The Opioid Epidemic: Are Women Most Vulnerable?

The opioid epidemic is a serious public health problem that impacts us professionally, as well as many of us personally. Asking about drug use is something we were taught while in nursing school. Assessing and managing pain has always been a big part of our training too. Now, as the United States is in the midst of an opioid epidemic, our assessment and communication skills must reach a new level. Those of us who are advanced practice nurses who are also prescribers, have even more to consider when it comes to pain management.

women-and-opioids.pngAs a women’s health nurse practitioner, new research on age and gender trends related to the opioid epidemic caught my eye. Findings revealed excessive opioid prescribing with persistent use among women. This new report, conducted by the QuintilesIMS Institute, states that “middle-aged women are prescribed more opioids than any other group – twice as many as middle-aged men – making them particularly vulnerable to opioid use.” The research report, The United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America, shows individuals undergoing surgery are at particular risk, due to the prescribing of opioids to manage postsurgical pain.

Here are some interesting facts from the report that you should know:
  • Patients receive an average of 85 pills following surgery.
  • Overprescribing leads to 3.3 billion pills left unused-leaving them available for misuse.  
  • In 2016, three million surgical patients became persistent opioid users.
  • The majority of opioid addictions start with prescription medications.
  • Surgery is an unintentional gateway to the opioid crisis.
  • 40% more women than men become persistent opioid users after surgery.
  • Women ages 40-59 are prescribed more opioids than any other age group and have the highest death rates from misuse.
Another report from the Office on Women’s Health demonstrates that between 1999 and 2015, the rate of deaths from prescription opioid overdoses increased 471 percent among women, compared with an increase of 218 percent among men; and heroin deaths among women increased at more than twice the rate than among men. Also, the differences in how prescription opioid and heroin use impacts women and men are often not well understood. There are potentially many factors that affect a woman’s path to opioid misuse and dependancy, including biological and social influences, past experiences, geography, and demographic characteristics. However, many knowledge gaps remain on how these relate to the opioid misuse.

According to the The Centers for Disease Control and Prevention (CDC), women are more likely than men to experience chronic pain, and use prescription opioid pain medications for longer periods and in higher doses. Women tend to use substances differently than men, sometimes using a smaller amount of drugs for a shorter period of time before they become dependent. In March of 2016, the CDC issued the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016, which summarized the research literature on the benefits and risks associated with prescribing opioids and provides an evidence-based guide for prescribers and patients to share decision-making responsibility about opioid use, and alternative treatment options for chronic pain management.   

As a women’s health nurse practitioner, this has significant impact to my practice, and my licensing. Some states now require opioid education in order to renew prescriptive authority. Combatting this problem requires a multi-factorial approach. We all need to be more aware and vigilant with prescribing, confirming orders, patient education, and post-surgical follow up.
Dowell, D., Haegerich, T., & Chou, R. (2016, March 18). CDC Guideline for Prescribing Opioids for Chronic Pain — United States,  2016. Retrieved from Centers for Disease Control and Prevention :

Office on Women's Health. (2016, December). White Paper: Opioid Use, Misuse, and Overdose in Women. Retrieved from Women'

Pacira Pharmaceuticals, Inc. . (2017, September 26). Plan Against Pain . Retrieved from The United States for Non-Dependence: An Analysis of the Impact of Opioid Overprescribing in America:
Lynne Centrella Rudderow, MSN, RN, CRNP, WHNP-BC, CCE



Posted: 11/6/2017 8:30:56 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Collaboration, communication, cooperation

Nurse Wubbels…If you haven’t heard, seen, or read this story, here is a link to The Washington Post article, which includes the video. Briefly, nurse Alex Wubbels was arrested after refusing to allow a detective to obtain a blood sample from an unconscious patient. And here are the details:
  • The detective didn’t have a warrant and the patient was not under arrest.
  • Consent could not be obtained because the patient was unconscious.
  • Nurse Wubbels followed hospital policy – and the law – by refusing the blood draw.
  • Nurse Wubbels acted professionally and responsibly, by confirming policy with her supervisor.
  • Nurse Wubbels was threatened, assaulted, and arrested.
My initial reactions were anger and shock, and these feelings still come to the surface when I read the story and watch the video. After more time has passed and I’ve given it more thought, three words come to mind: collaboration, communication, and cooperation. Here’s why…

My experiences with law enforcement at the bedside have always been positive. If there was a patient in our unit who was under arrest, the officers and nurses depended on each other to share information with each other that was necessary and within the law. Oftentimes, if a patient was restrained or combative, the officers were a calming presence for all the hospital staff; we felt safe. I think (hope) that the officers knew, we were providing care to a patient and would uphold the highest level of care, no matter who that patient was.

I don’t know anything about training of law enforcement, but I know how much emphasis is placed on communication during a nurse’s education! We focus on verbal and nonverbal cues, learn strategies to get the information we need, and practice our communication skills from those very first semesters of nursing school. It’s an important part of our job and I must give a shoutout to nurse Wubbels for maintaining professionalism despite being bullied.

team.pngI think of cooperation, not in the sense of doing what one is told, but to take this unfortunate incident and work together to learn from it. As nurses, we are obligated to our patients. Who are police officers obligated to? Is it the public? Is it the law? Nurse Wubbels put the patient first, while risking her own well-being and safety. The detective in this case did not demonstrate duty to the public, nor the law. It is that cooperation that is missing here – respectfully working together to meet the goals of our chosen professions and to serve the people who depend on us.

We’ve all got a job to do – and to do it well, we must work together.
*At the time of this writing, two members of law enforcement are on administrative leave, and an investigation is underway.


Posted: 9/5/2017 2:16:20 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Using the art and science of nursing to fight the opioid crisis

emergency.jpgEvery day we see it in the news and in our emergency departments, a person overdosing on prescription or street drugs. Every day, 90 Americans die due to an opioid overdose and in 2015, 33,000 lives were lost (Rudd, et al., 2016).  Age, gender, socioeconomic class, it doesn’t matter; opioid overdose has become a crisis that causes heartache for not only the overdose victim, but their loved ones too. Some victims are lucky; they receive naloxone and are revived, but too often they just repeat the behavior that landed them in trouble in the first place. So why are we, as one of the most developed nations in the world, in this predicament? What can we do as a country and as nurses to change this precarious course?  

We’ve all seen patients in pain and know it’s real. But, something happened over the past 20 years. Somehow, we thought patients should be pain free no matter what the cause, and we even considered it a 5th vital sign, although it was never meant to be considered that way (Morone & Weiner, 2013).  Let’s think about that for a minute. It’s completely unrealistic that after surgery or an injury, a person won’t experience pain; in fact, pain gives us information that something maybe wrong. We should have been focusing on decreasing pain, not totally alleviating it.  

With the availability of tablet formulations  growing in the 1990’s, the number of opioid prescriptions and the length of time they were prescribed grew. When their prescriptions ran out, many turned to less costly street drugs like heroin; in fact, 80% of patients who use heroin today used prescription opioids first (Muhuri, et al., 2013). Many people can access prescription opioids by using a family member’s or friend’s medication or buying them on the street. Today 21% to 29% of patients prescribed opioids for chronic pain misuse them and 8% to 12% of these people will develop an opioid use disorder (Vowles, et al., 2015; Muhuri, et al., 2013; Cicero, et al., 2014; Carlson et al., 2016). 

The federal government is trying to alleviate this crisis. The Department of Health and Human Services is working to improve access to drug treatment programs, promote the use of overdose-reversing drugs (such as naloxone), and improve public health surveillance. The National Institutes of Health has devoted funding for research on innovative pain management and addiction treatment. 

Nurses are an integral part of the interdisciplinary team fighting the opioid crisis. For those of us who prescribe opioids, before writing the prescription, we must now check the Prescription Drug Monitoring Program Database to investigate the patient’s opioid prescription history. We must advocate for and practice responsible prescribing of opioids; we do not want any organization dictating our prescription practices. We need to encourage patients to seek treatment for opioid addiction and help them find those resources. We need to teach patients how to properly dispose of their used opioid medications.

Nursing is both an art and a science, and using those principles can help guide our pain management practice through:
  • Educating patients that reducing pain, not completely alleviating it, is often the goal.
  • Evaluating and managing the patient’s anxiety through relaxation techniques.
  • Using correct patient positioning.
  • Using ice or heat when appropriate.
  • Using compression and elevation for sprains or strains.
  • Encouraging rest.
  • Using acupuncture, meditation, and other alternative or naturopathic techniques.
When we do administer an opioid medication to a patient, we need to consider: is this the right drug for the right level and right type of pain? Would an alternative drug such as acetaminophen, ibuprofen, gabapentin or something else be more appropriate?

The opioid crisis has brought too much heartache to this country. As nurses, we must recognize we are integral to assessing and managing pain appropriately, be able to identify patients who need addiction therapy and help them gain access to those resources, and we must be a voice for responsible prescribing. Together with the interdisciplinary team, we can help to alleviate the opioid crisis; we owe it to our patients!
Rudd RA, Seth P, David F, Scholl L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/mmwr.mm655051e1.
Morone NE, Weiner DK. (2013). Pain as the fifth vital sign: exposing the vital need for pain education. Clin Ther. 2013;35(11):1728-1732. doi:10.1016/j.clinthera.2013.10.001.
Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.
Muhuri PK, Gfroerer JC, Davies MC. (2013). Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.
Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. (2014). The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.
Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. (2016). Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.
Chief Nurse, Wolters Kluwer



Posted: 8/30/2017 4:52:14 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Body Mass Index and Body Surface Area: What's the Difference?

Body mass index (BMI) and body surface area (BSA) are two measures used frequently in health care, however, they are not well understood. While they are both indicators of body size, they provide very different information. What exactly do each of these measures tell us and how should they be used?

Body Mass Index (BMI)

BMI is a measure used to determine a person’s degree of overweight. Calculated based on height and weight,1 BMI is easy to measure, reliable, and correlated with percentage of body fat mass. It is a more accurate estimate of total body fat compared with body weight alone.2 BMI can also help gauge a person’s risk for conditions such as heart disease, high blood pressure, type 2 diabetes, gallstones, respiratory problems, and certain cancers. One downside of measuring BMI alone is that it may overestimate body fat in athletes or people with a muscular build. Conversely, it may underestimate body fat in the elderly or in people who have lost muscle.

BMI is calculated by taking the body weight in kilograms (kg) and dividing it by the height in meters (m) squared.

While there are programs and mobile applications that will calculate BMI for you, it’s important to know the formula and how to derive the answer. Let’s practice!

Example 1: What is the BMI for Mr. Jones weighing 210 pounds with a height of 6 feet, 3 inches?
  1. Convert pounds to kilograms: 210 pounds ÷ 2.2 kg/pound = 95.45 kg
  2. Calculate height in meters:
    1. 6 feet, 3 inches = 75 inches
    2. 75 inches x 2.54 cm/inch = 190.5 centimeters (cm)
    3. 190.5 cm ÷ 100 cm/m = 1.905 meters
    4. Square the height (1.905 x 1.905) = 3.63 m2
  3. Calculate BMI by dividing the weight by the height (m)2
    1. 95.45 ÷ 3.63 = 26.3 m2
Example 2: What is the BMI for Mr. Smith weighing 210 pounds and 5 feet, 4 inches tall?
  1. 210 pounds = 95.45 kg
  2. Calculate the height in meters:
    1. 5 feet, 4 inches = 64 inches
    2. 64 inches x 2.54 cm/inch = 162.56 cm
    3. 162.56 cm = 1.625 meters
    4. Square the height (1.625 x 1.625) = 2.64 m2
  3. Calculate BMI:
    1. 95.45 ÷ 2.64 = 36.2 m2
Example 3: What is the BMI for Mrs. Williams weighing 110 pounds and 5 feet, 8 inches tall?
  1. 110 pounds = 50 kg
  2. Calculate height in meters:
    1. 5 feet, 8 inches = 68 inches
    2. 68 inches x 2.54 cm/inch = 172.72 cm
    3. 172.72 cm = 1.727 m
    4. Square the height = 2.98 m2
  3. Calculate BMI:
    1. 50 ÷ 2.98 = 16.8 m2
What do these scores mean? According to the BMI Classification scale adopted by the National Institute of Health (NIH) and the World Health Organization (WHO), Mr. Jones would be considered slightly overweight, Mr. Smith would fall under the category of obese, and Mrs. Williams would be considered underweight.
The BMI scores are classified based on risk for cardiovascular disease and can be applied to people of Caucasian, Hispanic, and African-American race. However, these standards may underestimate the risk of obesity and diabetes in people of Asian and South Asian descent. A lower threshold should be used for these populations.

Measurement of waist circumference in conjunction with BMI can provide additional information on risk that is not accounted for by BMI. The NIH recommends measuring waist circumference in overweight and obese adults to assess abdominal obesity. A waist circumference > 40 inches (102 cm) for men and > 35 inches (88 cm) for women may indicate an increased risk for cardiovascular and metabolic disorders.2

When further assessing the patients above, Mr. Jones was found to have a waist circumference of 37 inches and was deemed to be at a lower risk for obesity. For Mr. Smith, measuring waist circumference is not necessary as most patients with a BMI > 35 kg/m2 are already considered at high cardiometabolic risk.

Body Surface Area (BSA)

BSA measures the total surface area of the body and is used to calculate drug dosages and medical indicators or assessments. The first formula was developed by Du Bois in 1916 and since then, several others have been developed. The Mosteller formula, which is the easiest to calculate and remember, is the most commonly used formula in practice and in clinical trials.2
The Mosteller formula takes the square root of the height (cm) multiplied by the weight (kg) divided by 3600.
Let’s use the same examples above and calculate each patient’s BSA.
Example 1: Mr. Jones
  1. Calculate weight in kilograms: 210 pounds ÷ 2.2 = 95.45 kg
  2. Calculate height in centimeters: 6 feet, 3 inches = 75 inches x 2.54 cm/inch = 190.5 cm
  3. Multiply height by weight and divide by 3600
    1. (190.5 cm x 95.45 kg) ÷ 3600 = 5
  4. Take the square root of 5 = 2.24 m2
Example 2: Mr. Smith
  1. Weight in kg = 95.45 kg
  2. Height in cm: 5 feet, 4 inches = 64 inches x 2.54 cm/inch = 162.56 cm
  3. (162.56 cm x 95.45 kg) ÷ 3600 = 4.3
  4. Take square root of 4.3 = 2.07 m2
Example 3: Mrs. Williams
  1. Weight in kg = 50 kg
  2. Height in cm: 5 feet, 8 inches = 68 inches x 2.54 cm/inch = 172.72 cm
  3. (172.72 cm x 50 kg) ÷ 3600 = 2.39
  4. Take square root of 2.39 = 1.55 m2
The average adult BSA is 1.7 m2 (1.9 m2 for adult males and 1.6 m2 for adult females). This number is used to calculate dosages for cytotoxic anticancer agents. To minimize variation in patient size, dosing for most chemotherapeutic agents use mg of drug per m2 of body surface area.2 Although this methodology has not been rigorously validated, BSA-based dosing has become the standard when prescribing most cytotoxic agents and some therapeutic monoclonal antibodies. In theory, BSA mitigates the variability of patient size and abnormal adipose tissue to help optimize drug efficacy, improve drug clearance and to minimize or prevent toxicity.2
BSA is also used to provide more precise measures of hemodynamic parameters such as cardiac index (CI = cardiac output divided by BSA), stroke volume index (SVI = stroke volume divided by BSA), systemic vascular resistance index (SVRI = systemic vascular resistance divided by BSA) and pulmonary vascular resistance index (PVRI = pulmonary vascular resistance divided by BSA). In addition, BSA is used to adjust creatinine clearance when comparing it with normal values to assess for the presence and severity of kidney disease.2
Let’s look at cardiac index. If Mr. Jones, whose BSA is 2.24 m2, has a cardiac output of 4.3 L/min, his cardiac index would be 1.92 L/min/m2 (4.3 L/min divided by 2.24 m2). If Mrs. Williams, whose BSA is 1.55 m2, has the same cardiac output of 4.3 L/min, her cardiac index would be 2.77 L/min/ m2. While 4.3 L/min falls within the normal range for cardiac output, Mr. Jones’ cardiac index of 1.92 L/min/m2 is below the normal range of 2.5 – 4.0 L/min/m2. Further assessment is required to determine the underlying cause of his low cardiac output and plan treatment modalities. He may require a fluid bolus for dehydration and tachycardia or an inotropic agent for heart failure.
I hope this review of BMI and BSA was helpful. We would love to hear your feedback for ways in which you use BMI and BSA in your daily practice.
  1. US Department of Health & Human Services. National Institutes of Health. Assessing your health and weight risk. Retrieved on 7/18/17 from
  2. UpToDate: Obesity in adults: Prevalence, screening and evaluation. Retrieved on 7/18/17 from
 Myrna B. Schnur, RN, MSN 


Posted: 8/23/2017 5:57:12 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Transmission-based isolation precautions for common pathogens

As a follow-up to our previous post on isolation guidelines, here is a list of transmission-based precautions recommended for common pathogens. 

Megan Doble, MSN, RN, CRNP
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at:

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at:

Add this infographic to your website by copying and pasting the following embed code:

Posted: 4/9/2017 5:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Diseases & Conditions Patient Safety

Brushing up on isolation guidelines

As the influenza season begins to subside, we can take a step back and reflect on best practices. Isolation guidelines in the health care setting continue to come up year after year as an area that brings some confusion to the clinical realm. According to the CDC, on average, 200,000 persons are hospitalized with influenza-related illnesses on an annual basis. It is imperative, therefore, that we take proper precautions to prevent the spread in the health care setting. 

Influenza is transmitted from person to person through large particle respiratory droplets which can travel up to 6 feet. Transmission may also occur via contact of infectious particles to mucosal surfaces, such as when someone coughs or sneezes in close contact or on a surface.  Thus, patients with confirmed or suspected influenza must, in addition to standard precautions, adhere to droplet precautions. According to the CDC, patients with confirmed or suspected influenza should adhere to droplet precautions for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms in the health care setting. Some health care facilities may have a specific policy requiring a longer duration of adherence to droplet precautions.

Most health care facilities have an infection control nurse or department to contact if there are any questions regarding the level of transmission-based precautions. Furthermore, the CDC offers a comprehensive reference with explicit details on preventing the spread of influenza in the health care setting.

As a review, the CDC guidelines for isolation precautions are presented in the infographics below.
(Please click infographics to view larger sizes.)
Isolation-Precautions-300x750.png  Transmission-Based-Precautions-300x750.png

Megan Doble, MSN, RN, CRNP
Centers for Disease Control (CDC), 2016. Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. Available at:

Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee, (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. Available at:


More Reading & Resources
Transmission-based isolation precautions for common pathogens
Evaluating Isolation Behaviors by Nurses Using Mobile Computer Workstations at the Bedside
Clinical Challenges in Isolation Care



Posted: 4/6/2017 9:34:16 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Patient Safety: A personal memory and professional history

cone-164333_640.jpgIt’s Patient Safety Awareness Week, and I am reminded of an experience I had as a nursing student. My first medication error has stuck with me all these years. Why? Because like all health care professionals, as nurses, our priority is to do no harm. While not all issues related to patient safety are due to human error, we do feel a personal responsibility to ensure our patients’ safety. In today’s fast-paced health care world, that is not an easy task. While technological advances have provided a lot of support, we know that we can’t rely solely on technology – attention and collaboration, as well as speaking out about our experiences, are key.

In February of 2017, Nursing's Evolving Role in Patient Safety was published in American Journal of Nursing. This content analysis documents the history of patient safety related to nursing care, as illustrated by articles published in the journal. What an interesting study demonstrating the importance of our role in keeping patients safe through the years. The analysis dates back to the first issue of AJN in October of 1900! Go ahead and give this a read – you’ll see just how much has changed and, equally important, how much has stayed the same. 

Posted: 3/14/2017 10:57:17 PM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Trauma-informed care

I stood in the doorway of room 630 and observed her staring out the window, consumed by thought. She was a 20-year old young woman who had been admitted to the medical unit due to gastrointestinal bleeding. I walked into the room, introduced myself and told her that I needed to perform my initial physical assessment. I put on my stethoscope and motioned closer, then she raised her hands and said “Please, don’t.” I stepped back, confused, and informed her that I needed to check on her bleeding and to make sure everything was ok. She shook her head as tears filled her eyes. I asked her why she was crying and she stated “because I don’t feel comfortable having a stranger touch me.” I assured her that I wouldn’t hurt her and after several more minutes of silence she stated, “I was sexually abused as a teenager.” I thanked her for sharing that very personal and painful information and asked how I could make her more comfortable. She was grateful and just asked for more time. It was early in my nursing career, and I didn’t have any specific training or experience dealing with trauma victims.

trauma-informed-care.jpgTraumatic events, such as sexual abuse, domestic violence, elder abuse, and combat trauma, can have serious long-term detrimental effects on the physical, emotional, and mental well-being of an individual. These life events may lead to depression, distrust, smoking, substance abuse, shame, and low self-esteem. Traumatic events can also shape an individual’s comfort level and attitude toward health care.1 Routine preventative health care visits that involve invasive physical exams and close contact with a health care provider could trigger fear and anxiety in the patient.

Trauma-informed care (TIC) is a term that has been used in recent years in a variety of areas, including social services, education, mental health, and corrections to address the needs of people who have experienced traumatic life events. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a methodology to respond to those who are at risk or have experienced trauma.2 There are four essential approaches and six principles of trauma-informed care.

The four essential approaches of trauma-informed care can be found in a program, organization, or system that2:
  1. Realizes the widespread impact of trauma and understands potential paths for recovery.
  2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
  3. Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
  4. Seeks to actively resist retraumatization.
The six key principles of trauma-informed care include2:
  1. Safety – make sure your patient and family members feel safe, both physically and psychologically.
  2. Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
  3. Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
  4. Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
  5. Empowerment, voice, and choice – identify individual strengths and differences and utilize them as the foundation for recovery and healing. Provide the patient with choices and an opportunity to share in the decision-making process, which results in a sense of control.
  6. Recognition of cultural, historical, and gender issues – set aside cultural stereotypes and biases.
How do we put these principles into every day practice? For patients who openly share their trauma history, clinicians should be careful when delving into their psychological histories, unless they have specific training in trauma.1 Many patients, however, feel ashamed and are not comfortable exposing their past. Every member of the health care team should be trained on universal trauma precautions, which is the idea that every person potentially has a history of trauma.2 There are several strategies that clinicians can utilize to implement the TIC approach in general patient care. 1

1. Patient-centered communication:
  1. Ask every patient what can be done to make them more comfortable during their appointment.
  2. Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
  3. Give the patient the option to shift their clothing out of the way instead of putting on a gown.
  4. Provide a pillow for back support for patients who are anxious in the supine position.
  5. Offer a mirror to see procedures or examinations that a patient cannot see.
  6. If a patient seems moderately to highly anxious, offer ways for patients to signal distress either verbally or by raising their hand during a procedure.
2. Understanding the health effects of trauma:      
  1. Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
  2. Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.
3. Multidisciplinary collaboration: 
  1. Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
  2. Keep referral and educational material on trauma available in waiting rooms.
  3. Engage in inter-professional collaboration to ensure continuity of care.
4. Understanding your own history and reactions:
  1. Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
  2. Learn the signs of professional burnout and prioritize good self-care.
5. Screening:
  1. Decide if your organization will screen for current trauma or a history of traumatic events.
  2. Consider if screenings will be face-to-face or self-reported by the patient.
  3. Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
  4. Ensure your organization has the resources available to properly care for the patient, or have processes in place to refer patients to other resources.
Unfortunately, traumatic events occur more often in our society than we think. Caring for patients with a history of traumatic life events requires a high level of sensitivity and compassion. Health care organizations can assist their staff in navigating delicate and difficult situations by providing educational training, tools and resources on the trauma-informed care approach.
Resources for Health Care Providers:
Child Welfare Information Gateway
National Council for Behavioral Health
Substance Abuse and Mental Health Services Administration
The Trauma Informed Care Project
  1. Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma Informed Care in Medicine: Current Knowledge and Future Research Directions. Family Community Health, 38(3), 216-226.
  2. Koetting, C. (2016). Trauma-Informed Care: Helping Patients with a Painful Past. Journal of Christian Nursing, 33 (4), 206-213.
Myrna B. Schnur, RN, MSN 

Posted: 11/10/2016 2:29:07 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Nurses ARE the Safety Net!

nurses-are-the-safety-nets.PNGThis year’s Nurses Week theme focuses on safety – “Culture of Safety – It Starts with YOU.”  Immediately many of us think of patient safety, and that’s as it should be – patients come first. We know that hospitals can be hazardous to patients because of nosocomial infections, medication errors, slips and falls, increased stress because of lack of sleep. Because of our around-the-clock presence, nurses have always been the sentinels, shepherding our charges towards discharge with no complications.

The ANA defines a culture of safety “as one in which core values and behaviors — resulting from a collective and sustained commitment by organizational leadership, managers and workers — emphasize safety over competing goals.”  That’s a great concept but not one that every hospital has put into practice.

Staffing, of course, has to be key – how can nurses fulfill one of our most critical functions – assessing and monitoring patients – if there are too few of us to be able to spend time with patients? How can we prevent pressure ulcers and promote return to strength and mobility if there are too few of us to safely assist patients to ambulate?  Patients who’ve been in and out of hospitals – the “experienced” patient – know that nurses are the key to recovery. I unearthed this from an AJN article published in the 1970s:

The patients were then asked what they felt was the most positive aspect of their experience on the intensive care unit as well as the most negative. Thirteen responded that the most positive aspect was “knowing that the nurses were there every minute”; 10 answered simply, “nurses.”

But a true culture of safety has to include our own individual commitment to safety. The 12-hour shift has come under fire as evidence is mounting that it’s not the best solution for nurses or for patients. (We’ve covered the issue in AJN in a March 2014 news article as it relates to fatigue, and also in the AJN blog, Off the Charts.)  The shifts often extend to more than 12 hours, often without breaks; and some nurses may pick-up extra shifts, working four or five straight days of 12-hour shifts. I don’t work in a hospital but in an office,  yet when I’m on deadlines and working 10-12 hour days, my brain is fried after four days and I know I’m not thinking as clear as I should be. I’d be afraid to have that kind of fatigue and have to give medications and make critical decisions with lives at stake.

We know nurses have been involved in auto accidents (In the February 2014 issue of AJN, we reported on a nurse who was killed on her way home) and involved in near-misses on the drive home from long shifts – my sister, a former NICU night nurse, always put the car in park when she came to a stop light after she found herself falling asleep and coasting through an intersection on her way home.

So for this Nurses’ Week, make a commitment to safety – your patients’ and your own.

Shawn Kennedy, MA, RN, FAAN

Posted: 5/11/2016 9:41:11 PM by Lisa Bonsall, MSN, RN, CRNP | with 4 comments

Categories: Patient Safety

Violence Against Nurses

Recently, there has been growing attention given to violence in the workplace. This new attention is extremely important because previously there was relative silence about violence against nurses and other health care workers, although it happens very regularly in our work settings. Personally, I have worked in a wide range of health care settings, including home care. Safety was a priority in home care because nurses must travel alone, often in unknown areas and situations. Do you know, however, that most workplace violence occurs in the hospital setting, particularly in psychiatric units and emergency departments? According to a recent study, 80% of emergency nurses reported that they experienced some level of violence in the past year, for home care that was 60%. As you are reading this, you may not think this is possible, but I suggest that you answer the following question to see if you have experienced workplace violence.

While performing your role as a nurse in a clinical, administrative, management, or education role, has a patient, resident, family member, or coworker ever: yelled at you, harassed you, threatened you, hit, punched, or scratched you, spit or thrown any other bodily fluid or waste at you?

Workplace violence, according to the Occupational Health and Safety Administration (OSHA), covers a range of behaviors from bullying to committing homicide, and it also covers actions that are from patients or residents who may be fully aware of their actions, as well as those who may have dementia, delirium, drug or alcohol intoxication, or mentally incompetence. Unfortunately, OSHA has no specific standards that they are requiring of all employers to prevent workplace violence.2 What exists is a general duty of employers to ensure safety and prevent workplace injury and illness.2

Quote-Karen-Innocent.pngPreventing Workplace Violence
First, it is very important to understand that as a nurse, or any type of employee, you have a right to be safe at work. Safety concerns at work were taken very seriously since 1970 when the United States Congress passed the Occupational Safety and Health Act, which set mandatory standards to prevent injury to employees for all types of causes, including violent acts. The OSHA website contains links to several health care and professional organizations and government agencies that provide guidelines for workplace violence prevention.

Recommendations include:
  • Employers should assess and mitigate risk, providing employee training, implementing safety programs, and report incidents.3
  • Your workplace may be at high risk for if you and your colleagues do not have training in early recognition and management of potentially violent situations; your facility does not have policies to ensure safety, like zero tolerance rules on violence, firearms, and carrying other weapons; or if the organization is frequently staffed inadequately and/or lacks security personnel.
  • OSHA relies on nurses and nursing administrators to speak out and report serious concerns about workplace safety, and protects those who report issues with whistle-blower laws.2 
  • Nursing organizations, including the American Association of Critical Care Nurses and the American Nurses Association, have also advocated for protection of nurses from workplace violence and have published position statements on the topic – Workplace Violence Prevention and Incivility, Bullying, and Workplace Violence, respectively.
  • Tap into your member organization for assistance with violence prevention programs in your workplace.
The Center for Disease Control and Prevention (CDC) is one of those government agencies that has resources to assist employers and workers in keeping their workplaces safe. For example, Workplace Violence Prevention for Nurses is a free course for nurses that is available on the CDC website. With so many factors that contribute to violence in health care settings, there is no single resource or solution that can be implemented to resolve the problem. Therefore, it is best to stay informed about the available resources and perhaps start by reading some of the workplace safety articles on Lippincott and take advantage of a National Nurses Week CE Collection discount this week.
1. Phillips, J. Workplace Violence against Health Care Workers in the United States. New Engl J Med. 2016; 374(17):1661-1669.
2. Occupational Safety and Health Administration. (n.d.) Workplace Violence: Enforcement. Retrieved on May 3, 2016 from
3. The National Institute for Occupational Safety and Health (NIOSH). June 26, 2014 Recent NIOSH Research on Occupational Violence and Homicide, Retrieved from
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Posted: 5/10/2016 10:27:58 PM by Lisa Bonsall, MSN, RN, CRNP | with 3 comments

Categories: Patient Safety

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