NursingCenter’s In the Round

A dialog by nurses, for nurses

Directing nurses back to patient care

clock July 25, 2014 03:09 by author Cara Gavin, Digital Editor

What made you decide to become a nurse? Was it the thrill of directly impacting a patient’s life? Or, was it because you really love tracking down medications and filling out paperwork? I’m going to guess it wasn’t the latter, and the people at the Institute for Healthcare Improvement agree.

In a recent article this week in the Wall Street Journal, Laura Landro explored the institute’s new partnership with the Robert Wood Johnson Foundation to develop Transforming Care at the Bedside, a program “to help hospitals increase to 70% the amount of time nurses spend in direct patient care while improving the work environment for nurses.”

This initiative attempts to answer the increasing need to streamline the work nurses are doing, while improving nurses’ delegation practices, “shifting more routine tasks to certified nurse assistants and other less high skilled staffers.” In an interview between Landro and Patricia Rutherford, a nurse and vice president at the institute, Rutherford explained, “We shouldn’t be using expensive professional nursing time doing unnecessary and inefficient things when that time could be reinvested in direct patient care.”

The institute isn’t the first to notice the lack of time nurses are spending with patients. In 2008, the American Journal of Nursing published a series of studies that found direct patient care “accounts for less than 50% of working hours.”

NursingCenter’s own clinical editor, Lisa Bonsall, MSN, RN, CRNP, remembers her frustrations at the bedside. “Patient care is what nursing is all about. I can remember clearly being pulled away from the bedside searching for supplies or medications, or even fixing or calibrating equipment. One time, I was caring for a patient admitted with DKA (diabetic ketoacidosis), who needed finger stick blood glucose checks every hour for titration of his insulin drip. We had two machines on our unit and one was broken. At about my third hour of the shift, the machine that was working needed to be calibrated…[which] took quite some time. This event not only took me away from the bedside, but put him at risk as I was unable to check his blood sugar for about two hours. Fortunately, no untoward events occurred, but I remember thinking at the time, ‘There’s got to be a better way!’”

Studies show the more time a nurse is at the bedside, the better the outcomes. Bonsall explains, “The relationship between patient safety and nursing care is documented in the research, including direct impacts on healthcare-associated infection, readmission rates, and mortality. We are the ones noticing the subtle changes in a patient’s status. If we are repeatedly pulled away from the bedside, those changes can go unnoticed.”

In a 2010 internal audit conducted by Presbyterian Medical Center, it was discovered that “nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift.” Nurses were spending too much time searching for missing test results and supplies and not enough time monitoring their patients. After implementing the Transforming Care at the Bedside program, the center was hitting “6.5 hours per shift at the end of 2013 with a goal to hit 8.5 hours by the end of 2015.”

Time will tell if the center is able to hit their goal. But, as more hospitals begin to take a robust approach at managing their nurses’ time and delegation strategies, the hope is to return nurses back to why they began their work in the first place – to care for the patients.

Ghosts in the Machine

clock November 18, 2011 05:21 by author Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

This blog post is reposted from Show Me the Evidence: The Blog of Lippincott's Evidence-Based Practice Network.

When you appraise research, do you look at who was the principle investigator and wrote the article? I recently attended a session at a symposium that has made me question how I review articles for credibility. Inappropriate authorship (honorary and ghost authorship) and the resulting lack of transparency and accountability have been a substantial concern for the academic community for decades (Wislar, Flanagin, Fontanarosa, & DeAngelis, 2011). For those of you who are unfamiliar with the definitions, an honorary author is someone who is named as an author but did not meet authorship criteria and did not contribute substantially to take public responsibility for the work (Wislar, et al. 2011). A ghostwriter is someone who has made substantial contributions to the writing of the article but was not named as an author (Wislar, et al. 2011). These types of authors call into question the validity and credibility of the published work due to a lack of transparency on what they did or did not contribute to the article. 

In the latest issue of BMJ, Wislar, Flanagin, Fontanarosa, and DeAngelis, explored the issue of ghost writing and honorary authorship in their study "Honorary and ghost authors in high impact biomedical journals: a cross sectional survey."  They used a sample size of 896 authors from the top 2008 high Impact Factor medical journals in the industry, Annals of Internal Medicine, JAMA, Lancet, Nature Medicine, New England Journal of Medicine, and PLoS Medicine. Of the 896 authors, 630 responded to the survey for a 70.3% response rate. The prevalence of honorary and ghost authorship in articles published in major medical journals in 2008 was 21% (Wislar, et al. 2011). This number was a decline from identical study the group did in 1996 looking at the same publications. In 1996, the prevalence of honorary and ghost authorship was 29% (Wislar, et al. 2011). 

Clearly, these results demonstrate a need for the scientific community and peer-reviewed publications to increase their efforts to promote the responsibility, accountability, and transparency in authorship, and to maintain integrity in scientific publication (Wislar, et al. 2011). As healthcare providers who depend on the research evidence to guide our practice, we must carefully appraise the evidence to make sure it is credible and trustworthy; this includes scrutinizing the authors as well as the methodology and the research results, before using the information to change our practice. I applaud the efforts of the study authors to educate the healthcare community on the important issue of inappropriate authorship. It is through their efforts and the efforts of authors, editors, and publishers that we can continue to improve the integrity of the scientific publishing industry. 


Wislar, J., Flanagin, A., Fontanarosa, P., DeAngelis, C. 2011. Honorary and ghost authorship in high impact biomedical journals: a cross sectional survey. BMJ.

Who is visiting whom?

clock February 6, 2011 01:35 by author Lisa Bonsall, MSN, RN, CRNP

I just finished reading yet another research study about visitation in an ICU. We were pretty flexible in our ICU, with open visiting hours from 11 am to 8 pm. Of course, there were exceptions, both where we had to limit visitation and other times where visitors were permitted to come in earlier, stay later, or even spend the night.

As a visitor to other critical care units, however, I often did not meet such “openness.” Visits to my own family members or friends at other hospitals were commonly limited to 15-minute intervals 3 to 4 times per day. And that was for all visitors. So, if 5 of us wanted to visit our grandmother, that left us with just 3 minutes per visit. Can you really call that a visit?

In Research Dimension: Critical-Care Visitation: The Patients' Perspective, from the January/February issue of Dimensions in Critical Care Nursing, the researchers look at patient satisfaction and patient preference regarding restricted visitation. In this article, the following quote from a 2004 JAMA article caught my eye and I think it is worth sharing:

"Who is visiting whom? To stabilize the details of ICU operations, health care institutions and professionals neglect the plausible assertion that they are the visitors in patients' lives, not the other way around."

Reference: Berwick DM, Kotagal M. Restricted visiting hours in the ICU's. JAMA. 2004;292(6):736-737.

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?”

ABC is now CAB

clock October 18, 2010 04:07 by author Lisa Bonsall, MSN, RN, CRNP

Wow - big changes announced today by the American Heart Association! Based on recent studies demonstrating the priority of adequate circulation in saving cardiac arrest victims, chest compressions are now the first step in cardiopulmonary resuscitation (CPR). The rate of chest compressions should be 100 per minute, with a depth of at least 2 inches in adults and children and 1.5 inches in infants.

Exceptions to the new guidelines include newborns and those with primary respiratory arrest. In these victims, the steps should remain airway management, followed by rescue breathing, and then chest compressions.

Here are some helpful links with more about these changes:

Also, here are links to the abstracts from the supporting studies:

Where do you get your nursing information?

Some day you could be held accountable for the information you provide to patients and use for applying to your nursing plan of care. How many times have you looked up a procedure, a medication, or a diagnosis on the internet and got that quick answer? Or even worse, do you use printed resources like books, compatibility charts, or policy manuals that may be a few years old?  Now nurses have ready access to the internet at their workplaces, and can access the most current information in minutes. However, I frequently hear that nurses are searching Google because it is quick and easy. The issue is how you determine what information to use? Whether this information is guiding your patient care or being used to write a paper for a class you're taking, you want to obtain the most current, accurate, and evidence-based information that is available. You wouldn't want to be in court explaining that the reason you chose to use content from a particular website was because it was free. I'm not knocking free sources. Lippincott's has lots of free content. It makes sense to be conscientious about the method you use to select sources, and to be able to articulate the process you use to determine if a source is credible.

It is best to use peer-reviewed journals. Your workplace is likely to have a subscription to a database with access to full-text journal articles. If you work at a smaller organization without employer paid library resources, a good place to start is Articles with government funded research are required to have free access, but to avoid limiting your search, you may have to pay to view articles. Still there are numerous free sources of reputable information including government agencies, professional organizations, universities, other sources vetted by experts in the subject matter. Some organizations including private foundations or community websites may have evidence-based research reports available for download or they may organize information from other sources. Be sure to check the original sources to verify that the information is correct and not misinterpretted. Go ahead and use your favorite search engine or consumer website to help you with ideas, but make your clinical decisions on information you can you can justify.   


Nurses and Librarians, Partnering for Better Patient Outcomes

How visible is your institution's librarian? Does your librarian participate in your leadership meetings, your unit council meetings or your journal club meetings? Does your librarian make rounds on a routine basis with the nursing staff and does she teach you how to do searches, and what the difference is between literature reviews and systematic reviews?

That is exactly what Diane Rourke, MS, AHIP, Director of Library Services at the Baptist Health South Florida Hospital System and Donna Flake, MSLS, MSAS, AHIP, Library Director of the North Carolina SEAHAC Hospital System do. At the Medical Librarian Association Meeting in Washington, DC this past week, Donna Flake presented: Going Beyond the Library to Integrate Your Resources into the Nurses' Environment and Diane Rourke presented: Supporting Today's Magnet Journey in Nursing. Diane is the MLA delegate to the American Nurses Credentialling Center's Magnet Certification Program. 

The role of the library is changing. No longer is the library thought of as this room where you go to search through books and journals.  Now the library is a living entity that is accessible through workstations on wheels in every nursing unit. Librarians can assist nurses with the finding the evidence-based research that supports practice change. Hospital systems that are integrating evidence-based, best practice at point of care, have found that the librarian-nurse partnership has the potential to positively impact nursing practice and patient outcomes. 

For more information on this topic, please join us at a webinar on June 30th at 1pm. Just go to to register.

Lancet retracts MMR vaccine and autism risk paper

clock February 3, 2010 06:37 by author Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC

Earlier this week, Lancet retracted an article published by Dr. Andrew Wakefield in 1998 which stated the MMR vaccine could increase childrens risk of developing autism.  "According to the judgment of the U.K. General Medical Council's Fitness to Practice Panel on January 28, 2010, it has become clear that several elements of the 1998 paper by Wakefield et al, are incorrect in particular the claims in the original paper that children were consecutively referred and that investigations were approved by the local ethics committee have been proven to be false. Therefore, we fully retract this paper from the publishing record."

While numerous studies following this paper reported that there wasn't a relationship between the MMR vaccine and Autism, the damage was already done. This study resulted in parents not having their children vaccinated and led to an outbreak of measles in the U.S. in 2008 and an increase in disease in the U.K. Too often lay persons and clinicians accept the results of one study as being enough to change assumptions and practice.  As nurses we need to educate our peers and the public that research must be reviewed for validity and accuracy.  Just because something is published, doesn't make it good science. We must use established evidence-based and best practice resources to guide our practice. Cochrane Systematic Reviews, the Joanna Briggs Institute, and other established evidence-based practice resources and journals can help us improve practice and improve outcomes.  What resources are you or your facility using to improve patient outcomes?

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