A while back, I wrote a blog post about using SBAR (Situation-Background-Assessment-Recommendation) as a method to help organize change-of-shift report. First implemented by the U.S. Navy to reduce miscommunications, use of this tool is becoming more widespread in healthcare settings. It has been theorized that the use of a standardized approach such as SBAR creates a “common language” among healthcare professionals and thereby decreases communication errors and may even impact our behavior. A recent study published in Health Care Management Review explored this potential impact of SBAR on the daily activities of nurses.

The researchers interviewed nurses, nurse managers, and doctors in two hospitals where implementation of the SBAR protocol was in its early stages. Analysis of the data revealed two findings: first, that most thought of SBAR as strictly a means of standardizing communication, and second, that SBAR actually had a “more far-reaching effect than just being a communication tool.” 

So what are these “far-reaching effects?”

1. Schema development – SBAR facilitated the development of schemas which help nurses make intuitive decisions.

2. Contribution to the accumulation of social capital – The common language of SBAR serves as a means to integrate nurses into the organization.

3. Providing legitimacy – The common practice also helps individuals gain credibility.

4. Shift in logic – SBAR supports a shift from individual autonomy to standardization and formalization of the nursing profession.

Interesting findings! This fairly simple tool does have far-reaching implications – for our individual practice and our profession. If we communicate more effectively, make decisions more easily, and are integrated into the organization as a credible member of the healthcare team as a nursing professional, won't that ultimately lead to better patient care and outcomes?

Reference: Vardaman, J.M., Cornell, P., Gondo, M.B., Amis, J.M., Towensend-Gervis, M., Thetford, C. (2012). Beyond communication: The role of standardized protocols in a changing health care environment. Health Care Management Review 37(1), 88-97.

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.

The holidays were not without incident at our house this year. Illness reared its head as it usually does when excitement builds and holiday events and preparations keep us too busy to get adequate rest and eat right. This year, however, it was my husband who was down-and-out, not one of our kids.

He had a cough for about a week and was fatigued, but, despite my clinical judgment that he should rest, I “encouraged” him to help out with all that still needed to be done before Christmas. On Christmas day, he really wasn’t looking so well – high fever, chills, productive cough that seemed constant. He spent the evening in bed taking ibuprofen around the clock to help alleviate his symptoms.

By late morning the next day, we called our primary care office and found that they were closed for the holiday. We ended up heading over to the emergency department (ED) at our local hospital. In triage, he was found to be febrile, tachycardic, and hypoxic. He got a stat dose of albuterol and was quickly taken back to a room in the ED. As we went through his medical and surgical history with the ED nurse, we both paused and looked at each other when he told her that he had a splenectomy when he was younger. 

Oops – did we forget the implications of being without a spleen and the need to seek care quickly when he gets sick? And hadn’t I just read something about the risks associated with splenectomy?

Shortly after, labs came back and his white blood cell count was 43,000. So, he spent 4 days in the hospital on I.V. antibiotics. His diagnosis? Pneumococcal pneumonia.

Yes, I had read “something” recently and even put in on our recommended reading list a few weeks prior. Needless to say, I did go back and read this one again: A close up view of Pneumococcal disease.

“Risk factors for acquisition of the disease are alcohol abuse, splenectomy, immunocompromised status, smoking, and asthma.”

All is well now. And next time, I’ll ease up on my “encouragement” and do a better job with my assessment!

Happy New Year everyone! I thought I’d start the year off here on In The Round with some positive energy and pull together nursing recognition days, weeks, and months for the beginning of 2012*. Please feel free to add to this list any that I may have missed by leaving a comment. Wishing everyone a happy and healthy 2012!

National Nurse Anesthetists Week 
January 22-28, 2012

National IV Nurse Day 
January 25, 2012

PeriAnesthesia Nurse Awareness Week 
February 6-12, 2012

GI Nurses and Associates Day 
March 28, 2012

Certified Nurses Day 
March 19, 2012

National Radiology Nurses Day 
April 10, 2012 

National Critical Care Awareness and Recognition Month 
May 2012

Oncology Nursing Month 
May 2012

National Nurses Week 
May 6-12, 2012 (National Nurses Day is May 6)

National Student Nurses Day 
May 8, 2012

National School Nurse Day 
May 9, 2012

International Nurses Day 
May 12, 2012

Neuroscience Nurses Week 
May 13-19, 2012

*Some of the links above may take you to pages from 2011. I will update these when new pages become available. Thanks!

I read a lot about nursing - mostly journal articles, but this year I’ve spent quite a lot of time reading nursing blogs and I love it! Some tell stories of certain patient experiences, some bloggers have written more about the changes our health care system is undergoing, and others use their blogs to teach students and lead newer nurses. Quite a few nurses out there do all that and even more on their blogs. I thought I’d share some of my favorite posts from the past year. These are the blog posts that have inspired me and left me with such a good feeling about nursing. Thank you to nurse bloggers who share their stories and experiences. It is so great learning from you all. 

A Nurse’s Week Reflection: The nurse’s night off
Nurse Story

Humility, Forgetfulness, and Glitter
Nursetopia

Receiving compliments
At Your Cervix

Return of Compassion
New Nurse, In the Hood

The Priceless Clarity of Inexperience
AJN’s Off The Charts

There are such talented nurse writers out there and I’m sure I’ve missed some good posts – please share your favorites as well. I'd love to read more and learn what posts have inspired you this year.

MAP, or mean arterial pressure, is defined as the average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP). True MAP can only be determined by invasive monitoring and complex calculations; however it can also be calculated using a formula of the SBP and the diastolic blood pressure (DBP). 

To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3. For example, if a patient’s blood pressure is 83 mm Hg/50 mm Hg, his MAP would be 61 mm Hg. Here are the steps for this calculation:

MAP = SBP + 2 (DBP)
                3

MAP = 83 +2 (50)
                3

MAP = 83 +100
             3

MAP = 183
           3

MAP = 61 mm HG

Another way to calculate the MAP is to first calculate the pulse pressure (subtract the DBP from the SBP) and divide that by 3, then add the DBP:

MAP = 1/3 (SBP – DBP) + DBP

MAP = 1/3 (83-50) + 50

MAP = 1/3 (33) + 50

MAP = 11 + 50

MAP = 61 mm Hg

There are several clinical situations in which it is especially important to monitor mean arterial pressure. In patients with sepsis, vasopressors are often titrated based on the MAP. In the guidelines of the Surviving Sepsis Campaign, it is recommended that mean arterial pressure (MAP) be maintained ≥ 65 mm Hg. Also, in patients with head injury or stroke, treatment may be dependent on the patient’s MAP. 

In what other clinical situations do you monitor MAP?  

References
Surviving Sepsis Campaign. Accessed December 8, 2011. 
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Twelfth Edition. Philadelpha: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

On December 2nd, Dr. Donald M. Berwick will step down as administrator for the Centers for Medicare and Medicaid Services (CMS). Replacing Dr. Berwick will be Marilyn Tavenner, who served as Berwick’s deputy principal administrator since April 2010. The first article I read about this development was last week on Reuters.com. Toward the end of the article, I read “Tavenner is a former Virginia health secretary and hospital chief executive. A nurse by training, she has been with CMS since February 2010, first as acting administrator and currently as principal deputy administrator." A nurse to head CMS? Yes!

Since last week, I’ve read more about the sequence of events leading to Dr. Berwick’s resignation as well as more about Marilyn Tavenner’s background and experience. In this blog post from the Washington Post, Tavenner’s path from ICU nurse to this nomination is chronicled in detail with comments from former colleagues describing her as respectful, quick-thinking, decisive, and hard-working. In an article on HealthLeaders Media, more former colleagues share their thoughts and feelings of Tavenner’s pragmatism, leadership experience, and decision-making skills. 

The American Nurses Association (ANA) has released a statement commending the White House for its decision to nominate Marilyn Tavenner, MHA, BSN, RN, to head CMS.  I’d like to join in on the commendation. Seeing a nurse take on such a prominent leadership role makes me feel proud – how about you?

When I started to think about a special post to write for Thanksgiving, I tried to remember a time when I really grew as a nurse. There was no question in my mind about a certain patient that was instrumental in that growth. The crazy thing was I never even knew her.

It started out like any other shift – I was assigned two patients (we were fully staffed), a wonderful leader and my former preceptor was our charge nurse for the evening, and a team of interns and residents who had been in our Medical Intensive Care Unit for a few weeks were working. All the beds were full and none of our patients were up for transfer out of the unit, so it seemed like we were in for a calm shift.

Linda was a young woman who had a uterine rupture during childbirth and had lost a lot of blood. She subsequently developed acute respiratory distress syndrome (ARDS) and had come to our unit about 2 weeks prior to this particular evening for intubation and management of her ARDS. She had no significant past medical history, no known allergies, and had an uncomplicated pregnancy with regular prenatal care.

During change-of-shift report, I learned from the day shift nurse that the MICU team had met with Linda’s family that day after a neurological exam and testing had revealed that Linda was brain dead. The family had decided to gather together this evening and we’d remove Linda from the ventilator. They had also requested to donate her organs.

A representative from Gift of Life arrived shortly after the start of my shift and the family started to drift in as well. Never had I been part of such an emotional patient experience. The strength and courage of the family of this young woman – this new mother – was incredible. While their grief was palpable in the room, so was their faith. They verbalized gratitude at being fortunate enough to be able to donate several of Linda’s organs and saw this as a way to continue her life.

So, this special thank you goes out to Linda and her family…

Thank you for allowing me to be part of that night.

Thank you for sharing your faith with me.

Thank you for sharing your stories with me.

Thank you for teaching me that death, even a tragic one, can give us strength that we might not even know is within us.  

Thank you for thinking of others and giving life. 

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. 

Reference:

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

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?