NursingCenter’s In the Round

A dialog by nurses, for nurses


clock June 12, 2011 06:54 by author Lisa Bonsall, MSN, RN, CRNP

I was on orientation in the Medical Intensive Care Unit and I had the most amazing preceptor. She really did know everything. I still have yet to meet a smarter nurse, or person, for that matter. Her knowledge of physiology, pathophysiology, medications, technology, and random entertaining facts to keep us going during night shift astounded me! Not only that, she was (and is) an amazing nurse --- caring, compassionate, a good listener, excellent at time management, and all things nursing!

And her teaching skills? Amazing.

I was a new graduate fortunate to work with and learn from this nurse every day. I had worked in this MICU as a nursing assistant for over a year, so I knew some of the basics (where to find supplies and knowing which room is which is huge when you are just starting out, right?) I’ll never forget this one time…

Amy (not her real name, of course) would often stand back in the corner of a patient’s room while I did my assessment at the start of a shift. Sometimes I’d forget she was there until she’d start with “the questions.” During this particular shift she said, “Lisa, what if all of a sudden the ventilator alarms for a high peak airway pressure?” I started to go through my list of troubleshooting ventilator alarms: look at the patient - is he in distress, what is his oxygen saturation, how is his color, listen to his breath sounds, is his endotracheal tube in place - and then moved on to the ventilator - any water in the tubing, is everything connected as it should be, etc.

Amy then said “Okay, you don’t find any concerns, but the high pressure alarm is still sounding. Now what?”  I replied, “I would disconnect the patient from the ventilator and bag him.” Amy said “Yes, and what else could you do to search for a reason for the alarm?” I could tell by Amy’s face that I was missing something.

She pretended to take a picture. Huh? I must have looked confused, because she did it again. I thought for a minute and then it hit me --- a chest x-ray!

8 rights of medication administration

clock May 27, 2011 00:10 by author Lisa Bonsall, MSN, RN, CRNP

Chances are that some of you may not have known that in addition to the well-known 5 right of medication administration, some experts have added 3 more to the list.When it comes to patient safety, it’s never a bad time to review some of the basics and increase your awareness of newer recommendations. Please add any of your own tips and medication safety advice by leaving a comment. Thanks!

Rights of Medication Administration

1. Right patient

  • Check the name on the order and the patient.
  • Use 2 identifiers.
  • Ask patient to identify himself/herself.
  • When available, use technology (for example, bar-code system).

2. Right medication

  • Check the medication label.
  • Check the order.

3. Right dose

  • Check the order.
  • Confirm appropriateness of the dose using a current drug reference.
  • If necessary, calculate the dose and have another nurse calculate the dose as well.

4. Right route

  • Again, check the order and appropriateness of the route ordered.
  • Confirm that the patient can take or receive the medication by the ordered route.

5. Right time

  • Check the frequency of the ordered medication.
  • Double-check that you are giving the ordered dose at the correct time.
  • Confirm when the last dose was given.

6. Right documentation

  • Document administration AFTER giving the ordered medication.
  • Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug.

7. Right reason

  • Confirm the rationale for the ordered medication.  What is the patient’s history? Why is he/she taking this medication?
  • Revisit the reasons for long-term medication use.

8. Right response

  • Make sure that the drug led to the desired effect.  If an antihypertensive was given, has his/her blood pressure improved? Does the patient verbalize improvement in depression while on an antidepressant?
  • Be sure to document your monitoring of the patient  and any other nursing interventions that are applicable.

Reference: Nursing2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, Pennsylvania.

Editorial round-up 3

clock April 9, 2011 01:59 by author Lisa Bonsall, MSN, RN, CRNP

Here are some of the latest thoughts from our journal editors ~ enjoy!

  • In Forging the future of nursing, Linda Laskowski-Jones MS, RN, ACNS-BC, CEN, FAWM writes: “We're at a historic crossroad as nurses. We must awaken as a profession and grasp the unparalleled opportunity to move forward in the same direction if we want our rightful place at the table. This means committing to ongoing education, actively engaging in dialog and decision making, and finally resolving the debate over entry-level educational requirements.”
  • In Taking responsibility for our practice, Elizabeth M. Thompson MSN, RN, CNOR  shares her thoughts on relating the theme of this year’s AORN Congress “Freedom to be” to perioperative nursing practice. She also uses a clinical example to help define the terms responsibility and accountability.
  • Kathryn Murphy DNS, APRN comments on The importance of cultural competence in the March/April editorial of Nursing Made Incredibly Easy! She reminds us that to be culturally competent nurses, we must remember knowledge (of cultures in your service area), attitude (avoid making assumptions and be aware of your own prejudices) and skills (learn new communication skills to simplify language).
  • In Food for thought about our most frequently used anticoagulants, AnneMarie Palatnik MSN, RN, APN-BC writes about the challenges of caring for patients on warfarin and heparin and reminds us to “Follow the protocols that have been put into place in your organization, and remember that these protocols are there to keep your patients safe.”
  • Suzanne K. Powell MBA, RN, CCM, CPHQ writes “…although many consumers are not clear what a "case manager" is and does, a case manager holds the promise of support and help during their experience in a complex, scary, and ever-changing healthcare environment.” Read more about case management professionalism in her editorial A Rose by Any other Name.

Thanks for reading!

Patient Safety

clock March 7, 2011 03:37 by author Lisa Bonsall, MSN, RN, CRNP

This week is Patient Safety Awareness Week, an annual education and awareness campaign led by the National Patient Safety Foundation. I did a quick search of articles from our nursing journals to bring you some of the great content we have related to patient safety...

Want to read more? We also have an entire collection of resources devoted to the topic of patient safety. In addition to articles and continuing education opportunities, Focus On: Patient Safety includes a PowerPoint presentation on medication error prevention and a quick reference on pressure ulcer prevention. Have a good week!

Editorial round-up

clock January 25, 2011 04:41 by author Lisa Bonsall, MSN, RN, CRNP

When I receive a new issue of a journal, I eagerly turn to the editorial right away. I like to feel that connection with the person bringing me the content within the pages (or through the links of online journals.) I find that editorials often tell me more than what is featured in the issue. Oftentimes, editors share their views and opinions on current events, clinical experiences, and sometimes personal stories. I thought I’d share some of my favorite editorials from recent issues here in this “Editorial Round-Up.”

  • In Defining a Culture of Safety, OR Nurse2011 editor-in-chief Elizabeth M. Thompson, MSN, RN, CNOR, shares her beliefs about leadership and how a team approach by perioperative nurses has impacted the patient safety movement.
  • In Leading Change, Advancing Health, AnneMarie Palatnik, MSN, RN, APN-BC writes “If we don't control our practice, someone else will. If we stay focused on the goal of providing accessible, affordable, quality care, and promoting health, how can we go wrong?”
  • In LACE, APRN Consensus... and WIIFM (What's in It for Me)?, Kelly A. Goudreau DSN, RN, ACNS-BC teaches us about the LACE (Licensure, Accreditation, Certification, Education) model and how advanced practice nurses are stakeholders in this regulatory movement.
  • In the January issue of Nursing Management, Richard Hader PhD, NE-BC, RN, CHE, CPHQ, FAAN reminds us in Circle Back Before Moving Forward that “No one knows everything and you don't have to either!!”
  • In Year of Pain, Year of Promise, Maureen Shawn Kennedy MA, RN  reflects on events of 2010 and looks ahead to 2011 while asking the question “There's a way to move forward, but are we willing?”

This is just a sampling of what our editors are writing about. I hope you enjoy reading them!

Knowledge, A Power Source for Nurses

In relation to patient care delivery, knowledge can give nurses greater power to take action and lack of knowledge can leave nurses powerless to provide safe or effective care. Evidence of knowledge as a source of power is that many employers during this difficult economic time prefer to recruit experienced RNs rather than incurring the expense of training new graduates.

Anderson and Willson (2009) offer a conceptual framework for nursing knowledge management that supports using technology to offer health care providers many tools to effectively use data to transform it into knowledge. Clinical decision support software such as those integrated with electronic medical records or those that clinicians access through mobile applications (apps) are examples of using data effectively to support knowledgeable clinical interventions. An example of how powerful this can be is that two nurses sharing a clinical rotation have access to texts for purchase in the books store and mobile apps that they can use on a Smartphone. One nurse feels more comfortable using the text and the other is very adept at navigating information technology including mobile apps. The nurse with the mobile product completes medication administration quicker because he finds all the drugs in his reference while the nurse with a book misses out on recent drug releases requiring an extra step to call the pharmacy or to look up drugs online.

There are many other examples and some that may have life-threatening consequences such as drug to drug interactions that information systems recognize that health professionals frequently overlook. In a time when health care quality is a mandate, organizations and professionals who use knowledge effectively will have the power to take control over costs and attain a higher rate of insurance reimbursement due to fewer complications. 

Reference: Anderson, J. A., & Willson, P. (2009). Knowledge Management Organizing Nursing Care Knowledge. Critical Care Nursing Quarterly , 32 (1), 1 - 9.


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?

Complexity Compression

clock November 29, 2010 15:26 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever heard the term complexity compression? I first learned of this term when reading Preserving a positive image of nursing in a complicated healthcare environment. This article caught my eye because although I had never heard the term, I certainly was familiar with the experience. By definition, complexity compression is "what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame." Sound familiar? We’ve all been there - having to perform tasks that take us away from direct patient care and having to do more in less time.

It didn’t take long to find the source of this terminology. In 2007, nurse representatives from the Minnesota Nurses Association and faculty from the University Of Minnesota School Of Nursing sought to validate what nurses were experiencing every day - complex patients and complex systems, both with increasing demands. Through the use of focus groups, the researchers identified six major themes that contribute to complexity compression: personal factors, environmental factors, practice factors, systems and technology factors, administration and management factors, and autonomy/control factors.  You can read the published study in its entirety here: Complexity Compression: Nurses Under Fire. 

What's the biggest factor that contributes to complexity compression during your workday?

Reference: Krichbaum, K., Diemert, C., Jacox, L., Jones, A., Koenig, P., Mueller, C., & Disch, J. (2007). Complexity compression: Nurses under fire. Nursing Forum.

Come Monday, it'll be all right?

clock November 22, 2010 13:49 by author Lisa Bonsall, MSN, RN, CRNP

During the month of November, two studies came across our newsfeed with regard to hospital admission on weekends. Researchers in the first study, Association between weekend hospital presentation and stroke fatality, published in Neurology on November 2nd, included consecutive patients with acute stroke or transient ischemic attack seen in the emergency department or admitted to the hospital. Of these 20,657 patients, stroke fatality was higher (8.1% vs. 7.0%) with weekend compared to weekday admission.

The second study, Weekend Admissions Predict Higher Mortality in Patients with End Stage Renal Disease, was presented at the American Society of Nephrology's Renal Week 2010. In this retrospective study, 19.7% of the 836,550 estimated admissions with end-stage renal disease were admitted on the weekend. Researchers found that those admitted on the weekend had significantly higher mortality (7.6% vs. 6.6%) than those admitted on a weekday.

A literature search on “weekend hospital admissions” revealed a few more similar studies published over the past 2 years. These included research on patients with acute kidney injury, gastrointestinal hemorrhage, and heart failure. All the studies concluded with similar results; that is, weekend admission is associated with a higher risk for death compared with admission on a weekday. What are the reasons behind this “weekend phenomena?”

The art of giving report

clock October 11, 2010 05:48 by author Lisa Bonsall, MSN, RN, CRNP

Have you ever left after a shift and realized you forgot to relay some important piece of information to the next nurse? It can be tough to organize and prioritize your communication in a timely manner. A structured format or even the use of a template can be helpful; however experience definitely plays a role here too. Like anything else, giving report to an oncoming shift or during any patient hand-off takes practice. A common acronym used to ensure an organized and thorough report is SBAR: Situation, Background, Assessment, and Recommendation.

When I first heard of this method, it seemed too short for me. How could 4 letters/headings be used to convey all the information about my patients after a 12-hour shift? As I learned a little more about SBAR, I realized it was not much different from the method of report I had been using for years.

S= Situation. Include admitting diagnosis, history of present illness, events of hospitalization (Tip: for patients with long hospitalizations, a timeline of events is helpful.) Also, what is the patient’s current situation? Include review of vital signs and events from the past 24 hours.

B= Background. Past medical history, past surgical history, family history, psychosocial history.

A= Assessment. Review of systems. My preferred method of organization has always been neurologic, respiratory, cardiovascular, gastrointestinal, genitourinary, hematologic/immunologic, and endocrine systems; skin; laboratory values and diagnostic findings; medications; psychosocial issues.

R= Recommendation.  Include anything that needs ongoing or further attention.

What method of report works best for you?

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