursing Assistants Week June 11-15

Healthcare Risk Management Week June 15-19

 

September

National Pediatric Hematology/Oncology Nurses Day September 8

Nephrology Nurses Week September 13-19

National Neonatal Nurses Day September 15

National Nurses in Staff Development Week September 20-26

National Gerontological Nursing Week September 27-October 3 

 

October

National Midwifery Week October 4-10

National Pediatric Nursing Week October 5-9

Emergency Nurses Week October 11-17 (Emergency Nurses Day is October 14)

National Case Management Week October 11-17

November

Emerging Nurse Leaders Week November 1-7

Medical-Surgical Nurses Week November 1-7

Urology Nurses and Associates Week November 1-7

Perioperative Nurses Week November 8-14

National Nurse Practitioner Week November 8-14

Forensic Nurses Week  (dates not yet announced)

Posted: 6/1/2015 12:08:51 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments
Tags: nurses, nurses week, nursing, nursing recognition
Categories: Inspiration


Preload and Afterload – What's the Difference?

A recent Quick Quiz on our Facebook page resulted in a mix of responses. Do you know what word is used to describe the amount of stretch on the myocardium at the end of diastole? The responses were split between preload and afterload. 
 
fb-quiz-preload.PNG 
 
Let’s take a closer look at what these terms mean.

Preload

Preload, also known as the left ventricular end-diastolic pressure (LVEDP), is the amount of ventricular stretch at the end of diastole. Think of it as the heart loading up for the next big squeeze of the ventricles during systole. Some people remember this by using an analogy of a balloon – blow air into the balloon and it stretches; the more air you blow in, the greater the stretch. 

Afterload

Afterload, also known as the systemic vascular resistance (SVR), is the amount of resistance the heart must overcome to open the aortic valve and push the blood volume out into the systemic circulation. If you think about the balloon analogy, afterload is represented by the knot at the end of the balloon. To get the air out, the balloon must work against that knot. 

Cardiac Output & Cardiac Index

Cardiac output is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate; normal cardiac output is about 4 to 8 L/min, but varies depending on the body’s metabolic needs. Cardiac index is a calculation of the cardiac output divided by the person’s body surface area (BSA). 

So, if you answered ‘D’ to the quiz above, you’re right!
References
Gowda, C. (2008). Don't be puzzled by cardiovascular concepts. Nursing Made Incredibly Easy!, 27-30.
Smeltzer, S. B. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Warise, L. (2015). Understanding Cardiogenic Shock: A Nursing Approach to Improve Outcomes. Dimensions of Critical Care Nursing, 67-77.


NCNP 2015

I didn’t have to travel too far this year to attend the National Conference for Nurse Practitioners! Held at the Philadelphia Downtown Marriott in historic Philadelphia, Pa., there was plenty to see and do within the venue and out in the city. My days were filled with conference sessions, fun in the exhibit hall, and dinners out with colleagues.  

The Conference

IMG_2837.JPGThere was so much to see, do, and learn. The opening session celebrated the 50 year mark of the NP profession, while the conference honored 40 years of the Nurse Practitioner journal and Nurses Week. The conference sessions focused on clinical updates and professional issues; I was able to meet both my CE needs as a Women’s Health NP and learn about the latest developments in acute care so that I can stay up-to-date in the world of critical care.



Here are highlights from some of the sessions I attended:
  • According to the U.S. News & World Report of 100 Best Jobs, nurse practitioner ranks #2!
  • Fifty percent of insurance plans now cover obesity medications. (New Drug Update 2015: What’s Hot and What’s Not, presented by Wendy Wright, MS, RN, ARNP, FNP, FAANP)
  • In terms of radiation exposure, one chest CT is equal to 750 chest xrays. (5 Things I Wish I Knew Last Year, presented by Louis Kuritzky, MD)
  • Research has shown that interactions that occur during a student’s education will shape his or her professional image. (Lateral Violence: Bullying in the Workplace, presented by Monica N. Tombasco, MS, MSNA, FNP-BC, CRNA)
  • When the GFR is < 30 mL/min, thiazide diuretics are not as effective; use loop diuretics instead. (Hypertension Update: The Latest Treatment Recommendations from JNC-8, presented by Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC)
  • Many states now have ‘breast density notification laws’ and several have legislation in progress. (Breast Evaluation: Screening to Diagnosis, presented by Constance A. Roche, MSN, CNP, APNG)
  • Pneumonia and aspiration are the most common direct lung injury causes of ARDS. (Acute Care Track: Diagnosis and Management of Acute Respiratory Distress Syndrome, presented by Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM)

The Exhibit Hall (and other fun!)

Food, fun, and learning happened during all of the exhibit hall hours! Exhibitors educated attendees on their latest products, and handed out samples and fun ‘giveaways’. Attendees also got to view the poster presentations.
IMG_2834.JPG       IMG_2832.JPG
IMG_2848.JPG       IMG_2843.JPG

Meals were served, prizes were awarded and there was even a band one evening!  Bonus morning sessions included Yoga for the Nurse Practitioner: A Gentle Practice with Techniques for Clinical Practice with Tom Bartol, NP and Rhythm and Funk: Low Impact, High Energy Workout with Jessica Clark.

1662403_687551668020855_9100488044502019215_n.jpg     12819_825830184170282_61060724755731286_n-(1).jpg     11008453_687551544687534_8909700138561368249_n.jpg
       
If you attended the conference this year, don’t forget to complete your CE (and view sessions online)! Hope to see you at NCNP 2016!

 


Banishing the Bully Among Us

It seems odd to end Nurses Week with a post about bullying – after all, when thinking about celebrating our week, why be a “downer?” Hasn’t there been enough talk and articles about this ugly side of nursing?

But like other problems, raising awareness is usually the first step towards change.  The sentinel event alert from JCAHCO in 2008 on the dangers to patients from intimidating and disruptive behaviors spurred many organizations to look seriously at the behaviors of their staff. We saw several research reports and reviews about the phenomena of bullying among nurses, nurses and physicians, nurses and ancillary staff and students. We can’t just point fingers at the clinical setting. Cynthia Clark and colleagues reported their research on faculty-to-faculty incivility in the April 2013 issue of the Journal of Nursing Education. In a study of 588 educators from 40 states, they found that faculty perceived this to be a “moderate to severe problem” and that it persisted because of “fear of retaliation, lack of administrative support, and lack of clear policies addressing the problem.”

But, maybe there are a few subtle signs that we’re starting to deal with bullying.

One piece of good news is that since it was first published in January 2009, Cheryl Dellasega’s article, Bullying Among Nurses,” always ranked among AJN’s top 20 most viewed and most emailed articles, which to me, meant it was all too relevant. I’ve heard from more than a few nurses in the clinical setting that people are getting tired of the sniping and are confronting those responsible. Articles moved from describing the problem to reporting on dealing with it, like: Organizations, too, are helping members with resources, such as the American Association of Critical Care Nurses, which developed standards for a health work environment. The ANA has a list of resources addressing bullying and incivility.

Later this year, look for an article in the American Journal of Nursing  on how one hospital successfully rallied staff to deal with bullying behavior.

Perhaps people are getting the message that we’re losing too many nurses because of the untenable work environment – the “toxic workplace” – that this can create. As I noted in a message I wrote in a 2011 editorial for Nurses Week, “Our work is too important; we can’t afford to be sidetracked by bullying and other forms of relational aggression. Use this Nurses Week as a catalyst for focusing on all that we share and accomplish as colleagues.”

Maureen Shawn Kennedy, MA, RN, FAAN
Editor in Chief, American Journal of Nursing


 


End-of-Life in Acute Care

In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
 
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
 
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
 
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
 
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
 
Reference
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.  

William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN 
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences​


 
Posted: 5/11/2015 5:23:06 AM by Lisa Bonsall, MSN, RN, CRNP | with 2 comments
Tags: end-of-life care, ethics in nursing, nurses, nursing
Categories: Patient Safety


Moral Distress

When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice.  The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession. 
 
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more.  As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
 
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner. 
 
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
 
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders.  The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.

Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
Editor-In-Chief, Nursing2015



 
Posted: 5/10/2015 6:25:55 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments
Tags: ethics in nursing, moral distress, nurses, nursing
Categories: Patient Safety


Displaying results 1-10 (of 146)
 |<  < 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10  >  >| 
Comments
Blog post currently doesn't have any comments.