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Peace and Health in ANS

clock September 19, 2013 03:47 by author Lisa Bonsall, MSN, RN, CRNP

The current issue of Advances In Nursing Science is a special one. The articles in this issue all are related to ‘peace’ and at a time when our country and our lives are faced with turmoil and violence, it is a welcome journal.

Here’s a look at some of the feature articles…

"No One Gets Through It OK": The Health Challenge of Coming Home from War
I was in a firefight one week and home in the next. And it was like, as an 18-, 19-year-old kid...you can't turn the switch off, you know what I'm saying? It was difficult for me to go home and make an instant switch to be a civilian. I didn't know how to act right. My energy was up here, but it needed to be down here.”

Critical Cultural Competence for Culturally Diverse Workforces: Toward Equitable and Peaceful Health Care
“…attaining equity-and ultimately peace-in health care delivery necessitates that nursing and other health care professions more carefully attend to the sociocultural context in which health care is delivered.”

Peace Through a Healing Transformation of Human Dignity: Possibilities and Dilemmas in Global Health and Peace
“Through personal experience in the region, I have witnessed the transformative power of Israeli-Palestinian relationship building through joint health initiatives. Yet, these experiences also reflect a reluctance of health care professionals working on such initiatives to explicitly address the conflict.”

The Language of Violence in Mental: Health Shifting the Paradigm to the Language of Peace
“…as language is a fluid medium that can be consciously reshaped just as a potter can reshape clay or an artist can rework a canvas, nurses can mold the language of nursing and health care to reflect the paradigm and the power of peace.”

I am happy to share this issue with you and I hope that it will inspire you to infuse more peace into your nursing practice and your life. All of the articles can be read at no charge on NursingCenter while it is our Featured Journal…now through 10/1/13. Enjoy…and I wish you peace. 



EOL Care: Progress and Ongoing Issues

clock February 11, 2012 15:45 by author Lisa Bonsall, MSN, RN, CRNP

End-of-life (EOL) care has always been a special interest of mine. I know the frustrations that often arise with EOL care in a critical care unit – for example, when a patient can no longer make decisions for himself and his family is unsure of his wishes, or when family members disagree. However, I also know how satisfying it can be when a patient’s death is a positive experience for all involved. Sometimes providing end-of-life care is just as rewarding as seeing a patient ‘turn the corner’ and get better. I imagine that some nurses find that EOL care is even more rewarding. 

When I read Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings, I was reminded that while challenges continue, we actually have come pretty far with regards to advance care planning (ACP) and EOL care. Resources such as the Center for Practical Bioethics’ Caring Conversations, Respecting Your Choices, and Five Wishes have emerged to help patients and families discuss their wishes with one another. Other highlights of progress include The Joint Commission standards on palliative care, advance care planning, and pain management; National Healthcare Decisions Day (April 16); palliative care consultation services at large numbers of hospitals; and increased numbers of people with advanced directives. I encourage you to read this article in its entirety to see the extensive list of examples provided by the authors. 

What issues remain? 

  • Advance care planning – increasing the number of patients with advance directives; living wills & power of attorney issues
  • Caring for patients who are in a minimally conscious state vs. persistent vegetative state
  • Providing hydration and nutrition
  • Communicating a patient's wishes or plan of care during transfer from one care setting to another (for example, from nursing home to hospital)

Take some time to read this article (it’s free to read online while on our Recommended Reading list!). On page 103 (page 5 of the pdf), you’ll find 'Ten Things Critical Care Nurses Can Do To Improve Advance Care Planning.' 

Reference: 

Rushton, C., Kaylor, B., & Christopher, M. (2012). Ethics in Critical Care:Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings. AACN Advanced Critical Care, 23(1). 



Support your fellow nurse

clock January 26, 2012 04:53 by author Lisa Bonsall, MSN, RN, CRNP

We see, read, and hear so much about horizontal violence and nurses not being supportive of each other, and also about other healthcare professionals being unsupportive of nurses. Another such case is occurring, but what is striking to me, is that while this one nurse is going through this tough time, nurses on the web are rallying together to support her and encouraging others to do the same.

The case is of Amanda Trujillo, a registered nurse in Arizona. According to a letter she wrote and the posts of many nurse bloggers, Amanda has been fired from her job, her nursing license is in question, and she is undergoing psychiatric evaluation after educating a patient about his illness and options. The patient decided to forgo surgical intervention and explore hospice care. The details of her case can be read on a number of nursing blogs, including vdutton’s posterous (with the transcript of details recorded by her attorney), Those Emergency Blues, and Emergiblog. The Nerdy Nurse also has several posts and an extensive list of resources about the case and ways to show support.

I can think of several instances where patients I’ve cared for had questions that either were not answered by the healthcare team or were answered, but the patient did not fully understand his condition or options. On many  occasions in my nursing career, I provided patient education that helped a family make an  informed decision. I’ve called together family meetings with the healthcare team and requested ethics committee consultations. Advocating and educating patients, within the scope of nursing practice and institution policies, of course, is our responsibility. 

I will be following the case to see what evolves and the response of nursing organizations. Thank you to the nurses who have been sharing Amanda’s story.



What do you do when...

clock November 9, 2011 04:01 by author Lisa Bonsall, MSN, RN, CRNP

I’ve been reading a lot of articles about ethics lately as I prepare to update our Focus On: Nursing Ethics collection. Of course, so many dilemmas that I’ve faced in my practice are coming to mind and I’ve been giving a lot of thought lately to these ethical issues and the decisions that I/the team made. Here are some of the issues that have been on my mind:

What do you do when…

…a patient wants to sign out AMA? Do you try to convince him to stay?

…you suspect someone you know personally has an eating disorder? Do you speak up?

…a patient is having pain and the prescriber refuses to order a pain medication? Do you go up the chain of command?

…you feel that your patient assignment is unsafe? Do you demand a change?

…you are sick but you know that the unit is already short-staffed for your shift? Do you go in to work?

What ethical dilemmas have you faced in your practice? How did you and your colleagues handle it?



When a patient or family member is a nurse

clock August 23, 2011 16:40 by author Lisa Bonsall, MSN, RN, CRNP

 

We’ve all been there...getting report when the oncoming shift finishes up and whispers to you that the patient’s family member is a nurse. How do you feel? What is your initial reaction? Do you change your approach to the patient? To the family?

It always made me a little nervous when a patient himself or a member of his family was a health care professional, especially when I was a new nurse. Would he be watching my every move, ready to pounce if I hesitated or didn’t have an answer to a question? Or would he be helpful, offering information and advocating for himself or his loved one?

There was one particular patient* that I cared for when the dynamic of a family member who was a nurse was particularly challenging. I don’t recall the specifics about the patient, only that he’d been transferred several times to different hospitals as a “challenge to wean” patient, meaning he was having difficulty weaning from the ventilator. His sister, a nurse, was his power of attorney and very involved with his care. The issue was that the patient appeared to be in severe pain from contractures and pressure ulcers. He was noncommunicative when he arrived at our hospital, but would have significant changes in vital signs and become diaphoretic and tense his muscles with nursing care. His sister requested that no analgesia or sedation be administered so as not to interfere with his ventilator weaning. 

The team caring for this patient was perplexed. We didn’t feel comfortable not treating his pain, but also were being influenced by the wishes of the patient’s sister. Our hospital’s ethics committee was consulted and a careful balancing act was employed to treat his pain adequately while allowing him to be awake enough to wean from the ventilator.

It was challenging to care for him. His sister would check medication doses and keep track of dosing intervals. It was a stressful time for the staff as we all worked together to provide the best care for the patient while being so closely observed. 

Of course this is only one example. More often, health care professionals who happen to “cross over” into the patient or family member role leave their scrubs or lab coat outside the door. In my next post, I’ll share my own experience being on the other end of the stethoscope. 

*Any identifying characteristics are purely coincidental. 

 



Decisions, decisions

clock April 14, 2011 10:02 by author Lisa Bonsall, MSN, RN, CRNP

Living wills. Life support. Do-Not-Resuscitate. These are all phrases that I used frequently working in an adult medical intensive care unit. I rarely had trouble using the words death, dying, hospice, or end-of-life with patients and families.

However, outside of the hospital, these words have been a lot harder for me. My parents do have living wills and have expressed their wishes to me, but not because I initiated any discussion with them. In fact, I’ve actually avoided those conversations despite knowing how important they are. 

There is not really a good time to have end-of-life discussions, so people tend to wait for the "right time" which often turns into the "wrong time" or "too late." The conversation might end up taking place in the hallway of the emergency department or in a critical care waiting room. Sometimes, information is conveyed and decisions are even made over the phone.

I am fortunate that my own family members have insisted on preparing for the end of their lives and sharing their plans and wishes with me. As a daughter, I really don’t like to hear about it. As a nurse, I know that this is a very good thing.

Saturday, April 16th is National Healthcare Decisions Day. Make this day the "right time" to talk with your loved ones and encourage the patients you care for to do the same.



Family meetings

clock December 20, 2010 05:27 by author Lisa Bonsall, MSN, RN, CRNP

I can remember a patient with an upper GI bleed, Minnesota tube in place, on maximum vent support and two pressors, who clearly was not doing well. I was checking yet another blood product with a nurse colleague, when a consulting clinician came in and told the family members at the bedside that “his numbers look good.” He then smiled and walked out of the room. The family responded with sighs of relief and “thank goodnesses” while the other nurse and I looked at each other as if to say “what just happened here?”

Have you experienced similar situations? I hesitate to name the clinician’s area of expertise because I don’t want to give any specialty a bad rap or make a generalization. However, the point is that sometimes a person not directly involved with a patient’s day-to-day care can make an observation to patients or families and give them a message that may not be correct. It isn’t always one of false hope either; perhaps a patient is doing better, yet his _______ (you can fill in the blank - rash, glucose level, wound, etc.) is not healing or normalizing and a caregiver might focus on that one clinical finding when talking with the patient and his family members.

It is for this reason that I was both surprised and discouraged when I read the results of a recent study published in Chest, “Effectiveness Trial of an Intensive Communication Structure for Families of Long-Stay ICU Patients.” In this study, 135 ICU patients received ‘usual care’ and 346 ICU patients had weekly family meetings where the patient’s progress and goals were discussed. The investigators were looking at the impact of this intervention on length of stay and no significant difference between the two groups was found.

Despite the negative findings of this study, it is important to remember the positives, or benefits, of sitting down with families for formal meetings where information can be shared and questions can be answered. For example, regular family meetings can allow you to:

• Provide personal contact
• Give updates on the patient’s medical condition and treatment options
• Discuss his prognosis
• Learn about the patient and family, including expectations and wishes
• Gain the opportunity to formulate a trusting and caring relationship
• Tailor the treatment plan according to the input of all staff and the patient’s family.

Please allow me to share the following quote from the authors in their conclusion of this study:

"Even if the use of regular formal family meetings does not alter resource use in all settings, the literature is replete with evidence of other beneficial effects of providing families with time to sit in a quiet location and talk at some length about the patient's goals and preferences and to explore issues related to quality of life, and providing families with consistent support as they face difficult decisions."

What is the standard procedure for initiating, scheduling, and attending family meetings where you work?



Two Texas Nurses Vindicated...ANA Code for Nurses Prevails

Two nurses, Anne Mitchell and Vickilyn Galle, settled with Winkler County, Texas and will share $750,000 in restitution following being fired and criminally prosecuted for upholding their duty to protect the public by sending an anonymous note detailing incompetent physician practice. The settlement is symbolic of both the personal vindication of these nurses and acknowledgement that the ANA Code for Nurses has prevailed.

This closes the book on this horrific experience that Mitchell and Galle endured. What's more is that there is a clear precedent which may discourage retaliation of this sort from happening to other nurses who attempt to blow the whistle whenever they observe substandard care.  



More to think about at the end of life

clock July 11, 2010 19:19 by author Lisa Bonsall, MSN, RN, CRNP

Providing end-of-life care can be one of the most challenging responsibilities as a nurse, yet can also be one of the most fulfilling. When a patient’s wishes are respected and dying with dignity is a priority, death can be a peaceful and positive experience for the patient, his family, and the staff caring for him.

Oftentimes, our focus during end-of-life care is primarily on pain management and relieving or preventing labored breathing. Research published last month in the Archives of Internal Medicine calls attention to other factors that need to be addressed to improve care at the end of life. These include communication deficits, the importance of dyspnea assessments, implantable cardioverter/defibrillator deactivation, and bowel regimens.

In my opinion, the importance of communication at the end of life cannot be stressed enough. This includes communication among staff, among the patient and his family members, and between staff and the patient and his family. How many times have you encountered family members who didn’t agree with the wishes of a loved one as stated in his living will or who didn’t understand that an illness was terminal? How about physicians, nurses, and other professionals who were reluctant to address end-of-life issues?

It is important for all decision-makers and caregivers to understand and agree on a plan in order to ensure a positive experience at the end of life. For this to happen, communication is key. Take some time to read the following articles. You’ll find some great information to help educate patients, families, yourself, and your colleagues about end-of-life issues and care.



To report or not to report?

clock February 15, 2010 09:48 by author Lisa Bonsall, MSN, RN, CRNP

Last week, a nurse in Texas was acquitted after a being on trial for reporting a doctor for practicing bad medicine.  Here are some of the details from the case, which came to be known as the “Winkler County nurses” trial:

  • Two nurses, Anne Mitchell and Vicki Gale, reported a doctor because they were concerned about his practice being below the standard of care and affecting patient safety. Another concern was his use of “nontherapeutic treatments and prescriptions.”
  • The case against Gale was dismissed; however the felony indictment will remain on her record.
  • Mitchell faced a third-degree felony charge and up to 10 years in prison for trying to protect her patients.
  • Both Mitchell and Gale were fired from their jobs.
  • The American Nurses Association (ANA) and Texas Nurses Association (TNA) both demonstrated their supported openly. The TNA created the TNA Legal Defense Fund to “to support the legal rights of these nurses in Winkler County – and the rights of every practicing nurse in Texas to advocate for patients.”
  • On February 11, 2010, Anne Mitchell was found not guilty.

You can read more about the details of the case as chronicled by the TNA here

“I was just doing my job,” relayed a jubilant Anne Mitchell, in a phone conversation with TNA immediately following the not guilty verdict, “but no one should have to go through this,” she said.  “I would say to every nurse, if you witness bad care, you have a duty to your patient to report it, no matter the personal ramifications.  This whole ordeal was really about patient care.”

My heart goes out to both Mitchell and Gale for all that they have endured over the last months. While the verdict is a success for nurses and patient safety, what damage has been done simply by the fact that such a case was brought to trial? What are your thoughts? Have you ever been in a similar position in which you felt patient safety was being compromised by a colleague? How did you handle it?



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