A research article was published in the September issue of Health Affairs, that looked at how patients are using healthcare services for acute care. The study reviewed 354 million visits to healthcare institutions or healthcare providers for acute care between 2001 and 2004. Twenty eight percent of the visits were handled by hospital emergency rooms, 22% were handled by general/family practitioners, 20% were seen by non-primary care specialists, 10% by general internists, and 7% by hospital outpatient departments. The uninsured received more than half of their acute care in emergency departments and much of this occured on the weekends or weekday after hours. Two of the most frequent conditions seen were stomach pain and chest pain.
By definition, shouldn't "acute care" issues be seen in acute care? If you or your relative was having chest pain, would you send them to the primary care provider's office? I would hope not; you would call 911 and send them to the nearest emergency department for evaluation for an acute myocardial infarction. If you or your relative were having severe abdominal pain, would you send them to the family practice office? No, of course not; you would send them to the nearest ED to be evaluated and have an ultrasound or CT scan done if appropriate.
I agree that our emergency departments are over taxed with patients coming in for complaints that could easily be treated in a primary care office or clinic. But, chest pain, severe stomach pain, fractures, and severe lacerations, just to name a few, need the attention of the experts who have the experience and the resources to treat those things that are clearly "acute care" issues.
Posted by Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
In 1859, Charles Dickens wrote the book, "The Tale of Two Cities," which was a comparison of life in London and Paris and compared life of the aristocracy versus life of the peasantry in those two cities. Throughout my 30 plus years of being a nurse and nurse practitioner, I have watched and participated in the ethical dilemmas nurses and other healthcare providers encounter on a day to day basis. I have spent the majority of my professional nursing career in acute and critical care. As a nurse practitioner, my role is different than when I was a nurse; however, the issues I face are the same as all nurses in regards to ensuring patients receive optimum care that improves quality of life, not necessarily extending it. This brings me to, "The Tale of Two Patients."
A few weeks ago I took care of two patients; two patients with similar stories, both had end-stage COPD and both were admitted to the ICU for a COPD exacerbation. Both patients received similar treatment, and both patients continued to deteriorate simply because their disease had progressed beyond recovery. As a nurse, I was always taught to focus on quality not quantity of life, and quality of life is defined by the patient, not the healthcare professionals or the family.
The first patient had an advanced directive and had obviously communicated well with her family. They were all in agreement the patient should not be intubated, and instead, be placed on hospice and made comfortable. There was great peace among the patient, her family members and the entire nursing and healthcare staff. They rejoiced in the fact the patient had lived a full life and could now go on to a better place to be with her husband who had passed two years prior. Everyone agreed -- following the patient's advanced directive and making her a do not resuscitate was the right thing to do.
The second patient did not have an advanced directive, and had never spoken to her family about her wishes. Despite numerous attempts to discuss the patient's prognosis with the patient and her family, the family insisted everything be done and the patient capitulated to their demands. The patient was intubated and placed on a ventilator. Everyone knew the patient would never come off the vent and would eventually die in the ICU. After several days, the patient went into multiorgan failure and the family finally agreed that the patient should be allowed to die in peace. The patient was placed on a morphine infusion for comfort and died with the family still fighting over her. There was great sorrow in the eyes and hearts of everyone taking care of her. Nurses are about quality care, and even though the patient eventually died comfortably, everyone knew the situation could have been avoided if the patient had discussed her wishes with her family and her primary care provider and had an advanced directive.
As nurses, we see the ethical importance of doing what our patient's want; we are their advocates and their voice even in their most desperate hour. Healthcare professionals have an obligation to speak with their patients before the patient is in a life-threatening situation. The first time a discussion occurs should not be when the patient is critically ill and facing no chance of recovery. Quality of life must be defined by the patient and no one else. In this day and age, the tale of two patients should not be a story we tell in healthcare.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer
Health, Learning & Practice
Nurse Practitioner, Critical Care Services
Penn Medicine Chester County Hospital
Adjunct Faculty
Drexel University
College of Nursing & Health Sciences
When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice. The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession.
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more. As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner.
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders. The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.
Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
Editor-In-Chief, Nursing2015
In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
Reference
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.
William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences
Change is upon us. According 2008 data from the U.S. Dept of Labor (DOL) Bureau of Labor Statistics, most of the 2.8 million employed nurses are working in hospitals. While the DOL projects that the demand for nurses will require over a half million new positions by 2018, nurses are more likely to be hired in non-acute care settings including primary care offices, home care, and long-term care facilities. There are a number of factors contributing to this trend including: the aging population, increased access to healthcare, and advances in healthcare technology. As more people are living longer, there is a greater need for continuing care beyond hospital discharge and services to manage chronic conditions and disabilities. Healthcare reform is going to provide more individuals with access to primary care and preventive care who couldn’t afford it in the past. As the science and technology of healthcare advances, more patients are opting for less invasive diagnostics and surgeries that reduce length of stay in hospitals or eliminate the need for an admission.
Instead of mourning the loss of hospital jobs, nurses should retool their careers for the new and expanded opportunities. The following are examples of education and skills that may prepare nurses for the future.
-
Return to graduate school and become a nurse practitioner to fill the demand for primary care providers.
-
Earn wound ostomy and continence nursing certification to fill the need for WOCNs in wound care clinics and in home care.
-
Obtain certification in infusion nursing or insertion or peripherally inserted central catheters (PICC) to meet the requirements of home infusion services or clinics that provide blood components, chemotherapy and other I.V. medications.
Of course there are many more skills and certifications that nurses could acquire that will position them well in the future job market. Regardless of nurses’ current roles or work settings, they should stay in tune with the trends and embrace change by continually developing contemporary skills and credentials.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
Have you made any adjustments in your career goals or education plans based on the RWJF and IOM Report , The Future of Nursing: Leading Change, Advancing Health, released last October?
I have been away from clinical nursing since 2001. I can’t believe that it has been 10 years. I’ve always believed that someday I would go “back to the bedside” and I really do miss taking care of patients. It’s been a little more noticeable to me lately just how much I miss the clinical side of nursing. I’m not sure if it’s because the fact that it’s been 10 years overwhelms me or because I am excited about the direction in which our profession is headed. Perhaps it’s a little of both.
The question that really gets to me is where do I want to be? Critical care was my home for most of my clinical career. I loved the thrill of caring for acutely ill patients and their families. Titrating vasoactive drugs, assisting with invasive procedures, using the latest technologies - all so cool! Admissions from the ER, “road trips” to diagnostic tests, end-of-life discussions, and the list goes on…
However, my “other list” is quite impressive to me also. As a women’s health NP, it was so fulfilling to be in the community and make a difference educating women about preventive care. Also, contraceptive counseling, prenatal care and teaching, helping someone find some relief from her symptoms of menopause, and so on…. Primary care practitioners have so much to offer and the need is so great.
The very first key message from the IOM report states “Nurses should practice to the full extent of their education and training.” Does this mean that it is my duty to practice as an NP because I have the degree and license? Would I be disregarding this message by returning to staff nursing in the ICU? I sure hope not. Then again, I could always pursue another degree…critical care NP might be the answer. Now there’s something for me to think about!
Perhaps as we prepare for the future of our profession, we should all take this time to look at our individual goals as well. What is your future in nursing?
On March 22, 2011, the Editors-in-Chief of the top LWW nursing journals got together for a roundtable discussion about the Institute of Medicine and the Robert Wood Johnson Foundation Report on the Future of Nursing. For those of you who listened in, I hope you enjoyed the conversation about how these nurse leaders interpret and understand the key messages and recommendations from the report. For me, the task at hand is now clearer. It is now up to us nurses to bring our profession and our own careers to the level we deserve. I’d like to share some of what I took away from this discussion.
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC, Chief Nurse of Wolters Kluwer Health/ Lippincott Williams & Wilkins and Ovid Technologies, moderated the discussion and reminded me that there are 3.1 million nurses (which is the largest group of health care providers) in the United States and we “need a seat at the table” to “make changes happen.” Anne then went on to explain in detail the key messages and recommendations in the report.
Maureen ""Shawn"" Kennedy, MA, RN, Editor-in-Chief of the American Journal of Nursing, spoke next about what the Report means to “nurses at the point of care” - which includes staff nurses, nurses practicing in home care, nursing homes, and other areas where direct patient care is occurring. She speaks about professional practice and having a voice when it comes to priorities of care. Later in the webcast, Shawn talks about the education of nurses being for the public good and she includes good points about responsibility for funding.
Rich Hader, PhD, NE-BC, RN, CHE, CPHQ, FAAN, Editor-in-Chief of Nursing Management and Senior Vice-President and Chief Nursing Office of Meridian Health System gave his take on the report and what it means for managers and other nurse leaders. Some of his great words included “forge partnerships with academic colleagues” and “produce lifelong learning.” He commented on the timeliness of the report and brought up the idea of economic incentive for nurses going back to school. Rich also lists some key ideas for leaders and managers.
Jamesetta Newland, PhD, FNP-BC, FAANP, DPNAP, Editor-in-Chief of The Nurse Practitioner and Clinical Associate Professor at New York University shared her views on the report with regards to advanced practice nurses (APNs). She commented about APNs being trained holistically and the push to move the healthcare system to one of wellness, instead of illness.
Janet Fulton, PhD, RN, Editor-in-Chief of Clinical Nurse Specialist and Associate Professor at Indiana University spoke about clinical nurse specialists in acute care. Her comments about all APNs collaborating with each other to provide inpatient and outpatient care were eye-opening, especially her quote “nursing collaborating with itself.” Another good one…for all APNs to “push the boundaries to meet the public’s need.”
Suzanne Smith, EdD, RN, FAAN, Editor-in-Chief of the Journal of Nursing Administration and Nurse Educator spoke about the meaning of the report for educators and students. She suggested that we refer to guiding reports from organizations such as the NLN and the AACN. Specifically, Suzanne refers to the AACN’s “call for imagination” and the need for “dramatic change in Master’s education.” This discussion proceeds to the issue of cost.
The entire webcast has been archived and will be available for a limited time.
It's the time of year when many who work in teaching hospitals are welcoming new medical students and interns into their organizations. Due to the inexperience and lack of clinical knowledge, July has been associated with poorer patient quality outcomes compared to other months. Experienced registered nurses, nurse managers, and advanced practice nurses can be more proactive during this time to reduce their own stress and provide support to their medical colleagues. For instance, if your unit has a set of protocols, provide them to the medical students and first year residents. Don't expect that someone else is going to do it. You may want to take a step further and schedule a unit orientation. You may need to coordinate this with the director of the graduate medical education; however, this could prove to be very helpful and appreciated. Lastly, many facilities are establishing inter-disciplinary rounds. This can be a great communication tool, it can facilitate learning, and it can improve patient outcomes.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
I just came across a great piece on communication in Journal of Perinatal and Neonatal Nursing. The author, Lisa A. Miller CNM, JD, is an educator who is “obsessed with communication.” As nurses, I think we all need to have a bit of an obsession with communication – it’s a big part of what we do! How we communicate with patients, caregivers, and our colleagues is important for both patient and staff satisfaction.
Think about a recent day at work. Now pick an interaction that occurred between you and another person or persons. Was it a positive or negative interaction? Could it have been improved and if so, how?
In her editorial, Ms. Miller identifies the following three principles for communication:
Communication Principle #1: It's not you against them, it's you against you.
Communication Principle #2: Don't take it personally.
Communication Principle #3: Know what you are talking about before you start talking.
Take a few minutes to go back and read the article in its entirety. It’s a quick-read and well worth it!
Reference:
Miller L. A. (2013). Can we talk? Musings on communication. The Journal of perinatal & neonatal nursing, 27(2), 193–194. https://doi.org/10.1097/JPN.0b013e31828ee826
Okay, so I know the words of this title should be hanging in an elementary school somewhere (and probably are), but think about all the reading you do as a nurse. It’s a lot, isn’t it?
From the big textbooks in nursing school to policies, procedures, and protocols in your area of practice, there is a lot of reading that we do. We read to keep up on health care news, drug information, technological advances, and treatment recommendations. We are constantly reading charts, care plans, laboratory reports, notes from other health care professionals, journal articles, and the latest research studies. The list goes on and on!
Social media has expanded our reading list even more. We are connecting online and reading each other’s stories and experiences through status updates, tweets, and blogs. Whole conversations are taking place without any words being spoken. Pretty amazing, isn’t it? Over the past year (since really diving in to the world of social media), I’ve connected with some amazing nurses whom I would have never “met” had I not read their words.
You can find the links to some of my favorite blogs here under Nursing Blogs (right column, about halfway down the page.) Do you have a favorite blog or even have your own? Please share the link ~ I’ll be sure to check it out! Thanks
Posted:
3/13/2011 2:34:09 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories:
Change is not usually easy. Nurses who have made nursing their second (or third or fourth…) career deserve much recognition and respect. Imagine being an expert accountant, someone who people seek out to answer their financial questions and meet their needs, and then starting over from scratch in a new environment, with new people, learning new skills and knowledge. Imagine returning to the novice role after already having travelled that path of novice to expert. Remember those days of care plans and clinicals, searching for a job, and then starting work in an unfamiliar unit or facility. Now imagine doing it all over again. A bit overwhelming, isn’t it?
In the January/February issue of Nursing Made Incredible Easy, Sally Jo Borrello, MSN, RN, CTTS, takes a closer look at the second-career nurse. She reminds us that while individuals pursuing nursing as a second career are usually adult learners who are more serious and confident than their younger counterparts, they still face the same long hours of studying and class preparation. Many are also sacrificing personal and family time to obtain their degree.
The author goes on to share tips for experienced nurses to mentor second-career nurses. Building a mutually respectful and trusting relationship is key. Remember that this mentee is bringing his or her background and knowledge to the relationship also, so be open to learning quite a bit yourself. Use positive feedback to support and guide this student or new nurse.
Are you a second-career RN or currently pursuing nursing as a second career? Please chime in with your thoughts and experiences!
I had originally planned a different topic for this week’s blog post, but I would be remiss if I didn’t use this time and space to share my experience at my primary care practitioner’s office today. I went in for my flu shot, not a big deal; I only spent about 10 minutes there. However, in those ten minutes I was paying particular attention to the nursing staff (don’t we all do that?) A young woman called my name and I followed her down the hall as she studied her clipboard - no eye contact, no hello, no smile, and no introduction. I also quickly noticed that while she was wearing scrubs, she did not have a name tag on, or anything identifying herself by name or role.
Off we went into a small room where another woman was working on her computer. There was no sink in the room. Just a desk with a pile of the CDC’s Influenza Vaccine fact sheets (not that it was offered to me); a cup of prefilled syringes and a cup of needles; a pile of alcohol swabs; and some other non-related items and pieces of equipment. I did notice on the wall a piece of paper with information about Guillain-Barre syndrome - definition, signs and symptoms, and prognosis. I’m not sure if it was placed there for the staff or for patients. In either case, there was no information offered about why it was posted there.
This staff member prepared my vaccine, the whole while her long hair swinging around. She put on gloves, asked me which arm I wanted the shot in (then approached my right arm after I replied “left”) and gave me the vaccine. A quick band-aid application and she handed me my “receipt.” No good-bye, smile, or any farewell greeting.
What has happened to common courtesy and manners? I won’t assume that this staff person was a nurse, but I’m sure that many other patients do and will. How can we promote a professional image of nursing when even a nurse herself (me!) feels this way after a quick visit?
I may have shared this article with you before, New Nurse Notes: 7 tips to improve your professional etiquette, but I think it’s worth sharing again. Okay, I’ll say good-bye now (with a handshake and a smile!)
Any article that has the word “tips” or “list” in the title always seems to grab my attention. To me those words mean that the article is a quick read with valuable information that I shouldn’t miss. In this month’s OR Nurse 2010, I quickly turned to 7 tips to improve your professional etiquette. In this article, the author advises us on introductions, the importance of a confident handshake, specifics about body language, and more. I especially appreciated the following list of gestures to avoid:
“Some gestures may be misunderstood and considered offensive to people from other cultures. To play it safe, try to avoid these in conversation:
• the "okay" sign
• thumbs up
• the "V" for victory sign, especially with the palm facing inward
• pointing or snapping your fingers
• waving your hand with your arm raised.1”
I must admit that I’ve been guilty of using several of these gestures, especially with mechanically ventilated patients or patients who were unable to communicate verbally for other reasons. Do you know of anything else that should be on this list?
1. Pagana KD. The Nurse's Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2008.
Attending any conferences this spring? Here’s a list of tips and timesavers to help you make the most of your time!
1. Make a schedule. Plan which sessions you’ll attend and create your itinerary! Use the most convenient form that works for you – paper and pencil list or electronic device. Some conferences even have a smartphone app to help you do this. Check the attendee program or ask at the registration desk for details.
2. Pack comfortable shoes. Conference centers can be large, especially if it’s a big event with a large number of attendees. Also, remember that the walk through airports, train stations, and other public transportation centers can be long as well.
3. Do your homework. If you would like to speak with a presenter or are interested in connecting with a particular exhibitor, prepare your questions ahead of time. Sometimes the lines can be long and there may be limited time between sessions. Make sure you make the most of your time and convey your message clearly and succinctly.
4. Bring a notebook. Make notes on your computer, mobile device, or use pen and paper. Things you are learning and hearing will be fresh and exciting at the time, but when you return to your “real world,” you might not remember everything like you thought you would.
5. Keep some snacks handy. Not all airlines provide snacks, or if they do, there may be a charge for them. Also, if you are attending back-to-back sessions without much of a break, having a snack or two on-hand can help ease your hunger and keep you alert.
6. Consider packing an extra bag. You may accumulate quite a bit of ‘extras’ during the conference. From handouts and journals to goodies from the exhibit hall and souvenirs, it might make packing for your return a little easier. Be aware of airline restrictions and fees however! You could even consider using a larger bag than you need so you’ll have extra room for your return trip.
Enjoy your conference! Let me know which you’ve attended or are planning to attend, and what exciting and innovative things you learn. Also, please share your own tips too!
BONUS: Use this handy infographic to remember and share all of our tips!
Add this infographic to your website by copying and pasting the following embed code:
<a href="/ncblog/april-2013/tips-timesavers-for-conference-attendees"><img src="/getattachment/NCBlog/April-2013/tips-timesavers-for-conference-attendees/Tips-for-Conference-Attendees-infographic.jpg.aspx?width=300&height=750” /></a>
<p>Going to a nursing conference? <a href="/ncblog/april-2013/tips-timesavers-for-conference-attendees"> Tips & Timesavers for Conference Attendees</a> By Lippincott NursingCenter</p>
|
In the opening address at Nursing Management Congress 2012, Sharon Cox presented ways that managers can “add value in a time of volatility.” While this was a conference geared toward nurse managers and other administrators and executives, her words and ideas are applicable to us all, both as nurses and as human beings.
One thing that she said (it’s on my list of favorite quotes from the conference) was “We teach people how to treat us.” While looking back at my notes, I found these words in all capitals and circled several times. This was a powerful statement!
Think about it. Do you have colleagues who aren’t true “team players?” Any bullying go on in the unit where you work? Are some nurses bullied more that others? Why?
You can ask yourself similar questions about any relationships, not just in the workplace. If we allow ourselves to be treated poorly, people will continue to do so. I agree with this statement by Sharon Cox because by allowing others to treat us with disrespect, it’s as if we are condoning that behavior.
So what is the solution? In my mind, the trick is to be “respectfully assertive,” that is, stand up for ourselves without being aggressive or becoming defensive. This is one of those things that is often “easier said than done,” but by being aware of how we receive and react to certain behaviors and making any necessary changes on our own end, perhaps we can make a difference.
There’s no better place to get excited about nursing than at a nursing conference! I spent four days this month in Denver, Colorado at the Dermatology Nurses’ Association 30th Anniversary Convention. What an amazing group of nurses! From a keynote address by Michael R. Bleich, PhD, RN, FAAN which motivated us to enact the changes recommended in the IOM Future of Nursing Report to informative presentations by experts in the field, my days were filled. The camaraderie and networking among the attendees and interaction with the exhibitors was phenomenal. I left there feeling so good about being a nurse and feeling supported by my peers – thank you DNA nurses!
If you will be attending any upcoming conferences, take a moment or two to read A Closing Word: 10 Tips for Getting the Most From a Professional Conference. Here are the ten tips (but be sure to read the article in it's entirety - there is some good advice!):
1. Choose your sessions strategically.
2. Networking is key.
3. Dress the part.
4. Attend the poster presentations.
5. Attend the exhibits.
6. Comfort is important.
7. Take care of those who take care of you.
8. Be respectful to your colleagues and to the speakers.
9. Stay organized during the conference.
10. Spread the enthusiasm and share what you learned.
Also, check out our events calendar for a complete list of upcoming nursing conferences.
Next up on my calendar is Nursing2012 Symposium in Orlando this April. Hope to see you there!
Reference: Aldridge, M.D. (2012). A Closing Word: 10 Tips for Getting the Most From a Professional Conference. Dimensions of Critical Care Nursing, 31(2).
Christine Kessler, MSN, CRNP of Walter Reed Army Hospital in Washington, D.C. delivered the opening address at Nursing2010 Symposium in Las Vegas on April 6. In her presentation titled ""What Would Florence Do? Nursing Past, Present, and Future"", Kessler reported on experts' projections about the severity of the nursing shortage over the next ten to fifteen years. Kessler also warned that we should not assume that the nursing shortage is over because many markets that are experiencing a downturn in the economy have little to no vacancies. The global trend is that the aging nursing workforce will result in many practicing nurses and nursing faculty retiring at high rates. Kessler made optimistic suggestions for increasing numbers in the profession, and generated keen interest from a group of nurses traveling from Jordan who shared their story about the nursing shortage.
I met two of the nurses from Jordan at the reception that evening and asked them if I could share their strory in my blog. Randa, a doctoral nurse and Alia, a baccalaureate nurse, were eager to discuss how there is a shortage of female nurses in their country. They explained that not only are fewer women entering the workforce than men, but that the women often leave the profession when they marry and have children. A factor that compounds the problem is that in this predominently Muslim nation, there are religious traditions that dictate who can deliver care based on gender. Randa said that ""men an women are separate floors in the hospital"" and ""women only are permitted to care for other women and children"". Therefore, these nurses are very concerned about the quality of care of women and children. Randa and Alia are encouraged by the government's action of setting quotas in nursing schools that require admission of a higher percentage of females. Still they are seeking additional ideas from Nursing2010 Symposium to take back to Jordan and disseminate in papers and presentations.
Like these Jordanian nurses, nurse exectives, nurse educators, and government officials around the globe must collaborate to find realistic solutions to the nursing shortage. To learn more about the global nursing shortage, go to the International Council of Nurses website at www.inc.ch and the World Health Organization website at www.who.int.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
I am at the HIMSS Conference in Atlanta, Georgia right now. For those of you who don't know what HIMSS stands for, it is the Healthcare Information and Management Systems Society. This conference is one of the most cutting-edge conferences I have ever attended. According to the HIMSS representative I spoke to, their attendance is 25,000 this year. For those of you interested in how technology can improve practice, this conference is for you. Nurses involved in informatics, clinical leaders, and nurse leaders presented how information management systems, electronic health care records, computerized prescriber order entry, and different types of monitoring systems can fit into workflow and give nurses the clinical support they need to deliver the highest quality, evidence-based care. What I was most impressed with was their Interoperability Showcase which used patient case studies to demonstrate how different systems can exchange information and seamlessly work together. Many of the sessions stressed the importance of having nurses part of the decision making process when new technology is being evaluated.
It was refreshing to see healthcare institutions sending their nurse leaders, clinical leaders, and nurse informatics specialists to this conference to find ways to use technology to improve patient care. If you're interested in how technology can improve nursing practice and improve patient outcomes, or your facility is looking at new technology, then I would highly recommend you attend this conference.
By Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
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?
I think that every nurse I know has a story about jumping in to help during an emergency outside of the work setting. I’ve had several over the years, the most recent being this past summer while out with my kids. It was an evening out at the park, close to dinner time, so it wasn’t very crowded. Suddenly a young boy ran from the swings holding his head. His mom (or another caregiver – I’m not certain what the relationship was) was seated at the next bench, not very far from me. She started to scream and cry.
I could see the blood coming down the little boy’s neck and quickly ran over to help. Fortunately I had a towel in my bag since we had just come from the pool. As I approached, the mom/caregiver stepped away crying and fell into the arms of another woman who was there. I quickly assessed his head (it was a pretty big gash) and held pressure with the towel while lowering him to the ground where we sat and waited for emergency medical services (EMS) to arrive.
All the while, my own children were watching in fear. After the EMS team arrived and took over the boy’s care, which included a trip to our local emergency department, we collected our stuff and headed toward the car. I reassured them that the little boy would be okay and that he might just need some stitches. The conversation that ensued with my one son went something like this:
Me: “It’s a good thing there was a nurse around, huh?”
My son: “There was?”
Me (shocked): “Yes! Me!”
My son: “Oh yeah…I forgot you’re a nurse. You're more of a ‘typer’ than a nurse though, mom.”
The conversation went on a little longer, but I must say it was as if something just hit me right then. I’d recently been considering getting back to patient care, but hadn’t even begun to look into job opportunities or refresher courses in the area. This brings me to my reason for sharing this story…
I’ve been away from bedside nursing for more than 10 years and have a few questions for anyone else that took a similar “hiatus” and then returned to patient care.
1. What steps did you take to prepare for a return to bedside nursing?
2. Did you return to your prior place of employment or a similar unit, or did you start over in a new area or with a different patient population?
3. How easy or hard was it making the transition?
Please share your story! I look forward to any advice you may have for me!
Thank you :-)
Dear New Nursing Graduate,
Welcome! What an exciting time for you! I realize that it probably is somewhat of an emotional and stressful time as well. My sons just “graduated” from elementary school and through all the events and ceremonies, I was reminded just how special these milestones and traditions can be. Probably the biggest one for me was finishing up nursing school and entering the “real world.”
So, first let’s get out all of the stress that you are probably feeling right now. These were my top 3 sources of anxiety, if I remember correctly…
1. Leaving the security of school with instructors who guided me and classmates who supported me. I did find other mentors and formed another support network rather quickly and you will too! Get to know other new nurses during orientation. Be receptive to learning from more experienced nurses and other staff.
2. Facing the NCLEX exam. How could I possibly know all that I was expected to know? I did, and you do too (but don't stop studying!)
3. Encountering a discouraging job search. I had to be persistent and open to options that weren't my first choice. Remember that any job can serve as a stepping stone to your dream job.
I recall hearing over and over again how the “real world” of nursing would be so different from nursing school. How can you make the transition a little easier? Here’s some advice:
- Never stop learning! Learn from other nurses, other disciplines, support staff, anyone around you! Some of my most critical skills and communication techniques I learned from my very first preceptor – a nursing assistant who had been working on the unit for more than 20 years! Take advantage of the knowledge and experience of those around you. Really listen to advice and observe how others do and say things. You may not want to emulate all of what you see, but you can learn from it.
- Keep up your education! I know you just finished school, but there is so much more to learn and things in healthcare are always changing. Attend inservices and maintain your continuing education requirements. Also, when the time is right, consider getting certified in your specialty and think about going back to school.
- Ask questions! This goes hand-in-hand with learning and education. Chances are, if you have a question, someone else is wondering the same thing. Don’t assume – get the answer or find out how to get the answer. Then share it with others.
- Join a nursing organization! This is a great way to stay informed and network with nurses who have similar interests.
- Take breaks! Remember to take breaks during your shifts. Also, be sure to enjoy “non-nursing” time with family and friends. One of my favorite nursing tips is ""Nursing is a 24/7 operation that requires teamwork - do your best to prioritize and work safely & pass on the rest.""
A last word of advice is to not forget this feeling of uncertainty and stress, as uncomfortable as it may be. This will help you when students or new nurses are on your floor. Welcome them and treat them with respect. Share your knowledge with them, even become a preceptor. They’ll thank you for it.
Best of luck to you as you make this transition!
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.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
Posted:
1/14/2011 2:15:11 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories: Technology
Since you are here reading this on our blog, chances are you are pretty familiar with the world of social media. You may even have navigated your way here from Facebook, twitter, or another social media “avenue.”
It’s amazing how social media is infiltrating our lives and changing the world in which we live. We have several blog posts already about social media (see here, here, and here), but now I’m interested in hearing a little bit about how you are using social media in your job. It is clear that social media is here to stay and will begin to play a more prominent role in health care and nursing. In just the past 3 months, we’ve had several articles in our journals dedicated to social media. For nurses, the use of social media gives us another way to communicate with patients, educate the public, and keep our own knowledge up-to-date. We must be mindful of course, to use social media in a professional manner and without violating privacy.
So here’s my question: What role does social media play where you work?
…and here are those recent articles I mentioned:
How Private Is Your Facebook?
Nurse Educator, May/June 2011
Career Scope: Using a blog to improve communication
Nursing Management, June 2011
Using Social Media as an Institutional Resource: Implications for the Clinical Nurse Specialist
Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, May/June 2011
Practice Points: Social Media Collaboration Checklist
Advances in Skin & Wound Care: The Journal for Prevention and Healing, July 2011
The good:
*The people... what’s better than connecting with others with similar goals?
*The knowledge...from anatomy and physiology to pathophysiology to pharmacology - wow, I learned a lot!
*The communication skills...these skills have helped me in “everyday life” too!
*The classes...electives on death and dying, nutrition, human sexuality - might not be interesting to everyone, but I loved them!
*The curve...how could I get a ‘C’ on an exam but then my grade turns into an ‘A’ because everyone else got a ‘C’ also?
The bad:
*The books...so many & so heavy! With all the technology available now, is this still the case?
*The anxiety...even the thought of giving someone acetaminophen made me nervous.
*The medications...how would I remember all of the generic names, trade names, indications, dosages, interactions, adverse reactions, and special instructions?
*The hours...I was at the hospital by 7 am and my roommates didn't have classes before noon!
*The care plans...need I say more?
The best:
*Knowing that in the near future, I would be making a difference!
By now, most of us have read about, heard about, discussed, seen the picture, etc., of the nursing student who posted a picture on Facebook of herself with a placenta. While we may have differing opinions about the ethics involved, whether HIPAA was violated, or whether the punishment of expulsion was too severe, the lessons to be learned are the same - think before sending anything out there into the realm of the world wide web, proceed cautiously before clicking that “submit” or “post” button, and consider the effects and possible repercussions of your actions.
Today, this nursing student, who was scheduled to graduate this May, will be taking action against her school and the involved faculty. I’ll be following the case, how about you?
I just returned from another business trip and this time I was at a conference in Las Vegas. What intrigued me most were the number of signs that post a number where you could call to find out wait times for the Emergency Departments of local hospitals. What a novel idea! Prospective patients could call ahead to see where the wait time was less and then go to that institution for service.
Where I live there are 3 hospitals within a 20 mile radius and more often than not, their patient census is bulging at the seams. We know on the weekend and at night, many people will go to the ED for care just because they don't have access to their primary care provider. While the "Minute Clinics" have certainly helped in my area, the EDs of our 3 local hospitals always seem to be busy. What an interesting marketing idea to let patients have the option to go where the wait time is less. This whole idea can really push EDs to streamline their patient flow.
By Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
In each issue of Nursing2010 Critical Care, Karen Innocent demonstrates the important relationship between technology and nursing. In the September issue she educates us about mobile applications and describes how easy access to current information right at the point of care can improve our practice. I’ve condensed the information from her table of free mobile apps here for our blog, but take some time to read the entire article Tech Talk: Mobile apps for nurses.
Free mobile apps:
You may have noticed these new ‘share’ options on each of our article pages. Since we can't all read everything (although I do try!), if there is something that really interests you or that you think will benefit your friends, followers, email contacts, people in your circles, or the like, please feel free to pass it along! I hope this new feature makes it easier to share the content from our journals.
Any problems or suggestions, you can comment here or email me at [email protected]. Thanks!
Posted:
1/21/2014 1:47:07 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories: Technology
Social networking and social media are not new concepts. Social communication has gradually advanced from face-to-face conversations and early forms of written and print communication to using the telephone for party lines and conference calls. Now we are using computers for group email (list serv), online forums, chat rooms, instant messaging, and blogs. Interactive social networking websites like MySpace.com and Facebook.com are becoming popular for staying connected with friends, classmates, and others with similar social, political, or entertainment interests. Some examples of professional networks are LinkedIn, Tagged, and Plaxo. These sites and professional organization websites are helpful for making business contacts, finding jobs, and discussing challenging professional and business issues.
The newer features of social networking allow the users to more easily exchange documents including articles, policies, and documentation forms. Some websites allow the nursing community to mentor newer nurses; recommend great job openings; and give advice about going back to school for advanced degrees. What's also helpful is that these discussions are archived and can be searched for later use.
Professional and social networking have many benefits for nurses, but some nurses have not been very cautious about their use of these websites. Here are some examples of how to avoid making mistakes online.
- Think before you post messages, photos, and videos. You would never want to tarnish your professional image, to embarrass a colleague, or to hurt your chances of career advancement.
- To protect yourself from identity theft, you must be aware that social networking sites are not private and limit the amount and type of personal information you share.
- To avoid risk of a HIPAA violation, never publish patient information without written permission.
For those who want to share new techniques you discovered, search for cost-effective ways to deliver patient care, or to announce your recent accomplisments, there are many great websites waiting for you to post your news or to ask your questions. Happy blogging!
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
Living wills. Life support. Do-Not-Resuscitate. These are all phrases that I used frequently working in an adult medical intensive care unit. I rarely had trouble using the words death, dying, hospice, or end-of-life with patients and families.
However, outside of the hospital, these words have been a lot harder for me. My parents do have living wills and have expressed their wishes to me, but not because I initiated any discussion with them. In fact, I’ve actually avoided those conversations despite knowing how important they are.
There is not really a good time to have end-of-life discussions, so people tend to wait for the "right time" which often turns into the "wrong time" or "too late." The conversation might end up taking place in the hallway of the emergency department or in a critical care waiting room. Sometimes, information is conveyed and decisions are even made over the phone.
I am fortunate that my own family members have insisted on preparing for the end of their lives and sharing their plans and wishes with me. As a daughter, I really don’t like to hear about it. As a nurse, I know that this is a very good thing.
Saturday, April 16th is National Healthcare Decisions Day. Make this day the "right time" to talk with your loved ones and encourage the patients you care for to do the same.
Providing end-of-life care can be one of the most challenging responsibilities as a nurse, yet can also be one of the most fulfilling. When a patient’s wishes are respected and dying with dignity is a priority, death can be a peaceful and positive experience for the patient, his family, and the staff caring for him.
Oftentimes, our focus during end-of-life care is primarily on pain management and relieving or preventing labored breathing. Research published last month in the Archives of Internal Medicine calls attention to other factors that need to be addressed to improve care at the end of life. These include communication deficits, the importance of dyspnea assessments, implantable cardioverter/defibrillator deactivation, and bowel regimens.
In my opinion, the importance of communication at the end of life cannot be stressed enough. This includes communication among staff, among the patient and his family members, and between staff and the patient and his family. How many times have you encountered family members who didn’t agree with the wishes of a loved one as stated in his living will or who didn’t understand that an illness was terminal? How about physicians, nurses, and other professionals who were reluctant to address end-of-life issues?
It is important for all decision-makers and caregivers to understand and agree on a plan in order to ensure a positive experience at the end of life. For this to happen, communication is key. Take some time to read the following articles. You’ll find some great information to help educate patients, families, yourself, and your colleagues about end-of-life issues and care.
I was a new graduate working in the Medical ICU, a few weeks off orientation, when I cared for Jenny*. She was 18 years old, the youngest patient on our unit. It was not the norm for such a young person to be a patient on our unit. In fact, it was odd.
She was a college student who had gone to Student Health Services with an upper respiratory infection. She was given antibiotics and sent on her way. Why did she develop acute respiratory failure? I’m not sure anyone ever knew that answer. It was just one of those things…
Jenny spent a long time in our unit – months – battling the gamut of ICU complications we were used to seeing, just not in someone so young. ARDS, renal failure, GI bleed…just to name a few. She had her share of time spent on vasopressors, paralytics, and sedatives; endured arterial lines, SWAN placement, and dialysis; received multiple blood transfusions and courses of antibiotics; and was on and off isolation precautions for various resistant organisms. A tracheostomy and g-tube were placed when she became more stable and ready to wean from the ventilator.
I was usually the nurse that wanted the sickest patients. I didn’t mind getting an unstable new admission or going on a road trip with a patient to a diagnostic study or procedure. One of my best days, however, was a slow one in the unit. Jenny was fairly stable, and she was my only patient that day. Her mom was there and was always eager to help with Jenny’s care.
As the shift went on, and it looked like things were going to stay quiet on the unit (not that we EVER said that our loud), I asked Jenny if she’d like me to wash her hair. Her eyes got real big and she looked at me questioningly. She nodded.
Like many tasks, it took longer to gather supplies than to actually perform it. I finally found real shampoo (and conditioner!), used a water pitcher for wetting her hair and rinsing, set up a trash bag to catch the excess water, and piles and piles of towels.
Jenny’s mom and I worked together washing her hair. We joked about opening our own salon and Jenny was smiling looking up at us. We made a mess and all got pretty wet, but it was worth it. We had gotten those weeks of knots and dried blood and betadine from her hair, combed it neatly, and it smelled so nice!
When we finished, Jenny asked for a paper and pen. She wrote “Think you could shave my legs?”
Her mom and I looked at each other. “Sure."
*Not her real name.
It was Sunday night, 7 pm, and I was just starting my third 12-hour shift in a row. I was happy to see my assignment was the same as the previous two nights - two fairly stable patients. One was a “challenge-to-wean” patient who was recovering from ARDS and who had two restful nights on Friday and Saturday. The other was a patient who was post-stroke; she was not intubated, was minimally communicative, and had stable vital signs (I had been surprised that she had not been transferred out of the ICU during the day.)
I was a few minutes early so I went to print out telemetry strips for both of my patients before getting report. Part of our documentation each shift consisted of printing and interpreting each patient’s ECG intervals. We had a certain way to fold the strips so we could tape them in the appropriate spot on the flowsheet (next to the strip from the previous shift).
It was then, when I went to tape the strip on that I noticed something very different. The patient’s ST-segment was significantly elevated compared to the strip 8 hours before. The day shift nurse came over to start report and we compared the strips - same leads, definite ST-segment changes. She grabbed the 12-lead ECG machine and yelled for the resident while I assessed the patient. She was lying in bed and appeared comfortable. Her vital signs hadn’t changed and her oxygen saturation was 93%. She did not look like someone experiencing an MI. But she was.
Within minutes (or so it seemed), anesthesia had arrived to intubate her, cardiology was at the bedside, and we were hanging nitroglycerin and heparin infusions. After a very busy night and despite all of our efforts, this patient coded and died.
I tell this story because it is not often that “cutting & pasting” a six-second telemetry strip leads to this turn of events. As a critical care nurse, I was both exhilarated by noticing the change in her ECG and devastated by the outcome.
When I considered writing about this particular night, my first thought was that anyone could have noticed the change in her ECG. Would someone who was not a nurse have recognized the change and realized the implications? Perhaps. But is there anyone else but a bedside nurse who is present and in tune to the patients they care for 24 hours a day, 7 days a week, 365 days a year?
Nurses are there. Nurses are present. Nurses are paying attention.
It’s been a little over a week since the National Conference for Nurse Practitioners in Chicago, and I am reviewing my notes and reminded of the learning and networking that took place during the conference. On my very first page, from the Welcome and Opening Remarks of Conference Chairperson, Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, SCP, FAAN, DCC, I had written the following:
I remember this point vividly, as Dr. Fitzgerald had commented that years ago, when our numbers were much smaller, not too many people had an issue with nurse practitioners practicing to the full extent of our education and training. Now however, as there are over 180,000 nurse practitioners, the power of our numbers is threatening to many, even despite recent research demonstrating our value in patient outcomes and satisfaction. This point is incredibly evident in this recent Op Ed piece from The New York Times, Nurses are not Doctors, where the author cites a study from 1999 to support his opinion, which is clearly not the most up-to-date, best available evidence. Have you read it? I encourage you to do so when you are sitting down, because it did bring out a bit of my temper. Rest assured that some leaders in nursing did reply with some Letters to the Editor and you can read them here.
And now back to some take-aways from NCNP…
*The states with the least restrictive NP regulations see twice as many patients as those in other states.
Carol L. Thompson, PhD, DNP, ACNP, FNP, FCCM, FAANP
Keynote Address: Awesome Practiced Daily
*Don’t use an ARB and ACE inhibitor concomitantly to treat hypertension.
Joyce L. Ross, MSN, CRNP, CLS, FNLA, FPCNA
JNC-Late: A Focus and Update on the Long-Awaited Hypertension Guidelines
*Not all infected patients are febrile and not all febrile patients are infected.
Lynn A. Kelso, RN, ACNP-BC, FCCM, FAANP
Acute: Fever of Unknown Origin in Adults
*If a patient has an inappropriate tachycardia related to his elevated temperature, consider pulmonary embolism as the cause.
Lynn A. Kelso, RN, ACNP-BC, FCCM, FAANP
Acute: Fever of Unknown Origin in Adults
*Sepsis doesn’t kill patients; multisystem organ failure resulting from sepsis does.
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
Acute: Understanding the Latest Sepsis Guidelines
*If a patient has kidney injury, used unfractionated heparin for DVT prophylaxis.
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
Acute: Understanding the Latest Sepsis Guidelines
*Our patients give us very important information, if we listen!
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know
*If a patient has loss of the hair that makes up the outer eyebrows, think hypothyroidism.
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know
*The presence of pulsus paradoxus is a sign of cardiac tamponade, but can also be seen in severe asthma.
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know
*To assess judgment in patients with traumatic brain injury, ask “What would you do if there was a fire in your kitchen?”
Tracey Andersen, MSN, CNRN, FNP-BC, ACNP-BC
Neuro Assessment and Diagnostic Work-up for Advanced Practitioners
Thanks for reading this wrap-up! Want to see photos from the event? Here’s our album – enjoy!
It’s been almost 2 years since the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) released Future of Nursing: Leading Change, Advancing Health and this landmark report is still being discussed and written about. This thrills me! People are hearing and learning about nursing. Other disciplines in healthcare have responded to the report. Nurses are making changes based on the report and sharing their plans and outcomes. Good things are happening!
We have a collection of articles and editorials all about the Future of Nursing Report and in the past few months several good reads have been published. Take a look:
Learn how the nursing staff at one New Jersey health system embraced the report and made changes to improve patient outcomes and satisfaction by reading Responding to Health Care Reform by Addressing the Institute of Medicine Report on the Future of Nursing (Nursing Administration Quarterly, September 2012).
In Nursing's future: What's the message? (Nursing Management, July 2012), the authors share the response of the Robert Wood Johnson University Hospital Division of Nursing, including “…creating opportunities within our hospital and our professional networks for honest conversation about the report and its implications, and then using strategic planning to design our action strategies.”
Read Wellness Promotion and the Institute of Medicine's Future of Nursing Report: Are Nurses Ready? (Holistic Nursing Practice, June 2012) and discover how the role of disease prevention and health promotion, or wellness, is a critical component for nurses in implementing the changes recommended in the IOM report.
In the NACNS Position Paper: The National Association of Clinical Nurse Specialists Response to the Institute of Medicine’s The Future of Nursing Report (Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, August 2012), the NACNS addresses several of the IOM recommendations with strategies and recommendations specific to clinical nurse specialists.
The American Association of Neuroscience Nurses has also developed specific recommendations based on the report which were published in the Journal of Neuroscience Nursing (June 2012) – Integrating the Institute of Medicine Future of Nursing Report Into the American Association of Neuroscience Nurses Strategic Plan.
There are over 35 editorials and articles that have been published in our journals since the release of the IOM report. All can be read online FREE --- be sure to check out Focus On: The Future of Nursing.
What changes have you implemented in your practice or career plans? Have there been initiatives at your workplace since the release of the IOM report?
Okay, so I know the words of this title should be hanging in an elementary school somewhere (and probably are), but think about all the reading you do as a nurse. It’s a lot, isn’t it?
From the big textbooks in nursing school to policies, procedures, and protocols in your area of practice, there is a lot of reading that we do. We read to keep up on health care news, drug information, technological advances, and treatment recommendations. We are constantly reading charts, care plans, laboratory reports, notes from other health care professionals, journal articles, and the latest research studies. The list goes on and on!
Social media has expanded our reading list even more. We are connecting online and reading each other’s stories and experiences through status updates, tweets, and blogs. Whole conversations are taking place without any words being spoken. Pretty amazing, isn’t it? Over the past year (since really diving in to the world of social media), I’ve connected with some amazing nurses whom I would have never “met” had I not read their words.
You can find the links to some of my favorite blogs here under Nursing Blogs (right column, about halfway down the page.) Do you have a favorite blog or even have your own? Please share the link ~ I’ll be sure to check it out! Thanks
My very first job was at a CVS store. I worked as a cashier there in high school and for 2 summers during college. As a cashier, I was responsible for restocking the cigarettes behind the counter…not a part of the job that I enjoyed, but it passed the time when we were slow. The area behind the counter was pretty narrow, and I would often have to step over and around cases of cigarettes while working. They sold quickly back then and my hands would smell of cigarettes after an evening of work.
I was impressed when I read the announcement yesterday that CVS stores would no longer be selling cigarettes. What an example this organization is setting, and I am hopeful that this will start a trend among other pharmacies and retailers.
""Ending the sale of cigarettes and tobacco products at CVS/pharmacy is the right thing for us to do for our customers and our company to help people on their path to better health,"" Larry J. Merlo, president and CEO of CVS Caremark, said in a statement. ""Put simply, the sale of tobacco products is inconsistent with our purpose.""
Along with this news, the company has announced the launch of a smoking cessation plan this spring.
Well done, CVS!
According to the 2014 Surgeon General's Report: The Health Consequences of Smoking—50 Years of Progress, there are 12 cancers and 20 chronic diseases linked causally to smoking. It is encouraging that the prevalence of cigarette smoking has declined from 42% in 1962 to 18% in 2012 (U.S. Department of Health and Human Services, 2014), however, it is even more encouraging that smoking cessation programs are continuing to be developed. There is more work to be done to educate the public and help people to not start smoking and to quit if they already do smoke.
More Resources:
Reference:
U.S. Department of Health and Human Services. (2014, January). 50 Years of Progress: A Report of the Surgeon General, 2014. Retrieved from SurgeonGeneral.Gov: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/50-years-of-progress-by-section.html
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!
My father-in-law is a retired professor of kinesiology and wrestling coach. He continues to be very involved with wrestling, often running clinics for students, athletes, and other coaches. While he may not hold the title “motivational speaker,” I believe him to be one. He stresses the importance of discovering one’s passions in life to his students, colleagues, friends, and family. He has several of his own passions and enjoys hearing about the passions of others, that is, what brings them the greatest fulfillment and joy.
The Level III nurses in the MICU where I worked each identified a diagnosis or patient population as their ‘specialty.’ It was part of the application process to attain that coveted position. I was always drawn to caring for patients with primary pulmonary hypertension (PPH), perhaps because many of the patients we saw with that diagnosis were young women, not much older than me at the time. These patients were often newly diagnosed and were admitted with only mild symptoms. Unfortunately, most of them had rapid progression of the disease and went home for only a short time, if at all.
It seemed only natural that this would be my clinical focus when I applied for my Level III position. I was the primary nurse for just about each PPH patient we admitted. I delved into learning everything about the disease and its treatment. At the time, we would do trials of inhaled nitric oxide to assess the response of a patient’s pulmonary arteries to vasodilators. If the pulmonary artery (PA) pressure decreased, they’d be treated with either oral vasodilators or a prostacyclin infusion. We’d monitor PA pressures, cardiac output, and systemic vascular resistance closely to get the optimal dose while being alert for adverse reactions. Sounds simple, but it rarely was. This was about 10 years ago and additional treatment options are available now.
Primary pulmonary hypertension was definitely my passion in critical care. Why? It’s hard to say - perhaps I identified with the young patients admitted, perhaps because the treatment trials involved frequent assessment of hemodynamic parameters and the changes in the numbers and the patients symptoms were clearly evident, or perhaps because most patients were awake and able to communicate (unlike the majority of the patients in our unit). Maybe all of the above!
Many of you may feel that nursing is more than a job and more than a career. Is nursing your passion? What makes it your passion? And is there a certain patient or diagnosis that you are most passionate about?
On New Year’s Day, an interview on the Today Show with Jon Gordon, a motivational expert and author, caught my attention. Mr. Gordon’s advice for those of us making resolutions for 2014, was to keep it simple by selecting one word to focus on for the upcoming year. Joni, over at Nursetopia, has been doing this for a few years and has shared her reflection on her words from 2012 and 2013, as well as her word for 2014.
After much thought, I’ve decided that my one word for 2014 will be “listen.” I often find myself thinking of my to-do list or what I will say next while someone else is talking, and before I know it, I’ve missed out on what was said. As nurses, being good listeners is incredibly important – patients often confide in us and share things that they don’t tell anyone else. If we miss it, how can we be the best advocates for them?
While it would be great to just say “I’m going to always listen well,” I know that even with my best intentions, this won't happen. Being a better listener is going to take some work. So I’ve dug through our library and searched the web for some strategies to help sharpen my listening skills. Here’s what I found…
Tips for improving your listening skills
- “SOLER” up:
Squarely face the patient
Open up your posture (keep your arms uncrossed)
Lean toward the patient
Eye contact
Relax
- Eliminate distractions.
- Be present in the current moment. Give your full attention and listen as if you will have to repeat what you are told.
- Don’t interrupt.
- Acknowledge the patient by nodding or using conversation cues, such as “yes” and “go on.”
- Pay attention to nonverbal cues.
- Use active listening or reflective listening to repeat back what a patient is telling you. This can encourage them to go on or to clarify what they are saying. For example, “It sounds like you’re saying the pain gets worse at night.”
- When you notice that you are not listening, fix it by refocusing your attention. If necessary, apologize and ask the patient to repeat what you missed.
I realize some of these tips can be tricky depending on the environment in which you work. My advice? Do the best you can and try to ensure you’ll have ample time to hear responses when asking open-ended questions. Good luck!
Oh, and --- What is your word for 2014?
References:
Calcagno K. M. (2008). Listen up ... Someone important is talking. Home healthcare nurse, 26(6), 333–336. https://doi.org/10.1097/01.NHH.0000324304.63835.0b
Jarrow, C. (2013, August 26). 10 Ways to Be Present and Be a Better Listener. Retrieved from Time Management Ninja: http://timemanagementninja.com/2013/08/10-ways-to-be-present-and-be-a-better-listener/
McMullen, L. (2013, August 24). How to Actually be a Good Listener. Retrieved from Huffington Post: http://www.huffingtonpost.com/2013/08/24/how-to-be-a-good-listener_n_3795849.html
Richardson L. (2012). Motivational interviewing: helping patients move toward change. Journal of Christian nursing : a quarterly publication of Nurses Christian Fellowship, 29(1), 18–26. https://doi.org/10.1097/cnj.0b013e318238e510
The current issue of Advances In Nursing Science is a special one. The articles in this issue all are related to ‘peace’ and at a time when our country and our lives are faced with turmoil and violence, it is a welcome journal.
Here’s a look at some of the feature articles…
"No One Gets Through It OK": The Health Challenge of Coming Home from War
“I was in a firefight one week and home in the next. And it was like, as an 18-, 19-year-old kid...you can't turn the switch off, you know what I'm saying? It was difficult for me to go home and make an instant switch to be a civilian. I didn't know how to act right. My energy was up here, but it needed to be down here.”
Critical Cultural Competence for Culturally Diverse Workforces: Toward Equitable and Peaceful Health Care
“…attaining equity-and ultimately peace-in health care delivery necessitates that nursing and other health care professions more carefully attend to the sociocultural context in which health care is delivered.
Peace Through a Healing Transformation of Human Dignity: Possibilities and Dilemmas in Global Health and Peace
“Through personal experience in the region, I have witnessed the transformative power of Israeli-Palestinian relationship building through joint health initiatives. Yet, these experiences also reflect a reluctance of health care professionals working on such initiatives to explicitly address the conflict.”
The Language of Violence in Mental: Health Shifting the Paradigm to the Language of Peace
“…as language is a fluid medium that can be consciously reshaped just as a potter can reshape clay or an artist can rework a canvas, nurses can mold the language of nursing and health care to reflect the paradigm and the power of peace.”
I am happy to share this issue with you and I hope that it will inspire you to infuse more peace into your nursing practice and your life. Enjoy…and I wish you peace.
I just spent a wonderful long weekend in Nashville, Tennessee at Nursing Management Congress 2012. What a great city, great venue (Gaylord Opryland Resort and Convention Center), and great event! I learned a lot, connected with lots of nurse managers and executives, and enjoyed my surroundings. I have lots to share with you over my next few blog posts, but I’m especially excited to share the following idea which was presented by one of the attendees and then shared by Sharon Cox, BSN, MSN during the opening session, titled “Nurse Managers: Adding Value in a Time of Volatility.”
During one of the preconference workshops, a discussion about staff recognition had begun, when one attendee (I wish I knew her name to give credit where credit is due) shared a means of recognizing staff members that has had positive results. Rather than recognizing a staff member with a pat on the back or a letter of recognition to be filed, this manager asks the staff member (and I’m paraphrasing here), “I’d like to let someone important to you know what a valuable asset you are to us. To whom could I send your letter of recognition?” She then wrote a personal note to to the person selected.
This manager said she’s written to parents, spouses, mentors, and children of her staff members and has gotten positive feedback from all involved. She even met one staff member’s parents at a wedding and was thanked in person for the note she had written about their daughter.
What a great idea!
It’s been a busy few days in the nursing community – first with the high of Miss Colorado, Kelley Johnson's moving monologue on being a nurse and then with the low of some uneducated comments on a celebrity talk show.
First, the monologue
I was so impressed with Miss Johnson’s monologue for her talent portion of the Miss America pageant. Nursing
is a talent, as is story-telling which she did very well in the competition. Miss Johnson shared the story of her relationship with a patient and what they learned from each other. She taught him that he’s not
just an Alzheimer’s patient and he taught her that she’s not
just a nurse.
So often, we nurses are tough on ourselves! We use phrases such as “just a nurse” despite knowing just how important our role is. While I cringed when I first heard her use those words, I was relieved to see the point that she was making. Take a look…
Then, The View
In their discussion about the Miss America pageant, the panel on The View made some derogatory remarks about Miss Johnson’s monologue, saying that she “basically read her emails,” calling it “basically hilarious,” and asking “Why does she have a doctor’s stethoscope on?” Wow – this stung initially and then really angered me. And I am not the only one! I’ve spent a good part of this evening reading the posts and comments in support of Miss Johnson’s monologue and I’m also really enjoying the new hashtags (#nursingismytalent, #nursesmatter, and #respectnurses, to name a few), as well as the selfies nurses are posting with their stethoscopes.
The point is being made – we are nurses and we are proud of it! Keep sharing your passion and educating others about the work that we do and the difference that we make!
Signed,
#notjustanurse
Each week we select 3 articles to feature on our Recommended Reading list. We rotate the items on this list so there are always 10 articles available – and they are all free to read! It’s fun for me to choose these articles for several reasons – first, I get to do a lot of reading, but most of all, because I do think about what I’m “hearing” here on our blog, out there on our social media pages, and in real-life discussions with my nursing friends, when I select the articles to include each week. We also select 3 continuing education articles to include on our Recommended CE list, and remember, all of our CE articles can be read online free!
A hot topic lately, and one that is dear to me, is communication. Interactions with both patients and our colleagues are so important for outcomes and patient and staff satisfaction. We know that patients trust us, we know that we know our patients well, and we know that we are important members of the healthcare team. One of our current featured articles, Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses, has a great section with the heading Nurses' Special Relationship With Patients:
“For those with a life-limiting illness, nurses are the ""constant"" in their journey through a frequently fragmented healthcare system. The nurse becomes familiar with the patient's medical history, health status changes, ""behind the scenes"" discussions of the team, family dynamics, and expressions of thoughts, concerns, and values. Thoughtful communication is essential throughout the trajectory. As the nurse builds a relationship based on trust and consistency, he/she may be viewed as ""more approachable"" than others in the healthcare team and, as a consequence, be part of informal discussions with patients and families. Therefore, the nurse is well positioned to facilitate discussions focused on goals of care and treatment choices in the setting of a progressive debilitating illness.”
We do have special relationships with our patients. They are relationships that allow us into patients' lives during critical times, they are relationships that allow us to advocate for our patients, and they are relationships that allow us to provide the best possible nursing care to our patients. I hope you enjoy this article and the others on our Recommended Reading lists!
Happy Reading
Reference
Peereboom, K., & Coyle, N. (2012). Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses. Journal of Hospice and Palliative Nursing, 14(4).
Yesterday was Veterans Day and all around me I saw people saying thank you to veterans who have served our country by defending our right to freedom. Many of the nursing websites and journals posted messages thanking the veteran nurses who have served our country so well. I also tried to do a blog post yesterday to say thank you to our military nurses but, technology was not on my side and wouldn't allow me to post. As I pondered this experience on my drive to work this morning, I had another thought. It is not the day that is truely important, it's the overall feeling that we should say thank you to our military nurses everyday. They are truely the unsung heros in our profession. I have had the honor to work with many nurses who have served our country over the years. I am in awe of their dedication and devotion to helping individuals who are in need even if it means putting their safety in jeopardy. The next time you are searching for an example of a nurse who really embody the spirit of giving; look no further than a nurse who is actively serving or who has served in the military.
By Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Posted:
11/12/2010 8:42:42 AM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories: Inspiration
Last week, more than 5,000 nurses participated in a conference call with First Lady Michelle Obama and Mary Wakefield, PhD, RN, FAAN, the administrator of the Health Resources and Services Administration. The call focused on the role of nurses in educating the public about the Affordable Care Act. After sharing the personal experience of her daughter’s meningitis and the impact of the nurses who provided her care, Mrs. Obama went on to describe details of the Affordable Care Act:
“…insurance companies can no longer discriminate against kids because they have a preexisting condition. Patients can no longer be dropped by their insurance companies because they get sick. People suffering from a serious illness like breast cancer can focus on their treatment because they no longer have to worry about hitting their lifetime limit on coverage. And college kids and young adults just starting out on their own can now get coverage through their parents’ plan.”
“And some of the biggest new changes and benefits are the reforms that deal with preventative care…Things like mammograms, cervical screenings, colonoscopies, childhood immunizations, prenatal and new baby care, high blood pressure treatment, all of these are included in new insurance plans with no deductable, no copay, no coinsurance, nothing.”
Mrs. Obama is calling upon nurses to “spread the word” of these changes and educate our patients and the public. You can read the transcript of the teleconference as well as the American Nurses Association's highlights of the newly enacted provisions of the Affordable Care Act for more information.
The inappropriate and unnecessary overuse of antibiotics within hospital and outpatient settings has led to the rise of drug-resistant strains of bacteria over the past several decades. These “super” bugs cause 2 million illnesses and over 23,000 deaths in the U.S. alone, according to the Centers for Disease Control and Prevention (CDC)
1. In March of 2015, the White House issued a
National Action Plan for Combating Antibiotic-Resistant Bacteria. The goals of the plan include
1:
- Slow the emergence of resistant bacteria and prevent the spread of resistant infections.
- Strengthen national one-health surveillance efforts to combat resistance.
- Advance development and use of rapid and innovative diagnostic tests for identification and characterization of resistant bacteria.
- Accelerate basic and applied research and development for new antibiotics, therapeutics, and vaccines.
- Improve international collaboration and capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development.
By 2020, a primary outcome of Goal 1 will be the establishment of antibiotic stewardship programs in all acute care hospitals and across all healthcare settings
2. The core elements of hospital antibiotic stewardship programs will include
1,2:
- Establishing leadership commitment by dedicating necessary human, financial and information technology resources.
- Appointing a single physician leader, ideally formally trained in infectious diseases, responsible for program outcomes.
- Appointing a single pharmacist leader with drug expertise, responsible for working to improve antibiotic use.
- Securing support from the multidisciplinary team, including infection prevention control, nursing, information technology, laboratory and quality improvement.
- Implementing policies and interventions to improve antibiotic use, ensuring that patients receive the right antibiotic at the right time at the right dose for the right duration.
- Implementing at least one recommended action, such as systemic evaluation of ongoing treatment after a set period of initial treatment (i.e. “antibiotic time out” after 48 hours).
- Monitoring antibiotic prescribing and resistance programs.
- Educating clinicians about resistance and optimal prescribing.
Healthcare leaders and clinicians in all settings should focus efforts on implementing these recommendations in order to decrease antibiotic resistant bacteria.
Myrna B. Schnur, RN, MSN
Some wise words were spoken at Nursing Management Congress this year. Here’s my top list of quotes from the conference. Thank you to all of the experts who shared their experience and stories with us!
Without further ado…
1. “Our knowledge of what we do everyday is very limited; based on tradition, not science.”
Richard Hader, RN, PhD, FAAN, CHE, CNA, CPHQ, Conference Chairperson, Editor-In-Chief, Nursing Management Journal, Senior Vice President and Chief Nurse Executive, Meridian Health
2. “Intrapreneurs are ‘dreamers who do.’”
Kathy Russell-Babin, MSN, RN, NEA-BC, ACNS-B, Senior Manager, Institute for Evidence-Based Care, Meridian Health
3. “Prioritization is a fact of life in clinical practice.”
Sean Clarke, RN, PhD, FAAN, Director, McGill Nursing Collaborative for Education and Innovation in Patient and Family Centered Care, McGill University and the McGill Teaching Hospital Network
4. “We teach people how to treat us.”
Sharon Cox, BSN, MSN, Founder and Principal Consultant, Cox and Associates
5. “Shift from ‘busy’ to ‘productive.’”
Sharon Cox, BSN, MSN, Founder and Principal Consultant, Cox and Associates
6. “Don’t forget the patient in the shared decision making model.”
Richard Hader, RN, PhD, FAAN, CHE, CNA, CPHQ, Conference Chairperson, Editor-In-Chief, Nursing Management Journal, Senior Vice President and Chief Nurse Executive, Meridian Health
7. “As a patient, if a provider comes in with an unkempt appearance, do you want that person to touch you?”
Richard Hader, RN, PhD, FAAN, CHE, CNA, CPHQ, Conference Chairperson, Editor-In-Chief, Nursing Management Journal, Senior Vice President and Chief Nurse Executive, Meridian Health
8. “People can change when they are fighting for a cause bigger than themselves.”
John O’Leary, President, Rising Above
9. “When you know your ‘why’ you can endure any ‘how.’”
Victor Franco, Holocaust Survivor (shared by John O’Leary, President, Rising Above)
10. “One person always makes a difference.”
John O’Leary, President, Rising Above
Please keep in mind that I was not able to attend every session as the breakout sessions occurred concurrently. I'm sure I am missing many great quotes on this list! All of the sessions that I did attend were informative, but even more impressive to me, was how invigorating they were. From the enthusiasm in the audience and some of my conversations in the exhibit hall, I know I was not the only one feeling this way.
Every year Nurses Week rolls around and nurses are told “thank you” by their institutions; if you are lucky, you may receive a token of appreciation like a lunch bag, a water bottle, or a beach towel. The research is clear, nurses do make a difference in patient outcomes and nurses are the most trusted profession according to the Gallop poll. This is my 28th year experiencing Nurses Week, but this year I am seeing it a little differently.
My mother passed away last year on May 25th from small cell lung cancer. From the day she was diagnosed to the day she died was 2 and a half months. She tried chemo but it didn’t work, it often doesn’t. She never regretted trying the chemo because it gave her the time to say good bye to all of her family and friends. Her friends were incredibly supportive of her and the rest of our family. You see, her friends were all nurses. They helped prepare meals, assist with her activities of daily living, and administer her medications. They even stayed overnight when one of the family couldn’t stay. They allowed me to be the “daughter” not always the caregiver. When my mom died, she was surrounded by her children and three of her best friends who were all nurses. These women made all the difference in the world to my mom and our family. They made it possible to keep her where she wanted to be – at home.
Being a nurse doesn’t end when you retire or take time off to raise your family. It is an innate part of who you are and how you conduct yourself each and every day. So, during this Nurses Week, if you come upon a nurse who is retired or is taking some time off, say “thank you…you make a difference.”
Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies
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.
As Nurses Week is winding down, I am honored to share this excerpt from “The American Nurse.” Created by Carolyn Jones, this book explores the unique lives of nurses using photographs and personal stories.
This infographic was shared with us by Erica Moss, who is the community manager for the online nursing programs at Georgetown University School of Nursing & Health Studies. Click the image to see its full size.
I just returned from Italy - an absolutely glorious vacation…the people, the culture, the food…wonderful!!! I am now settling back in to home and work routines and got to thinking about how different this transition is for those of us who don't work in a clinical setting. As a clinical editor, I have the luxury of picking and choosing what to catch up on first - reading the latest journal articles, catching up on social media, writing the next eNewsletter, or editing some upcoming articles. The list goes on…
Sure, I need to prioritize what needs to be done sooner rather than later, however my return to work is a lot different now then when I was taking care of patients. As a clinical nurse, there really is no easing back into work. Assessments need to be done, medications need to be given, procedures must be performed, and patient education and support must be provided. This list also goes on...
Thinking about this also brought to mind another common occurrence in my experience. After a return from vacation, I remember being given a heavier assignment, maybe the sicker patients or the families who needed a little more time and TLC. I was considered fresh, well-rested, and ready to go. Never mind the jet-lag or any family drama experienced while away!
I will confess that these are not only memories of my returns from vacation, but also in my role as charge nurse when colleagues returned from vacation. “Sure, Sally can take the patient maxed out on pressors who is a full-code. She just spent a week in Hawaii.” Or, “Give Jeff the ER admission with the fresh GI bleed. He’s been off all week.”
As I write this, I am disappointed in myself and think…would this be considered horizontal violence? It’s just the way that things were and no one ever questioned it, but that shouldn’t make it right. Thoughts?
As you can imagine, I do a lot of reading about nursing. Journals, books, newsletters, blogs - you name it and pretty much I’m reading it! I think I’ve mentioned before how some titles really hook me. I love lists, so when I come across anything that starts with “Top 10” or “Tips for” or “List of” chances are that I will open to that page or click that link. Another one of my favorite things are mnemonics, or easy tricks for remembering complex things, which in nursing school and in practice, are very helpful!
Here are some of my favorites:
To help organize your day…
IMAGE: Introduce yourself, Medications, Assessment, Goal, Explain & Educate
To evaluate a symptom…
PQRST: Provocative/Palliative (what makes it better/worse), Quality/Quantity, Region/Radiation, Severity, Timing
To assess skin lesions…
ABCDE: Asymmetry, Border, Color/Configuration, Diameter/Drainage, Evolving
To assess pupils…
PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation
To include in your documentation…
PIE: Problem, Intervention, Evaluation
More to come soon...do you recall the one for remembering all the cranial nerves?
Hi again! Here’s part 2 of my mnemonics list. These tips need a little more explanation, but they worked for me, so perhaps you’ll find some value in them as well.
To remember the types of white blood cells and their descending proportion in a blood sample…
“Never Let Monkeys Eat Bananas” = Neutrophils, Lymphocytes, Monocytes, Eosinophils, Basophils
To remember where lymphocytes mature…
B cells mature in the Bone marrow; T cells mature in the Thymus
To remember the cranial nerves…
“On Old Olympus Towering Tops, A Finn And German Viewed Some Hops” = Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic, Glassopharyngeal, Vagus, Spinal Accessory, Hypoglossal
And to remember the functions of the cranial nerves (sensory [S], motor [M], or both sensory and motor [B])…"Some Say Marry Money But My Brother Says Bad Business Marry Money."
To remember the location of the adrenal glands…
Think ADD RENAL; they're "added" to the renal organs, the kidneys.
That’s all for now! Here’s R-E-M-E-M-B-E-R (Part 1) in case you missed it!
As I sit here, looking out at the 16+ inches of snow, telling my kids that “Yes, you have another snow day,” I am reminded of the 'snow days' back when I was working in the ICU. Those days were a little different. They involved phone calls upon phone calls trying to round up staff in preparation for an upcoming storm, setting up cots in hallways, and packing a bag knowing I’d be spending a few days at the hospital. One year, our manager actually got a hotel room across the street from the hospital. We’d ‘tag-team’ each other, taking turns heading over to get a few hours of sleep. I have to admit it was fun and definitely fulfilling, despite the sleep deprivation!
Do you have any particular snow day memories in your career? Do you find that you are spending a little extra time at the hospital this winter? Thank you, nurses, for your dedication and caring! Be safe!
In 2008, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) launched an initiative that looked at where the nursing profession was and where it needed to go. Their purpose was to make recommendations for an ""action-oriented"" blueprint for the future of nursing. The group looked at the educational levels of nurses, the roles of nurses, and where nurses practice. This week, RWJF and the IOM released recommendations on how the nursing profession needs to transform to better meet the healthcare needs of people across the country.
The four key messages are:
1. Nurses should practice to the full extent of their education and training.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
3. Nurses should be full partners, with physicians and other health care professinals, in redesigning health care in the United States.
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.
As I read the report brief, it occurred to me that their recommendations seem like common sense. The evidence clearly shows all these things are true. It will be interesting to see if we are able to steer through the "politics of bureaucracy" and make these recommendations a reality. What do you think?
By Anne Dabrow Woods, MSN, RN, CRNP, ANP-B
Last month’s
Clinical Symposium on Advances in Skin & Wound Care (CSASWC) was a wonderful meeting of clinicians, including nurses, physicians, physical therapists, wound care specialists, educators, podiatrists, administrators, and others who strive to stay up-to-date on the latest evidence and products. From networking between sessions, learning from expert presenters, and connecting with exhibitors, this was a not-to-be-missed event.
The Symposium celebrated its 30th Anniversary and was held at the Hyatt Regency New Orleans. The backdrop for this event was spectacular – a wonderful city, incredible sports fans (both Louisiana State University and the Saints played that weekend), and endless options for food and entertainment contributed to the appeal of attending this conference! You can see some pictures from the event in our
CSASWC 2015 album on Facebook.
Please allow me to share a few of the clinical pearls that I picked up during the conference:
- “Typically, neonatal and pediatric pressure ulcers are a result of medical devices.”
International Pressure Ulcer Prevention and Treatment Guidelines: How Do You Use Them?,
Laura Edsberg, PhD
- “All antibiotics are antimicrobial, but not all antimicrobials are antibiotics. Antibiotics can inhibit or kill the organism; antimicrobials inhibit bacterial growth, but do little or no damage to the host.”
When Dressings Just Aren’t Enough: Pharmaceuticals and Supplements for Wound Healing
Phyllis Kupsick, RN, MSN, FNP-BC, CWOCN, PRN
- “Deep tissue injury is common in the ICU population. The sacrum and the heels are the most common sites.”
What is? Wound Care Jeopardy!
Gregory Bohn, MD, FACS, FACHM
- “Even with the change to ICD-10, documentation is the key to success!”
10-Day Countdown to ICD-10-CM
Kathleen D. Schaum, MS
Our upcoming events include
Lippincott’s Clinical Nursing Symposium and
Nursing Management Congress. Find more information on key nursing and healthcare events
here.
What are your conference plans this fall?
For those of you who follow me on twitter, you know that I try to write a daily nursing tip. Sometimes, these tweets generate discussion. One tip in particular that seemed to get people talking was this:
“Don't palpate both carotid arteries at the same time or press too firmly; pt could faint or become bradycardic.”
I did ponder posting this one, because really – don’t all nurses know this already? But then I got to thinking – did I know this already as a nursing student? As a new nurse? When did I learn this?
It’s been a while since I was in nursing school, but I do remember learning a lot about nursing theory, even more about care plans, and of course, I’ll never forget the steps of the nursing process (assess, diagnose, plan, implement, evaluate!) I can’t deny that all of these things built the foundation of my nursing knowledge. But what isn’t clear to me is when the clinical skills and knowledge became ingrained in my brain – when I learned how to calculate a dopamine infusion to maintain someone’s systolic blood pressure above 85 mmHg, when I learned to approach a family about end-of-life issues, or how I learned to prioritize the needs of critically ill patients. When did these things happen?
In 1984, Patricia Benner published From Novice to Expert: Excellence and Power in Clinical Nursing Practice. In her landmark work, the author describes nurses as going through five stages of development – novice, advanced beginner, competent, proficient, and expert – with each stage building upon the knowledge and skills of the previous one. Think of your own experiences – where do you fit in this model? How will you get to the next level?
Answers to this question vary depending on the level of nursing education and practice. I have been a member of different types organizations at different stages of my career depending on my practice setting, type of patients I cared for, and the certifications I earned. I have always seen the value of association membership in helping me to advance my career, but clearly all professionals don't feel the same way. As a result, membership in organizations has been decreasing in recent years. Maybe you should take a look to determine if membership will help you achieve your career aspirations.
First, some of us got our introduction into a membership society with honor societies. Your first membership in an honor society may have started as far back as high school. This is membership by invitation and doesn't necessarily imply a personal committment or involvement.
How about membership in a State Nurses Association? Now you're making a conscious choice to affiliate yourself with fellow nursing professionals who have common goals to advance the nursing profession and to protect the rights of nurses as a whole.
As you have move further into your career, you may choose a specialy area such as rehabilitation, critical care, or medical surgical nursing. If you have earned certification in your specialty, you certainly have a made an effort to solidify your commitment to the specialty. I recommend that if you have not joined the related nursing organization, go online and find out what they have to offer you. There are mentorship opportunities, local meetings, and continuing education offerings to help you maintain your certification.
Lastly, there are interdisciplinary organizations such as American Heart Association, American Cancer Society, or American Pain Society. These organizations are made up of individuals from multiple health professions and members of the healthcare industry who have common goals for researching, diagnosis, managing, and treating specific diseases or caring for a partcilar body system. As you develop your career, it will be imperative for you to be activity involved in a professional organization. Don't wait until it's time to make the next move. Membership may enhance your career at any stage.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
How many of you are really familiar with how nursing will impact health care reform? I recently had a discussion with a colleague of mine about this issue and I was dismayed about her lack of understanding about this issue. As I asked more and more nurses about what they knew about ""what's in it for nursing,"" it became clear that many nurses aren't familiar with the important role nurses will play in implementing health care reform. We are key drivers in this change that will provide health care for 34 million people who aren't currently receiving care. Keeping patients healthy and out of the acute care system through preventative care, transitional care, and chronic disease management will start to move health care in this country from a focus on illness to one of optimum health and wellness.
I encourage you to read Diana Mason's article in the July issue of the American Journal of Nursing titled: Health Care Reform: What's in it for Nursing. This article will give you a great overview of the importance of nursing in health care reform. Every nurse needs to be able to speak articulately about our role in health care reform to not only other nurses but, to everyday people. After all, we are their hope for better health.
By Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Recent articles such as The New Doctors in the House and Doc deficit? Nurses' role may grow in 28 states highlight the role that nurse practitioners can play in health care reform. No matter what your feelings about health care reform, I think as nurses and nurse practitioners, we need to embrace this opportunity to demonstrate our value to patients.
While our roles may overlap with other health care disciplines, our presence and expertise should not be threatening. Our goals are the same - to keep people feeling well, help them when they are not feeling well, and improve quality of life. Why are we so concerned about stepping on each other’s toes? As described by Anne Woods in a previous post: Healthcare providers: will we ever play nice in the same sandbox?
Part of the threat, I think, is due to the word “doctor.” Nurse practitioners are not medical doctors. That sounds simple enough, but the difficulty lies in the question: how should we refer to ourselves? I don’t have that answer. When discussing this blog post with a colleague, she recounted the following story to me:
“I have a friend with a PhD. who had a nurse managed primary care office and she hired her collaborating physician. When you called the office, the receptionist answered, ‘Hello, Doctor’s office!’
Hmmm - is that an appropriate greeting? When I was in practice, I introduced myself as Lisa. I was comfortable with patients calling me by my first name. I also explained that I was a nurse practitioner. Many questioned what that meant, some insisted on seeing the medical doctor, and others were happy that a nurse practitioner was part of the practice. How do you introduce yourself? What do patients call you? How do you explain your role?
Let’s take this one step further. When a nurse practitioner has a doctorate degree…then what? “Hi, I’m Dr. ________ and I’m your nurse practitioner.” Is this too confusing to patients? What do you think?
When I graduated from nursing school, I instantly became the “go-to” person in my family for all things medical. I’m sure many, if not all of you, can relate to this phenomenon. I was immediately the one who was called if anyone was injured or sick. It was just expected that I had all the answers because I was an RN, even when the questions were beyond my knowledge and experience.
Over the past year, it has also been expected that I had the answers about the proposed health care reform bill. How would it affect my parents’ medication expenses? Will everyone really have access to health insurance, even those with preexisting conditions? Would my 25-year old cousin who is unemployed be able to access coverage through his mother’s employer?
Last evening, the U.S. House of Representative passed President Obama’s health care reform bill (passed by the Senate in December). While there are still political technicalities to be addressed before the bill becomes law, I think it’s important for us nurses to know what this health care reform can mean in the immediate future and down the road. Here are some resources that I think are helpful for understanding the details of HCR:
Please share your resources on health care reform information by leaving me a comment here. I’m sure more questions will be headed my way!
Last week, Gallup released the results of the survey: Nursing Leadership from Bedside to Boardroom: Opinion Leaders' Perceptions. The results of this survey, performed on behalf of the Robert Wood Johnson Foundation (RWJF), revealed that nurses do not have as much influence on health care decision making as perhaps we should. The experts interviewed (insurance, corporate, health services, government and industry thought leaders, and university faculty) reported viewing nurses as trusted professionals and the majority said that nurses should have more influence on health policy, planning, and management.
So what are the barriers? Here is what they found:
• Compared to doctors, nurses aren’t perceived as important decision makers or money makers.
• Nurses focus on primary rather than preventive care.
• Nurses don’t have a single voice on national issues.
On a similar note, each year, Gallup surveys Americans about the most honest and ethical professions. 2009 marked the 8th consecutive year that nurses have been voted the most trusted profession in America.
So if the both the experts and the American public feel this strongly about our trustworthiness and decision making capabilities, and if we believe that we can truly make a difference, what are our next steps as a group? How about as individuals? How can we overcome the reported barriers?
This infographic was shared with us by Maryville University.
“Learning is one of life’s most essential activities.” — Annie Murphy Paul
Enrollment in all types of professional nursing programs increased from 2011 to 2012, according to new survey data from the American Association of Colleges of Nursing. These findings are based on data reported from 664 of the 856 nursing schools in the U.S. with baccalaureate and/or graduate programs.
The survey also saw a 3.5% increase in entry level Bachelor of Science in Nursing programs. The number of students enrolled in RN-to-BSN programs increased by 22.2% from 2011 to 2012, which, according to the AACN, signals a growing interest for baccalaureate-prepared nurses from both nurses and employers.
"AACN is pleased to see across-the-board increases in nursing school enrollments this year, given our commitment to encouraging all nurses to advance their education as a catalyst for improving patient care," said AACN President Jane Kirschling in a press release. "As the national voice for professional nursing education, AACN is committed to working with the education and health care community to create a highly qualified nursing workforce able to meet the expectations and challenges of contemporary nursing practice."
A few other interesting survey findings:
- Enrollment in master’s and doctoral degree programs increased “significantly.”
- Survey data indicated an 8.2% jump in enrollments for nursing schools with master’s programs (432 institutions reported data).
- Doctor of Nursing Practice programs saw a 19.6% enrollment increase (166 schools reported data).
- Baccalaureate nursing graduates are more than twice as likely to have jobs at the time of graduation than those entering the workforce in other fields.
- Graduates from master’s degree programs (MSNs) were most likely to have secured jobs at graduation (73%).
"Momentum is clearly building for advancing nursing education at all levels,” Kirschling said in a press release. “Given the calls for more baccalaureate- and graduate-prepared nurses, federal and private funding for nursing education should be targeted directly to the schools and programs that prepare students at these levels."
"Further, achieving the Institute of Medicine’s recommendations related to education will require strong academic-practice partnerships and a solid commitment among our practice colleagues to encourage and reward registered nurses committed to moving ahead with their education."
This post was written by Erica Moss, who is the community manager for the online masters in nursing programs at Georgetown University.
I'm very excited now that I am less than two weeks away from starting a doctor of nursing practice (DNP) program at George Washington University. In reflecting on my decisoin to pursue this practice-focused degree, I thought it would be helpful to share my journey through the decision-making process with you.
It is 15 years since I completed a master's degree and became certified as adult NP. When I started, I was sure I would continue my education to the doctoral level, but I was struggling, to decide on what degree I should pursue. I really didn't think I wanted to go into the academic role, nor did I think I would fully take advantage of the years of research training, not to mention the blood sweat and tears of a dissertation. Therefore, I never applied to any PhD programs. Until the recent emergence of DNP programs, I did not find any doctoral program that were going to help me in my practice and professional development roles. "Finally..they created a doctoral degree for me!"
Boland, and others in the April 2010 issue of The Nurse Practitioner journal did an excellent job in providing the background on the history and process of developing DNP programs. In summary, the doctor of nursing practice is intended to provide advanced education to clinical leaders and advanced practice nurses. Don't worry if you are not a nurse practitioner. DNP's can be in varying roles including: nurse executive, clinical nurse specialist, or nurse informaticist. In contrast, the PhD prepares prepares nurses for a research-focused role. In addition to clincial roles, the authors expect that DNPs will also be an essential part of the nursing faculty in BSN, master's, and doctoral programs.
What some master's prepared NPs are concerned about is whether they should go back to school. With the expectation that new NP graduates have DNPs by 2015, it is a job security issue. I recall, when I was beginning my master's program, there were several NPs and nurse midwives who had certificates who were grand-fathered and allowed to practice. But they were challenged by the employment market or pressured by employers to return to school. Therefore, if you have a career of 10 years or more left, it might be the logical conclusion. Nursing may not have come to terms on entry into practice; however, it is clear that a doctoral degree is where we are going.
By Karen Innocent, MS, RN, CRNP, ANP-BC, CMSRN
Last week, I had the pleasure of speaking with Susan Fletcher, EdD, MSN, Professor at Chamberlain College of Nursing. I had heard about the International Nursing Service Projects that she developed and was anxious to learn more about the experiences of the students who accompanied her to countries such as Brazil, Kenya, Bolivia, and Uganda.
Dr. Fletcher, whose background includes community health, emergency room, and school nursing, has been taking students on mission trips for over 12 years. I was in awe after hearing about the patients they cared for and how innovative the students were in their planning and interventions. They had to think “outside the box” and come up with clever ideas to improve the quality of life of the people. For example:
- In the slums of Fortaleza, the students saw a quadriplegic man who was regaining some use of his arms. His house was a brick area the size of a closet and he spent his life in bed. Family members would bring him food sporadically. The students noticed pinpoint red marks on his toes. After seeing him for 3 days in a row, they realized these marks were rat bites. The students thought to all take off their socks and put them on his feet to make it harder for the rats to get to his skin.
- Another patient, an elderly woman, was bed-bound with heel decubiti. There was nothing to use to elevate her feet and reduce the pressure. Students filled rubber gloves with water and placed them under her ankles.
- In Bolivia, students met a woman with a severely prolapsed rectum. They gave her pads and a belt to use for support.
- In Africa, where the prevalence of HIV infection remains high, there are many orphans. Students saw families of children taking care of children. In one case, an 11-year old girl was responsible for 3 younger brothers and sisters. She’d cook over an open fire dug into the ground. Students cared for burns, infections, and injuries in various stages of healing.
- Another patient, a man with TB and AIDS, was dying. Students would help the family clean him up. There was one student whom he consistently followed with his eyes. This student learned that “sometimes all you can do is ‘be there.’”
Dr. Fletcher discussed the transformative nature of these experiences. The students developed amazing clinical skills and enhanced their critical thinking ability. They learned to understand the differences in cultures and the problems related to the lack of healthcare facilities, caregivers, and medical supplies. Students became more comfortable using local resources and learned to “create from nothing.”
To be eligible to go on a mission trip, students must maintain a certain grade point average, complete an interview form, provide a letter of recommendation from clinical faculty, and have a one-on-one interview. Dr. Fletcher described the living conditions as “often sleeping on the floor, sometimes eating rice three times per day.” In Kenya, students woke at 6 am, walked 3 miles to the village and then spent all day in the clinic. On that trip, the students saw about 2,500 people in 2 weeks.
Difficulty of leaving… “touch and let go”
In Kenya, as the group was preparing to leave, a 2-year old orphan was squatting outside the clinic, crying. The students “couldn’t stand it; they wanted to take her home.” Dr. Fletcher reassured them that someone had taken the time to dress this child and would be back for her. She told students, “These are the life circumstances here and we can’t rescue all the orphans.” Another important message, conveyed by one of the team members with the group, was “although you are upset, remember that because you were here, you’ve saved lives.”
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.
Posted:
12/18/2011 11:23:33 AM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
1 comments
Categories: Inspiration
Have you ever heard someone say “I used to be a nurse” when asked what they do? Me neither! In fact, when someone asks me what I do, the first thing I say is “I am a nurse.” This is usually followed by questions about where I work, what type of patients I care for, and the like. If the person I’m talking with is truly interested, I’ll explain my background in critical care, my role as a nurse practitioner in women’s health, and now my career in the world of publishing. I am proud of what I’ve done in the past and what I do now, but the biggest sense of pride comes with being able to say “I’m a nurse.”
A recent conversation with my mom went something like this:
Mom: “Have you heard from your cousin?”
Me: “Yes, he’s been great.” I then went on to fill her in on recent events in his life, as well as what his family and friends have been up to.
Mom: “Wow, why is it that everyone calls you with their latest news?” She then answered her own question with “I think it’s because you are a nurse.”
That warmed my heart! You can probably relate similar stories, especially when it comes to others, sometimes complete strangers, sharing their healthcare stories and questions.
Nurses – we truly are a special group!
Posted:
7/31/2011 12:14:09 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
5 comments
Categories: Inspiration
How does a week in Disneyworld sound? Good, right? Add in two dynamic nursing conferences and you’ve got an amazing week! While it was busy, I’d like to share some highlights and encourage you to make attending a nursing conference a priority. There is nothing like being surrounded by nurses, hearing from nurses, and hanging out with nurses to renew your passion for nursing!
LCNC
Lippincott Clinical Nursing Conference (LCNC) was up first. Geared to front-line nurses, this clinical-intensive included skill building sessions related to cardiac, pulmonary, and neurologic assessments. During the opening address, Christine Kessler, MN, CNS, ANP-BC, ADM, CDTC, FAANP gave attendees a choice in what they wanted to learn about – managing patients with diabetes or the impacts of shift work. I don’t know many speakers who can poll the audience and then present based on those results! If you’re wondering, attendees opted to hear about shift work and the session was informative and thought-provoking. While some might think that night shift is the most opportune time for nurses to take care of certain tasks (think baths and other personal care), it’s not always what’s best for patients.
Another opportunity that presented itself to me at LCNC was the chance to speak myself. It’s been a while since I presented to a large group and it felt good to connect with attendees during the session on adverse drug reactions. I quickly got through my nerves and I think that we all learned some things!
Nursing Management Congress
Nursing Management Congress (NMC) followed and did not disappoint. Never have I attended a conference session where the opening session ended in a standing ovation followed by silence. I’ve been a fan of Carolyn Jones’ work on The American Nurse Project for several years. I am not kidding that I was somewhat starstruck sitting there in the front row while she presented and then again later when I met her in the exhibit hall. I’m also really looking forward to her new project, Dying in America. I’ve mentioned before about my interested in end-of-life care and after watching the trailer for this new film, I know I won’t be disappointed.
I also spent time helping out with the New Manager Intensive preconference workshops. Day one focused on finance and day two focused on leadership. Wow! I knew nurse managers have a lot to juggle, but these two days really opened my eyes to the amount of calculations, hiring and firing issues, workplace conflict situations, and so much more that’s involved in their work each day. I’ll be sharing some more from this conference in the next few days, so stay tuned…
Don’t forget to visit
Lippincott’s eConference Center to complete your session evaluations and obtain your CE certificates. You can see more photos from these conferences on
NursingCenter’s Facebook page!
As a follow-up to last week’s
conference wrap-up, here are some of my favorite pearls and words of inspiration that I picked up during Nursing Management Congress 2015.
- “You learn as much from people who do things the wrong way as from people who do things the right way.”
Pamela Hunt, BS, MSN, RN
New Manager Intensive: A Focus on Finance
- “As a manager, the worst thing you can do with a ‘ring leader’ is avoid them.”
Shelley Cohen, RN, MSN, CEN
New Manager Intensive: A Focus on Leadership
- “Get to know your nurses. You already know them as nurses; get to know them as people.”
Debra Ruddy, CMSRN, MSN
Winner of the Richard Hader Visionary Leader Award
- “With regard to debriefing, remember it’s not who’s right – it’s what’s right.”
Jim "Murph" Murphy
Plan. Brief. Execute. Debrief = Win: A Fighter Pilot’s Secret to Success
- “Strong, effective leaders lead from a place of confidence, with humility.”
Jeff Doucette, DNP, RN, CEN, FACHE, NEA-BC
The Courageous Leader: Dare to be Different
- “The patient experience is not owned by nurses. It is a team sport.”
Amy Cotton, MSN, APRN, FAAN, EMHS
Look Out for the Booby Traps: Navigating the Patient Experience Landscape
What are some pearls that you’ve taken away from recent conferences?
The 2014 Ebola Virus Disease (EVD) outbreak of West Africa was a wake-up call for healthcare administrators and clinicians in the United States. EVD had been viewed as a third world problem, a crisis that would most likely never strike America. Last October, however, we witnessed the first patient diagnosed with EVD on U.S. soil, a Liberian man who ultimately passed away in a Dallas hospital after infecting two of his nurses, both of whom fully recovered. At the time, healthcare providers faced with the potential spread of the infectious disease had to piece together protocols based on limited knowledge and standards of care for patients infected with EVD. The majority of hospitals were unprepared should an infected patient walk into its Emergency Department (ED). Most did not have appropriate isolation rooms, personal protective equipment (PPE) or adequate staffing to safely care for these patients.
According to the World Health Organization (WHO), EVD remains a Public Health Emergency of International Concern (PHEIC)
1. Two active chains of EVD transmission continue, one in New Guinea and one in Sierra Leone, resulting in approximately 5 new cases each week
1. Are U.S. hospitals better prepared and are nurses safer today to care for patients with highly infectious diseases than they were a year ago? The answer may be yes for a handful of centers that have received advanced training, education and government funding, however, that is not the case for over 5,000 hospital institutions across the country.
In response to the outbreak, the Centers for Disease Control and Prevention (CDC) established a three-tiered approach to guide hospitals and other emergency healthcare clinics in developing preparedness plans for patients under investigation (PUI) or with confirmed EVD
2. According to this plan, hospitals can serve in one of three roles: as a frontline healthcare facility, an Ebola Assessment Hospital or an Ebola Treatment Hospital.
All hospitals are considered
frontline healthcare facilities and each plays a critical role in the identification, isolation and evaluation of PUIs for EVD. Once identified, the institution is responsible for informing the facility infection control department, as well as the state and local public health agency, and promptly placing the patient in isolation. The frontline hospital is not expected to provide prolonged care for the patient for more than 12 to 24 hours and should coordinate immediate transfer of the patient to an Ebola assessment hospital or Ebola treatment hospital.
3
Ebola assessment hospitals are facilities that are prepared to receive and isolate PUIs and care for the patient until diagnosis of EVD can be ruled out or confirmed and until discharge or transfer is completed. They should be prepared to care for PUIs for up to 96 hours, should be equipped with adequate PPE for four to five days and ensure that staff members involved in or supporting patient care are appropriately trained for their roles. This includes demonstrated proficiency in putting on and taking off PPE, proper waste management, infection control practices, and specimen packaging and transport.
3
Ebola treatment hospitals are facilities that plan to care for and manage a patient with confirmed EVD for the duration of the patient’s illness. These centers must meet minimum criteria determined by the CDC, including infection control capacity, physical infrastructure, staffing resources, PPE supplies, waste management processes, worker safety training, environmental services and laboratory set up.
3 Staff must be trained in and have practiced putting on and taking off PPE for Ebola, as well as providing clinical care using PPE. CDC Ebola Response Teams (CERTs) are ready to deploy to any Ebola treatment center to provide technical assistance for infection control procedures, clinical care and logistics of managing patients with EVD as soon as the health department or hospital requests assistance.
3
Fifty-five hospitals have been identified as Ebola assessment centers. Of those, nine hospitals have been designated as Ebola regional treatment centers and have received government support and advanced training to meet the CDC minimum criteria. The Department of Health and Human Services (HHS) does not mandate that every state adopt this approach, however, all are encouraged to identify Ebola assessment hospitals that can successfully manage PUIs or confirmed cases of EVD.
2
The CDC released
comprehensive guidelines for frontline hospitals in the management of patients with EVD from identification through treatment. The recommendations are not government mandated and can be expensive to implement, therefore most facilities have not instituted these safe practices nor have they provided training to their frontline nurses. The responsibility falls on healthcare administrators, local state departments of health and the Occupational Safety and Health Administration (OSHA) to ensure these guidelines have been executed.
California is one state that has issued mandatory safeguards to protect healthcare workers from EVD by requiring hospitals to provide head-to-toe PPE and comprehensive training for staff caring for Ebola patients.
4 The guidelines require California hospitals to provide staff with full-body protective suits that meet the ASTM F1670 standard for blood penetration and the F1671 standard for viral penetration and that leave no skin exposed or unprotected.
4 Hospitals must also provide powered air-purifying respirators with a full cowl or hood for the head, face and neck of any RN or other staff member who provides care for a suspected or confirmed Ebola patient. Hands-on training must be provided for any worker who is at risk of exposure.
4 These regulations are mandatory in California and if hospitals do not comply with the guidelines, they will incur fines and penalties.
The precedent set by California is one that should be adopted by every state and local health department across the country. All nurses deserve adequate information and training on the care of EVD patients and their safety and well-being must remain the highest priority. Do you believe that your institution is prepared today to care for an EVD patient? Do you feel that you have received adequate training and that you would be at minimal risk of contracting EVD or other highly contagious diseases? (
You can see how some nurses responded to this question in this JONA article.) Please let us know how you feel by leaving a comment!
In-Person Ebola Training should be mandatory and include:5
- Learning to don (put on) and doff (remove) the PPE – performed under direct observation following itemized and standardized verbal instructions; practiced four to six times; no one is allowed in the warm zone (anteroom) or hot zone (patient room) without donning full PPE under close observation and direction of trained nurses
- Performing routine tasks while wearing multiple layers of PPE
- Enhancing safety skills: slowing down; paying attention to sharp objects, stopping and thinking through movements before beginning a task; placing one’s immediate safety before the needs of the patient; always working in pairs – one nurse cares for the patient, while the second nurse watches for breaks in PPE, disinfects the environment, prepares trash for removal, and assists with turning or two-person procedures
- Handling waste: moving slowly when handling bedpans, canisters and urinals, always covering the container; all liquid waste is decontaminated for 15 minutes before flushing
- Cleaning and disinfecting healthcare environments
Myrna B. Schnur, RN, MSN
Over the past week, several people have asked me about recent news related to red meat and processed meat causing cancer.
Could it be true? Is it really as dangerous as smoking? Do I need to stop using my grill?
While the association between red meat and cancer is not new information, a recent systematic review presented at the International Agency for Research on Cancer (IARC) has both categorized the risk and reignited the conversation among healthcare professionals and the public. Here are some related definitions and a summary of the results that the researchers shared:
- Red meat is unprocessed mammalian muscle meat, including beef, veal, pork, lamb, mutton, horse, or goat meat.
- Processed meat has been transformed through salting, curing, fermentation, smoking, or other processes.
- The group looked at “more than 800 epidemiological studies that investigated the association of cancer with consumption of red meat or processed meat in many countries, from several continents, with diverse ethnicities and diets.” (You can read more specifics on the studies in The Lancet Oncology. Free registration on the site is required).
- Overall conclusions:
“Overall, the Working Group classified consumption of processed meat as “carcinogenic to humans” (Group 1) on the basis of sufficient evidence for colorectal cancer. Additionally, a positive association with the consumption of processed meat was found for stomach cancer.”
“The Working Group classified consumption of red meat as “probably carcinogenic to humans” (Group 2A). In making this evaluation, the Working Group took into consideration all the relevant data, including the substantial epidemiological data showing a positive association between consumption of red meat and colorectal cancer and the strong mechanistic evidence. Consumption of red meat was also positively associated with pancreatic and with prostate cancer.”
So what does this mean?
The evidence groups assigned by IARC refer to how likely a particular cancer risk is to actually cause cancer. Group 1 carcinogens (processed meat, smoking, alcohol) are classified as definite causes; Group 2a carcinogens (red meat, shift work) are classified as probable causes. But remember, it’s all about how confident the IARC is that something causes cancer, not how much cancer results.
This analogy shared by
Cancer Research UK makes this a little easier to understand:
“To take an analogy, think of banana skins. They definitely can cause accidents – but in practice this doesn’t happen very often (unless you work in a banana factory). And the sort of harm you can come to from slipping on a banana skin isn’t generally as severe as, say, being in a car accident.
But under a hazard identification system like IARC’s, ‘banana skins’ and ‘cars’ would come under the same category – they both definitely do cause accidents.”
So while processed meat and tobacco are in the same Group 1 category – known to cause cancer – the risk of cancer from tobacco use is much higher than the risk of cancer related to eating processed meat. (You can see some great infographics
here).
Am I going to stop eating red meat?
No, I’ll still enjoy the occasional hamburger or hot dog. When it comes to meat, I already opt for chicken, turkey or fish more often than red meat, so I do feel pretty good about the balance in my current diet. And of course, I try to get plenty of fruits and vegetables too!
Has this recent report influenced you to make any changes to your diet? How do you answer patients (and friends and family) when they ask you “Should I stop eating meat?”
References
Bouvard, V., Loomis, D., Guyton, K., Grosse, Y., Ghissassi, F., Benbrahim-Tallaa, L., . . . Straif, K. (2015). Carcinogenicity of consumption of red and processed meat. The Lancet Oncology.
Dunlop, C. (2015, October 26). Processed meat and cancer - what you need to know. Retrieved from Cancer Research UK: http://scienceblog.cancerresearchuk.org/2015/10/26/processed-meat-and-cancer-what-you-need-to-know/
World Health Organization. (2015, October 29). Links between processed meat and colorectal cancer. Retrieved from World Health Organization: http://www.who.int/mediacentre/news/statements/2015/processed-meat-cancer/en/
World Health Organization. (2015, October). Q&A on the carcinogenicity of the consumption of red meat and processed meat. Retrieved from World Health Organization: http://www.who.int/features/qa/cancer-red-meat/en/
Today, I listened in on the
Ovid Webcast, Beyond the Search: Maximizing the Quality of Systematic Reviews. Dr. Edoardo Aromataris, PhD, Director of Synthesis Science at the Joanna Briggs Institute in Adelaide, Australia and Dr. Craig Lockwood, PhD, RN, BN, GDip, ClinNurs, MNSc, Director of Translation Science at the Joanna Briggs Institute in Adelaide, Australia successfully gave me a better understanding of systematic reviews.
Whether you are reading journal articles, completing educational requirements, or performing research yourself, it is important to be aware of the components of a comprehensive systematic review. Why? The presence of specific defining features indicates a high level of rigor in the research which helps ensure that the review is reproducible (same results) and transparent (same conclusion).
So what are these defining features of a systematic review?
- A prespecified question
- Defined inclusion and exclusion criteria
- An extensive literature search that includes international research
- Selection of studies based on the inclusion criteria
- Assessment of the quality of the included studies
- Extraction of the data
- Analysis of the data
- Presentation of the results
- Interpretation of the results
We are fortunate that these two experts also co-authored books in the
Lippincott-Joanna Briggs Institute Synthesis Science in Healthcare Book Series. It was a pleasure learning from them today! Also, for those of you performing systematic reviews, remember to check out the
JBI tools on the Evidence-Based Practice Network to help you appraise and synthesize the evidence.
References:
Egger, M., Smith, G., & Altman, D. (2001). Systematic Reviews in Health Care: Meta-analysis in context. London: BMJ Publishing Group.
Glasziou, P., & et al. (2004). Systematic Reviews in Health Care: A Practical Guide. Cambridge: Cambridge University Press.
Family presence has always been a hot topic in the healthcare community. I can remember when family presence in an ICU meant visiting for 15 minutes three times per day. At least that was the policy in the local hospital where my grandparents were patients when I was a kid. We’d wait and wait for the clock to strike that magic moment and then take turns, two at a time, to visit. I’m not sure that communication with the staff even occurred during those minutes, or if it did, it may have been just a quick word or two.
It just so happens that later on, as a nurse in the medical intensive care unit (MICU) at a large teaching hospital, our unit transitioned from set visiting hours to open visiting hours from 11 am to 8 pm. It was then up to the discretion of the staff if family could come in earlier or stay later, even all night. Interdisciplinary rounds, led by the attending physician, took place each morning outside of each patient’s room. If family members were present, sometimes the attending updated them at that time and teaching of interns and residents occurred in front of the patient and family. More often, however, he or she told the family that they’d get an update when rounds were completed.
Much has been written about family presence, especially with regard to visitation and emergency care and resuscitation efforts, however little has been studied about including family members in medical or interdisciplinary rounds. In
Family Presence on Rounds, the author performed a systematic review of 17 studies on this topic. The
PICO question guiding this study was “In critical and noncritical pediatric and adult patients, does family presence on rounds compared with non-inclusion of family members lead to positive outcomes and increased satisfaction?”
While it is clear that further research is warranted on this topic, the author does a nice job of organizing results from the review based on family members’ outcomes, both positive and negative, and health care staff outcomes, both positive and negative. She even takes it one step further, by dividing the health care staff outcomes among nurses (although only 5 of the 17 studies addressed nurses’ perceptions) and medical staff.
Positive outcomes outnumbered the negative outcomes for all groups, but interestingly, the nurses did not perceive
any negative outcomes to family presence on rounds.
What is the policy where you practice? What’s been your experience with family presence during interdisciplinary rounds?
Reference:
Cypress, B.S. (2012). Family Presence on Rounds: A Systematic Review of the Literature. Dimensions of Critical Care Nursing, 31(1).
---Updated March 15, 2021---
March 19th is
Certified Nurses Day. A large number of nursing certification programs exist (I count 92!). This number alone tells me that this is something important that all nurses should consider. I was proud to use the credential CCRN during my days working in a medical ICU. The exam was tough and maintaining the necessary continuing education requirements was challenging, but my own sense of pride and the respect I received from patients, my colleagues, and my employer made it worth it.
So what is specialty certification exactly? The
American Nurses Credentialing Center (ANCC) states, "Professional certification is a voluntary designation earned by individuals who demonstrate a level of competency, skill, and knowledge in their field. Certification affirms advanced knowledge, skill, and practice to meet the challenges of modern nursing.” Many definitions exist, depending on where you look or from which organization you are seeking certification. In general, being certified demonstrates that you have advanced knowledge and competence in a given specialty.
Barriers to certification have been identified as time, cost of preparation and examinations, test anxiety, lack of support from supervisors, and continuing education requirements (Valente, 2010). Overcoming these barriers, both on personal and professional levels, are important because of the value and benefits associated with specialty certification. Kaplow (2011) categorized this value associated with certification into three realms: value to patients, value to employer, and value to self.
With regard to value to patients, certified nurses demonstrate greater confidence in decision making, increased patient safety (including less falls and decreased pressure ulcers), and higher patient satisfaction. Also, certified nurses have been shown to be more likely to provide care based on evidence-based guidelines (Kaplow, 2011).
Specialty certification sends a message of commitment to a current or potential employer. Nurses who are certified demonstrate a personal responsibility to their education, and in turn, patient care and outcomes. Some studies have even shown an association between certification and turnover, vacancy, staffing, nurse retention, job satisfaction, higher nurse performance, and patient satisfaction (Watts, 2010).
Finally, the personal benefits that come with certification are numerous. The sense of accomplishment, feeling of empowerment, and validation of knowledge had a great impact on my confidence. Other benefits can include an impact on salary and career advancement, as well as improved marketability (Kaplow, 2011).
If you’re interested in learning more about certification, take a moment to explore our
Guide to Certification. This handy table of specialty certification boards and contact information along with the associated credential and requirements is a good place to start your journey to certification. Good luck!
References:
American Nurses Credentialing Center. (2021). Celebrate Certified Nurses. https://www.nursingworld.org/education-events/certified-nurses-day
Kaplow R. (2011). The value of certification. AACN advanced critical care, 22(1), 25–32. https://doi.org/10.1097/NCI.0b013e3182057738
Valente S. M. (2010). Improving professional practice through certification. Journal for nurses in staff development : JNSD : official journal of the National Nursing Staff Development Organization, 26(5), 215–219. https://doi.org/10.1097/NND.0b013e31819b561c
Watts M. D. (2010). Certification and clinical ladder as the impetus for professional development. Critical care nursing quarterly, 33(1), 52–59. https://doi.org/10.1097/CNQ.0b013e3181c8e333
Thirty years ago, when I was in my Bachelor's program for nursing, I was taught to aspirate for intramuscular (IM) injections to make sure I didn't puncture an artery or vein. I am confident that all of you reading this post were taught the same technique. The question we need to ask is, is the technique based on evidence or is it just the way it has always been done.
In an integrative review published in the March issue of
Nursing2012, To aspirate or not: An integrative review of the evidence, researchers examined the literature to determine if there was any evidence supporting the practice of aspiration for injections. The researchers used an Integrative review methodology to review the literature. The integrative approach answers a targeted clinical question using a systematic search strategy and a rigorous appraisal method (Crawford & Johnson, 2012).
The results were not surprising; there was no research evidence to support the use of aspiration in giving IM or SC injections. The researchers recommended the following for consideration:
- Aspiration is not indicated for subcutaneous injections of immunizations, heparin, and insulin
- Aspiration is not indicated for IM injections of vaccines and immunizations
- Aspiration may be indicated for IM injections of medications such as penicillin
- Until a standard can be established, injection techniques must be individualized to the patient to prevent incorrect needle placement (Crawford & Johnson, 2012).
Unfortunately in nursing, we often practice a certain way because that is the way it has always been done. I applaud the work of the researchers who did this study; they are truly moving nursing practice forward based on evidence. Translating evidence into practice is a series of steps and the researchers have taken the first steps to appraise the evidence and recommend practice changes based on the evidence. It is up to each of us to take the evidence presented and integrate it into practice.
Reference:
Crawford, C., Johnson, J., 2012. To aspirate or not: An integrative review of the evidence. Nursing2012, (42), 3, 20-25.
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
The debate over standardization of nursing uniforms is well-documented, however, the existence of rigorous, well-designed studies is lacking. In the latest issue of
JONA, Journal of Nursing Administration, an
integrative review examining the professional appearance of RNs examines the evidence. While the strength of the evidence is low, it is essential for us to recognize the importance of patients being able to identify us as nurses and to understand how our attire impacts the public’s perception of our knowledge and skills.
Seven studies were included in this review and a nice table comparing each of the studies can be found in this
supplemental digital content. One study found that among nurses, students, and patients, solid color scrubs reflect more skills and knowledge than print scrubs or T-shirt tops. Another study, which looked at uniform color preference among patients, found blue or white to be most preferred, while red was least preferred. Take a close look at this table to learn more about how both patients and nurses feel that uniform and general appearance impact perception. It’s pretty interesting.
Is there a standard uniform for nursing staff where you work?
Reference:
Cassidy, C., Del Guidice, M., Hatfield, L., Pearce, M., Polomano, R., Samoyan, J. (2013). The Professional Appearance of Registered Nurses: An Integrative Review of Peer-Refereed Studies. JONA, Journal of Nursing Administration, 42(2).
We know that evidence-based practice (EBP) leads to improved patient outcomes. Yet it is also known that nurses identify barriers to implementing evidence-based practice, such as lack of knowledge, support, time, and authority to change practice (O'Nan, 2011). Change can be difficult, but as nurses it is our responsibility to our patients and our profession to develop and implement activities that promote evidence-based practice. One such activity that can help us overcome barriers and incorporate research findings into practice is a journal club. A journal club can be described as “the sharing of contemporary knowledge and appraising the value of that knowledge for applications in clinical practice” (Duffy, Elpers, Hobbs, Niemeyer-Hacket, & Thompson, 2011).
What are the benefits of a journal club?
- Sharing knowledge of current clinical research
- Facilitating the learning process
- Enhancing literature critique and appraisal skills
- Encouraging interaction and dialogue with other nurses
- Encouraging research utilization
- Promoting team building
- Promoting EBP in a cost-effective manner
What are the steps for starting a journal club?
- Decide if the journal club will be unit-based or hospital-wide.
- Gain the support of unit managers or senior nursing administration. Be prepared to discuss the benefits, objectives, scope of work, timetable, and key stakeholders (Chabot, et al., 2011).
- Determine meeting schedule and length.
- Identify a leader/facilitator.
- Identify the topic of interest.
- Select and disseminate article(s).
- Hold meeting and discuss the topic/appraise the evidence.
- Determine if further research or action is needed.
You can learn more by reading the articles referenced below. There are great ideas to help you get started and also to determine the best schedule for your group, the roles and responsibilities of the facilitator and members, and how to evaluate your group’s success. Also, consider the use of an
online journal club or use of the
tools available from the Joanna Briggs Institute to help you appraise the evidence. Good luck!
References
Chabot, J., Conners, S., DeNigris, J., Dunn, R., Panzera, A., & Patel, P. (2011). Evidence-Based Practice and a Nursing Journal Club: An Equation for Positive Patient Outcomes and Nursing Empowerment. Journal for Nurses in Staff Development, 227-230.
Duffy, J., Elpers, S., Hobbs, T., Niemeyer-Hacket, N., & Thompson, D. (2011). Evidence-Based Nursing Leadership: Evaluation of a Joint Academic-Service Journal Club. JONA: Journal of Nursing Administration, 422-427.
O'Nan, C. (2011). The Effect of a Journal Club on Perceived Barriers to the Utilization of Nursing Research in a Practice Setting. Journal for Nurses in Staff Development, 160-164.
Last week I had the pleasure of attending Nursing2012 Symposium in Orlando, Florida. One of the sessions, titled Faculty-Guided Poster Tour: Ask the Experts, was a highlight for me. This session was exactly what the title implies; an informal tour of the posters being presented at the conference. Three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led the session which was held right in the exhibit hall where the posters were displayed. Frank Myers who critiqued each presentation first, initially broke the ice by sharing that he’s taken about 15 research courses throughout his career and education and asked “What does that make me?” While I thought “an expert,” “amazing,” and “impressive,” he answered for us all by saying “Boring!” It certainly was a fun and interactive session!
The leaders shared their reactions and feedback on 6 of the posters. They pointed out key features of the posters themselves as well as the research being presented. It was helpful to get tips about what a poster should look like, what the elements should be, and a little bit more of the intricacies of research and evidence. Here are some of the things that I learned and I hope that you find them useful too!
The poster should…
• Be visually attractive.
• Be about 1/3 pictures and/or graphs.
• Have about 20% white space.
• Be legible from 3-4 feet away.
• Be organized so that the content flows in a logical manner.
• Include your references.
Regarding the research…
• Be clear about what you are testing.
• Make sure you have a good reason to do the research.
• Get approval from the Internal Review Board (IRB) if needed.
• Understand the difference between an observation study and an intervention study.
• When using graphs to show your data, note the intervention period on the graph.
• When considering endpoints, pay attention to other fields or disciplines.
• Know what the “popcorn effect” is – remember that during the first weeks of an intervention, people are more likely to like it and perform it.
• Use rate (for example, amount/1000 patient days) rather than just a number when reporting results.
• Understand the difference between statistical significance and clinical significance.
• Compare mean and median to balance outliers. It’s generally okay to discard outliers when they are 2 standard deviations from median or when you disclose that you’ve done so (ask yourself if patient who is an outlier matches your patient population).
• With regard to sample size, it should never be smaller than 30 and more than 1,500 won’t impact your findings. The more covariants you have, the bigger your sample size needs to be.
• Anytime something “jumps” out, such as a peak or downward trend, explain it.
Other tips…
• Spell out acronyms with first use.
• Remember your audience; not everyone is an expert in statistical analysis.
• Don’t cut and paste from statistical analysis programs; create new tables and graphs.
• Supplement your poster with print copies and also copies of any tools you developed for the intervention.
• Include information about the financial impact of your intervention to “sell” it to administration.
• Be savvy with terminology – use “cost avoidance” rather than “cost savings.”
Poster presentations can be used as a “stepping stone” to publication. Consider turning your research into a poster and presenting it at an appropriate conference. It’s a wonderful way to get feedback from your peers which you can then incorporate into a manuscript.
My first preceptor was a nursing assistant who had been treated for breast cancer several years prior to my orientation. While I didn’t know the extent of her disease or treatment, I can still remember the tight wrap that she wore on her left arm and the arm exercises that she would do whenever we had a little “down time” on the unit.
I couldn’t help but think of this woman, who helped me get started on my path into nursing, when I read Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011, published in the August issue of Nursing Research. Self-management has long been recommended for the treatment of lymphedema as this chronic condition cannot be cured medically or surgically; lifetime self-management is necessary to control swelling exacerbations, prevent infections, and manage other lymphedema-associated symptoms, including reduced activity and fatigue.
Sixteen articles met the inclusion criteria for this systematic review and based on the review, the authors identified ten categories of self-management:
* Advanced pneumatic compression devices
* Aromatherapy
* Compression garments
* Full-body exercise
* Infection management
* Phase 2 complete decongestive therapy (includes self-administered manual lymphatic drainage [MLD], compression garments, bandaging, exercise, and skin care)
* Simple MLD
* Skin care
* Self-monitoring
* Weight reduction
This review found that full-body exercise and Phase 2 CDT are likely to be effective self-management techniques for lymphedema, however, randomized control trials supporting Phase 2 CDT are lacking. Effectiveness was not established for advanced pneumatic compression, compression garments, full-body exercise, self-monitoring, skin care, simple MLD, and weight reduction as stand-alone therapies. Also, based on the evidence, aromatherapy was deemed effectiveness unlikely and should not be recommended as a self-care technique.
Unfortunately the evidence does not provide much guidance for self-management recommendations for lymphedema. Further research is indicated, yet in the meantime, a thorough assessment of each individual patient’s symptoms and the availability of resources should be used to guide the plan of care.
Reference:
Armer, J. M., Cormier, J.N., Fu, M.R., Ridner, S.H., Stewart, B.R., Wanchai, A. (2012). Self-Management of Lymphedema: A Systematic Review of the Literature From 2004 to 2011. Nursing Research, 61 (4).
We all know the importance of patient and family education. Many tools have been developed over the years, strategies have been explored, and recommendations have changed. We know that our approach must be individualized for each patient regardless of diagnosis, prognosis, age, gender, etc. We also are aware of barriers to providing patient education in the hospital setting – time, staffing, and access to resources – among others.
In Patient Education Strategies for Hospitalized Cardiovascular Patients: A Systematic Review, the authors sought to identify and examine the characteristics and outcomes of cardiovascular (CV) health education interventions for hospitalized CV patients. Of the 25 studies that met the inclusion criteria, 80% (n = 20) were randomized controlled trials and 20% (n = 5) were quasi-experimental studies. A summary of the study population, intervention elements, outcomes, and results for each study as well as a synopsis of the characteristics of the educational interventions are presented.
Based on the interpretation of their results, the authors share 3 clinical pearls at the conclusion of their article:
1. Evidence suggests that, compared with single-session interventions, programs that incorporate scheduled follow-up sessions as a core component are generally more effective.
2. Interventions designed to build self-care, communication, and problem-solving skills may be more effective in improving behavioral and clinical outcomes than those focused solely on increasing knowledge.
3. Patient education strategies that fit with the patient's learning styles, cognitive level, and motivation by using tailored interventions offer a more directed way to enhance compliance among patients.
Do you have a particular strategy for patient education? What types of educational interventions do you use most often?
Reference:
Commodore-Mensah, Y., Himmelfarg, C.R. (2012). Patient Education Strategies for Hospitalized Cardiovascular Patients: A Systematic Review. Journal of Cardiovascular Nursing, 27(2).
We are excited to share the launch of
Lippincott NursingCenter’s YouTube Channel! Our first nursing videos are compilations of inspiration from nurses at the ANCC National Magnet Conference® this past October. Learn how your nursing colleagues keep up with new research, information and evidence. Also, discover what inspired them at this year's meeting and their plans for sharing this inspiration with their colleagues.
Take a look:
We are looking forward to sharing more nursing videos as we move into the New Year! Stay tuned for Clinical Resources, Training Guides, webinars, and more nursing videos as we delve into this platform. Go ahead and
subscribe today to stay up-to-date and inspired.
In addition to the traditional gifts of stethoscopes and pen lights, here are a few of my favorite items that you may want to consider gifting to the nurses in your life. This past fall I spent some time reading recent books by some of my favorite nurse authors and I really enjoyed them. I’ve also already shared my strong feelings about a certain documentary, but I have to include it here on this list too. Take a look…
Becoming Nursey by Katie Kleber, BSN, RN is a must-read for nursing students, new nurses, and those nurses who need to be inspired by that new-nurse feeling that they had in the past. Miss Kleber, also known as
Nurse Eye Roll, is someone I’d like to work with! You can tell from the personal experiences that she shares in the book that she is a team player, organized, and compassionate and respectful to patients, their families and caregivers, as well as her colleagues in nursing and other disciplines. The discussion on time management is spot-on. Another favorite aspect of this book is how Miss Kleber keys in on preventing medication errors, and the importance of owning them so that we can learn from them. Consider
Becoming Nursey as a gift for nursing students and new nurses – they’ll definitely relate to Nurse Eye Roll’s experiences and benefit from her advice.
Theresa Brown, RN, has been a favorite nurse author of mine for a long time. She is a frequent contributor in
the New York Times and
American Journal of Nursing, and in 2011, wrote
Critical Care: A New Nurse Faces Death, Life, and Everything in Between. In
The Shift, Miss Brown takes the reader through her full 12-hour shift in a busy oncology unit. In addition to learning about the patients she cares for with such knowledge and skill during this shift, what strikes me is how Miss Brown illuminates her decision-making. We know that as nurses, critical thinking comes with experience, yet Miss Brown truly explains how she prioritizes care without the reader even realizing that is what’s happening. Read the book – you’ll see what I mean! This will make a perfect gift for hospital nurses who understand just how much can happen in one 12-hour shift.
This film…I could watch it over and over again! This is truly a treasure for the nursing profession. In
the American Nurse Project, the director, Carolyn Jones, captures the passion of several nurses as she shares their unique stories. This year, at Nursing Management Congress, I actually got to meet Miss Jones, which was such a highlight for me. The
book is on my wish list this December – I’ll keep you posted if I receive it! Think about sharing this film with all nurses who are passionate about the care they provide and the people they touch.
What’s on your wish list this holiday season?
See also: Three more gift ideas for nurses
Posted:
12/15/2015 5:48:04 AM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
1 comments
Categories: Inspiration
Happy New Year! Here’s the list of nursing recognition days, weeks, and months for 2016*. Please let me know if you know of others!
*Note that some dates are from 2015. I will update dates and links as they become available.
January
February
March
April
May
June
September
October
November
There’s no doubt that gun control is a hotly debated topic today. Supporters of tight gun control argue that access to guns is too easy. Those on the opposition believe it is unconstitutional and that despite a rise in gun ownership, gun homicide rates have dropped. Irrespective of this debate, the statistics are staggering. There have been over 200 mass killings (defined as four or more victims) in the United States since 2006
1. The rate of people killed by guns in the U.S., is almost 20 times higher compared to similar socio-economic countries in the world. It is clear that Americans experience too many senseless deaths associated with firearm violence and that we need to work harder to find a solution to this devastating problem.
According to the Centers for Disease Control and Prevention (CDC), in 2013 there were 33,636 deaths attributed to firearms or 10.6 deaths per 100,000 Americans
2. That same year, there were 33,804 motor vehicle traffic deaths or 10.7 deaths per 100,000
2. Auto accidents have declined over the last several decades largely due to mandatory education and government regulations. You cannot drive without first taking a driver’s test, acquiring a license and paying for car insurance. In addition, your car must pass emissions and inspection testing on a regular basis. Guns manufactured in the U.S. do not need to pass federal safety standards.
Last week President Obama proposed “executive actions” on gun violence, a set of recommendations to close loopholes in gun control legislation in an effort to prevent future mass shootings. A few of the initiatives include increasing mental health treatment, improving universal background checks, requiring gun dealers to be licensed and keep formal sales records, and advancing technology on safety locks and “smart guns” that can only be fired by the registered owner. The presidential proposal will likely meet resistance and possible reversal should Americans elect a Republican in the upcoming election.
Regardless of the outcome of the new gun control initiatives, what role can healthcare providers play? Nurses, who often treat victims of violent crimes and their family members, are uniquely trained to promote safety, public health and education. Several nursing organizations have issued position statements on gun control, including the
American Nurses Association (ANA) and the
National League for Nursing. In addition, over 30 nursing organizations signed a
call-to-action letter to national, state, and local governments requesting better access to mental health services, a ban on assault weapons, and other gun control reforms.
The following recommendations could help us come closer to finding a cure for gun violence.
- Increase access to mental health programs for individuals, families, and students from elementary school through college:
a. While the majority of people with mental illness are not violent, serious psychosis and schizophrenia combined with substance abuse could lead to erratic behavior. Funding should be increased to train nurses and health professionals to recognize signs of violent tendencies, as well as community and hospital based psychiatric care, housing, and access to medications.3
- Include a gun safety assessment as part of routine health screenings for all patients:4
a. Several states continue to propose legislation to ban practitioners from documenting gun ownership in the patient’s record. However, the American Academy of Pediatrics endorses counseling parents on gun safety measures.5 This philosophy is also supported in adult dementia and elderly patient populations.
- Develop and implement Evidence-based Hospital Violence Intervention Programs focusing on:
a. Intimate partner violence
b. Behavioral health including anti-bullying
c. Substance use
- Improve Community engagement/outreach and education programs with initiatives targeting:
a. Life skills
b. Anger management
c. Conflict resolution
d. Suicide prevention
e. Violence prevention programs: successful research-based community programs that have proven to decrease homicide rates include Cure Violence, Aim4Peace and Wraparound Project.6
- Gather more data, conduct research and educate families on how to best protect themselves and their families from gun injuries:4
a. Keep guns away from household members who would not safely use them such as children or people with dementia.
One measure alone is not the answer. Rather multiple strategies implemented in our local communities, within the mental health system, and ultimately at the federal level are needed to make an impact on the number of gun-related fatalities. We as a society need to strike a balance between maintaining individual constitutional rights and protecting the lives of each and every American. Perhaps by focusing on empathy, public health, and education we can change our culture, protect our freedoms, and save lives.
References:
-
Overberg, P., Hoyer, M., Hannan, M., Upton, J., Hansen, B., & Durkin, E. (2013) Behind the Bloodshed: The Untold Story of America’s Mass Killings. USA Today. Retrieved from http://www.gannett-cdn.com/GDContent/mass-killings/index.html#title
-
Centers for Disease Control and Prevention (2016) FastStats; All Injuries; Motor vehicle traffic deaths; All firearm deaths. Retrieved from http://www.cdc.gov/nchs/fastats/injury.htm
-
-
-
Graziano, M. & Pulcini, J. (2013) Policy & Politics: Gun violence and the role of healthcare: A confusing state of affairs (2013). The American Journal of Nursing. 113(9). Retrieved from /JournalArticle?Article_ID=1590663&Journal_ID=54030&Issue_ID=1590611
-
Myrna B. Schnur, RN, MSN
As we get further into the New Year, it’s exciting to reveal some milestones that we’ve reached already in 2016!
In 2016, we want to deepen our relationship with you, our members! Make sure your
profile is up-to-date so we can personalize your NursingCenter experience in the coming months. You can get to know us better by viewing these
Behind the Scenes videos, just published on our YouTube channel!
Thank you!
There is about a foot of snow outside already this morning. The blizzard of 2016, #blizzard2016, or Jonas – they are calling it. I am reminded of being snowed in at the hospital back in 1996, during a similar storm. We had packed our bags and headed in for what looked to be a few days spent at the hospital, doing what we always did – putting patients first. All essential hospital staff were expected to report to work and to remain there until the storm passed. Rooms were set up for us to rest, when it was our turn, and food was being prepared. We were going to be taken care of too.
There are no snow days for nurses. I know many of my friends and colleagues are hunkered down in the hospital again today. Thank you all!
Here are some past journal articles that might be comforting or helpful to you during these next few days…
The Snowtacular
Home Healthcare Nurse
"Not nurses, we are essential personnel. I have to go," I responded. As I donned my sweater, coat, knee-high boots, and gloves, I felt prepared for the challenges of the day. Little did I know...?
Reflections: What One Thing Will Make Today Better for You?
AJN, American Journal of Nursing
It's been at least 10 years, but I still remember that it was a difficult morning getting to work. The snow was piled high and the roads weren't yet plowed. Nevertheless, all staff showed up-the usual when you worked on a busy oncology unit.
Surviving Winter Storms
Nursing2005
On the road this winter? If winter storms are a possibility in your area, keep this advice in mind.
Stay warm, be safe, and keep up the good work!
Be ready to answer questions and advise patients appropriately. For full updates on the Zika virus, visit the
Centers for Disease Control and Prevention.
1. What is Zika virus?
The Zika virus was first documented in May 2015 in Brazil. The virus is spread to humans via the bite of an infected mosquito, though transmission via blood transfusion and sexual contact have been reported. The symptoms include fever, rash, joint pain, and conjunctivitis. Though rare, there have been cases of Guillain-Barré syndrome in patients with suspected Zika infection.
2. Why is there a travel advisory for pregnant women?
There have been reports of poor pregnancy outcomes and microcephaly among babies of mothers infected with the Zika virus. Further investigation of this causal relationship is ongoing, however, to be cautious, the CDC recommends pregnant women and those trying to conceive avoid travel to
areas with documented Zika virus transmission.
3. What should I include in my assessment of pregnant patients?
*Ask all pregnant women about recent travel, especially to
areas with documented Zika virus transmission.
*Ask all pregnant women about the presence of symptoms consistent with Zika virus disease during or within two weeks of travel.
*In those with recent travel, be alert for ultrasound findings of fetal microcephaly or intracranial calcifications. If present, testing for Zika virus infection (in consultation with state or local health departments) is indicated.
4. What should be done if infection with Zika virus is confirmed?
In pregnant women with laboratory evidence of Zika virus infection, fetal growth and anatomy should be monitored via serial ultrasounds. Referral to a maternal-fetal medicine or infectious disease specialist is recommended. There is no specific treatment for Zika virus; supportive care is recommended.
5. How can those who are traveling prevent infection with the Zika virus?
To prevent Zika virus infection, and other mosquito-borne illnesses,
recommendations include:
*Use insect repellants, as directed. (If using both sunscreen and insect repellent, the sunscreen should be applied first).
*Wear permethrin-treated clothing.
*Wear long-sleeved shirts and long pants.
*Keep mosquitoes outside, or if necessary, sleep under a mosquito bed net.
*Empty standing water from flowerpots, buckets, or other containers.
Reference:
Centers for Disease Control and Prevention. (2016, January 24). Zika virus. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/zika/
More Resources
I know, I know, another care plan…but this one is for YOU! Use this quick care plan to make sure you are on the right track to meet your goals!
Assessment
What do I need to do this year to meet my professional requirements?
- When is my nursing license(s) due for renewal?
- Am I on track to meet my CE requirements for license renewal?
- Do I need to obtain CE to maintain my current certification(s)?
How can I be a lifelong learner in nursing?
- Is it time for me to go back to school?
- Should I get certified in a specialty?
- Which professional nursing organization(s) should I join?
Do I have good work-life balance?
- When’s the last time I had a physical exam?
- Am I due for any immunizations or screenings?
- Am I seeing my family and friends?
- Do I have time to do things that bring me joy?
- How is my stress level?
Nursing Diagnoses
- Knowledge deficit related to meeting my professional requirements.
- Readiness for enhanced knowledge related to striving to provide evidence-based nursing care.
- Readiness for enhanced self-health management related to identifying my own health care needs.
- Readiness for enhanced self-care related to maintaining personal relationships and managing stress.
Planning
Meeting my professional requirements
- Look at my current nursing license(s) and certification(s) and check the expiration dates.
- Visit the website of my state board of nursing for information on license renewal and CE requirements.
- Contact my certification organization for information related to renewal and CE requirements.
- Consider my options for meeting my CE requirements.
*Online CE activities.
*Live events, such as national or local conferences.
*Check for opportunities to earn CE through my employer.
Lifelong learning
- Explore BSN and advanced degree programs.
- Investigate specialty certification opportunities.
- Consider which professional organizations would be a good fit for me.
Balancing work and life
- Look back at my own medical records and make a list of what screenings and immunizations are recommended based on my age and medical and family history.
- Update my calendar with my work schedule and upcoming social events. Schedule “me-time” too!
- Think about how I best deal with stress. Is it a yoga class? Reading? Being outdoors? Find activities to meet my stress-relief needs.
Implementation
Meeting my professional requirements
- Mark expiration dates on my calendar.
- Develop a file (actual or online) to store my CE documents.
- Use My Planner on Lippincott NursingCenter’s CEConnection to plan my CE activities and store my certificates.
- Register for conferences and make travel plans. Inquire if my employer will contribute to covering costs.
Lifelong learning
- Apply to a nursing program that meets my educational needs and goals.
- Get certified!
- Join and get involved with a professional nursing organization. Take advantage of related benefits and consider joining a committee or leadership position.
Balancing work and life
- Schedule appointments and screenings.
- Stick to my schedule, as best as I am able.
- Sign up for a class, gym, or other activities that help me manage stress. Remain committed to these endeavors.
Evaluation
Revisit this care plan throughout the year and fill this in. Ongoing evaluation and revisions are key components to meeting my goals.
Leave a comment here – writing down your goals and plans is a good first step! Good luck!
It can be overwhelming to keep track of license and certification expiration dates and continuing education requirements for renewal. This infographic will help you stay on track to meet your professional requirements.
Use
My Nursing Care Plan for 2016 for a full look at assessing, planning, and implementing your goals for the year ahead!
Add this infographic to your website by copying and pasting the following embed code:
Lifelong learning is essential for your professional development and to ensure evidence-based patient care and improve outcomes. Use this infographic to help you stay on track and meet your goals!
Use
My Nursing Care Plan for 2016 for a full look at assessing, planning, and implementing your goals for the year ahead!
Add this infographic to your website by copying and pasting the following embed code:
The secret to getting ahead is getting started ~ Mark Twain
As nurses, there are many different roads we take on our journey to where we are now professionally. We all have different starting points and are currently at different places on this professional road. Similarly, there is immense variation in how we set and achieve our goals. There are volumes of literature on goal setting and achievement and the methods are not a one-size-fits-all formula. The key to successful goal management is figuring out what works for you, being honest with yourself about what your current and future goals are and coming up with a plan to achieve what you set out to do. Personality, life circumstances, and family-work balance all play roles in how we set and achieve goals, as well as our motivation to accomplish them.
Personally, I began my professional career in medical research with a degree in the sciences. I quickly determined that I wanted to interact with patients rather than study them from inside a room (my project involved taking measurements on carotid arteries [recorded loops on VHS] – in a dark room – as part of a cardiovascular research project). When I came to this realization, I organized my first five-year plan with a goal of becoming a nurse. I applied to and was accepted to a nursing program. I went on to receive my BSN and subsequently my MSN, which I completed in 2001 with the help of a National Health Service Corp Scholarship. I began working at a Federally Qualified Healthcare Center as a Family Nurse Practitioner. and after fulfilling my commitment to the scholarship, I was able to do a loan repayment program at the same health center. Within five years, I had all of my undergraduate and nursing loans payed off. Using the five-year framework allows for short and long-term goal setting with some flexibility factored in for the unexpected. While I personally work better with this flexibility, others may find more success with a stricter plan; this is where we need to be honest with ourselves and come up with a method that works best.
Fast forward eight years. Following a job transition, I was offered a position working in an ICU as a nurse practitioner. Although this was not in my original plans, and well out of my comfort zone, the opportunity was one that I could not pass up and presented an exciting new challenge. Around this same time, the
Consensus model for APRN regulation: Licensure, accreditation, certification, and education (APRN Consensus Work Group, 2008) was released. This landmark publication for NP practice essentially recommended that NPs practice in the discipline/setting for which they were educated and certified. Although this seems straight forward, NP history is one whose roots began in primary care with evolution to the acute care setting. Educational programs for acute care NPs were introduced later in the historical timeline, and the fact is that there are many primary care NPs practicing in hospitals. So now, with no plans to leave the ICU, my current five-year plan includes completion of a post-master’s program to become certified as an adult-gerontological acute care nurse practitioner. This was an adjustment I needed to make, but it is a great opportunity to improve my skills and my job performance.
I mentioned the flexibility to my plans earlier. There was an approximately five-year period in my life (i.e. when my children were infants) when I struggled to keep up with my plan, or rather, I had no plan! Memories of these years include crunching to find online CME and overnight expressing my license applications and sometimes struggles to just get through the day. For me, despite being a competent nurse at work, I found it overwhelming trying to figure out parenting and how to be a working mom. The learning curve of parenting and navigating the work-life balance was steep. Eventually, I was able to get back on track. Moving forward, I have reset my five-year plan once again (it’s a moving target). I hope to complete the acute care NP program in December 2016 then take and pass (fingers crossed) the exam in the spring of 2017. After that, I may try to teach, or possibly consider a DNP or PhD program.
I have not done extensive research from an academic or literature perspective on goal setting, but I do know that there are many successful methods for those that have difficulty with a flexible plan or prefer a more established format. For myself, it has been immensely helpful to take time, every so often, to reflect on where I am and where I would like to be. NursingCenter’s blog post,
My Nursing Care Plan for 2016, provides an excellent resource for some of our requirements to keep up our professional obligations. Because in addition to our professional goal, there are tasks that we need to complete to stay current and licensed.
How do you like to set and achieve your goals? Has anyone found a more standard goal setting process that works for you? Please share your experiences with us!
It can get complicated to juggle our personal and professional lives. This infographic will help you take a closer look at what you need to do to keep yourself healthy – physically, mentally, and emotionally.
Add this infographic to your website by copying and pasting the following embed code:
During the month of February, we celebrate many great traditions – Black History Month, Valentine’s Day, and the birth of our forefathers to name a few. February is also American Heart Month, which was first declared by President Lyndon B. Johnson in 1964.
1 Since that time, February has been dedicated to promoting cardiovascular health by many organizations, such as the American Heart Association
1. Heart disease is the leading cause of mortality in both men and women in America.
2 It is a disease that can largely be prevented through lifestyle modification
1. Due to advances in medical therapies and better heart disease education, the number of deaths associated with cardiovascular disease has seen a steady decline over the last three decades
1.
This month brings back many memories for me. My first job out of college in the mid-90’s was in the Intensive Care Unit (ICU) at a large medical center in mid-town Manhattan. This was a unique ICU setting where the staff rotated through the medical, coronary, surgical, and cardiovascular (post-operative) ICUs every few months. It was during these first years that I gained an appreciation for cardiovascular disease and how it could be medically and surgically managed. In the medical ICU and coronary care unit (CCU), I cared for patients who were transferred from the Emergency Room with acute coronary syndrome (ACS) and were awaiting cardiac catheterization for diagnosis and possible angioplasty. The presentation of each patient varied widely. A stable ACS patient with mild symptoms, such as indigestion, could deteriorate rapidly into acute distress and severe chest pain and possibly full code. Stabilizing these patients with aspirin, oxygen supplementation, and sublingual nitroglycerin were critical and electrocardiogram (ECG) monitoring was of the utmost importance. I don’t think any nurse forgets witnessing ST-segment elevation for the first time.
In the surgical and cardiovascular ICU, patients returned from the operating room with a tangle of wires, arterial lines, central lines, pulmonary artery catheters, as well as chest tubes, drains and complex surgical wounds. Monitoring vital signs, titrating IV drips, managing oxygenation and potential bleeding were all part of the post-surgical course. Open-heart surgery patients had to be assessed frequently for elevated jugular venous pressure and pulsus paradoxus (a systemic drop in blood pressure during inspiration
3), both impending signs of cardiac tamponade, an accumulation of fluid in the pericardial space. It didn’t occur too often, but when it did, it resulted in emergency subxiphoid percutaneous drainage – one of the more stressful moments for a new nursing graduate.
After a few years in New York I felt called back to Philadelphia. While attending graduate school, I worked nights in the Cardio-Thoracic Intensive Care Unit (CT-SICU) of a large teaching hospital, caring for patients following open heart surgery. I thought I had seen it all in New York and quickly realized that I had just scratched the surface when it came to caring for cardiac patients. Academic institutions often receive patients with very high acuity due to their ability to offer some of the most advanced treatment options such as intra-aortic balloon pumps (IABP), left ventricular and bi-ventricular assist devices (LVAD and BiVAD), extra-corporeal membrane oxygenation (ECMO), ventilators, and continuous hemofiltration and dialysis. There were moments when I felt more like a mechanic than a nurse working on multiple machines surrounding a fragile life at its center.
Patients typically experience short stays and quick turn-overs in surgical ICUs, however, we had our fair share of patients who spent many weeks and months on our unit. Mr. B.* was one of those patients. Mr. B. was transferred from a local community hospital to our institution with severe heart failure. Mr. B., whose medical therapies had reached a maximum threshold, had been hospitalized multiple times with acute exacerbations of heart failure over the prior year. Each hospitalization worsened requiring increased doses of intravenous (IV) dobutamine and milrinone to improve his heart pumping capacity. Upon arrival Mr. B., who was categorized with Class 4 heart failure (severe), was evaluated by the team for heart transplant. At 64, he was above the upper limit for age exclusion, however he had no signs of lung, liver or kidney disease. He was placed on the transplant list immediately and due to his critical condition the decision was made to place a left ventricular assist device (LVAD) to support his heart. Mr. B.’s post-operative course was riddled with complications. He experienced difficulty weaning from the ventilator and subsequently developed pneumonia. Anticoagulation was carefully titrated to prevent clotting in the LVAD, however this led to bleeding in the gastrointestinal tract. His blood glucose levels rose acutely requiring an IV insulin drip. He battled these challenges and once stabilized, Mr. B. was able to ambulate with his new device and begin rehabilitation in preparation for his transplant. He was extremely positive, cracking jokes with the nurses and always smiling. I could tell he was truly grateful for each day he was alive. Today, LVAD patients may be discharged home and are able to live comfortably with the device, some as a bridge to transplant and some as destination therapy if transplant is not an option. Mr. B. was with us for several weeks due to his complications, but was eventually discharged home.
One cold November morning, Mr. B. and his family were notified that there was a donor heart available and that he was a match. He was admitted back to our unit that afternoon and later that evening he received the gift of a new heart and a second chance at life. The surgery went extremely well. Mr. B. spent four days of recovery in the CT-SICU where we monitored him closely for rejection. He was then transferred to the general surgical ward for cardiac rehabilitation and was discharged from the hospital on post-op day 15.
The most gratifying part of being an ICU nurse is seeing your patients recover. Mr. B. returned often to say hello and thank you, which always warmed our hearts. He is one of many cardiac patients I will never forget. While Mr. B.’s story ends well, many more patients with cardiac disease are not as lucky. We as healthcare providers should continue to emphasize the importance of heart health education and lifestyle modification to prevent the progression of cardiac disease. Happy American Heart Month to all!
References
-
-
Center for Disease Control and Prevention (2016) Heart Disease Facts. Retrieved from http://www.cdc.gov/heartdisease/facts.htm
-
*Note: Any identifying characteristics are coincidental.
During these busy days, time management is a challenge for many people. If you have a career where your schedule is frequently changing, the challenge becomes even more pronounced. Maybe you even flip-flop your nights and days sometimes or juggle teaching or taking classes on top of your already busy schedule. The point is, time management skills are essential to keep us rested, healthy, and productive!
Here are some top tips to help you manage your time effectively.
- Write it down. Use a calendar – paper or electronic – to keep track of all your appointments and responsibilities in one place.
- Stay focused. When at work, focus on work. When at home, focus on home.
- Break it down. Divide large tasks into smaller items that are more manageable.
- Declutter. Clear your work area. Whether it’s a desk, medication cart, or bedside table, don’t let excess clutter take your attention away from what you are doing.
- Delegate. Proper delegation and teamwork are time management wins for you and your colleagues.
- Set aside time to answer messages. Answer phone calls, texts, and emails at convenient times, rather than allowing those rings and beeps to distract from your current task.
What other time management tips would you add to this list?
Related Reading
Add this infographic to your website by copying and pasting the following embed code:
I was going to put together a collection of information and statistics to share about multiple sclerosis, but as I started to write, it became more about what I personally do to raise MS awareness. My hope is that my story will give insight and shed some light onto a patient’s perspective. I feel like understanding is one of the keys to better support and care for patients living with a chronic illness.
March is MS Awareness Month – a topic near and dear to my heart. I’ve been living with relapse-remitting multiple sclerosis since 2003 and I try to live my life every day as if it is “MS Awareness Day.”
Unfortunately, I’m not a scientist who will discover a cure. I’m not a neurologist or a nurse who will treat patients. And lastly, I’m not fortunate enough to be rolling in money that I could fund clinical trials or research studies. So what can I do to raise awareness about MS?
I can SUPPORT.
Whenever I hear about someone who is newly-diagnosed, or someone who may be struggling with the disease, I’m always ready to hand out my phone number or email address. I know all too well that it can be a continuous struggle, but I want them to know they are not alone. There is hope, and they will get through this battle learning strategies to improve life and ultimately discovering how truly strong they are.
I can stay POSITIVE.
I went through all of the typical emotions after my MS diagnosis, and I had to go through the grieving process and let go of my life, or at least my perceived life, before MS. Now, I’m actually thankful for MS. I have let go of a lot of toxic people and negativity, and I try not to sweat the small stuff. I have chosen to take the path where I value life and take little to nothing for granted.
I can EDUCATE.
I have always been very open about living with multiple sclerosis. I love shocking people with the fact that I have MS. I encourage questions and enjoy sharing my experiences and knowledge. There is a lot of misinformation out there and people tend to have such misconceptions about what MS looks like, and what it means to live with MS. It is such a varying disease that presents so differently and affects people in so many different ways.
I can LIVE fully.
I live the best life that I can with MS, and along the way, I try to educate others on what MS is and what it means to people battling it every day, every month, every year. Raising awareness for MS and living fully is my way of advocating and giving back to the MS community.
I will never give up HOPE.
I have this silly personal belief that if I say something, or believe something long enough, it will manifest and become reality. So…There will be a cure for MS. There will be a cure for MS. There will be a cure for MS…
To continue raising awareness, I’m marking my 13th year living with MS by participating in my first half marathon this summer. 13 years, 13.1 miles! Never give up!
Please use these free resources on NursingCenter to learn more about MS and to help spread awareness by sharing with your colleagues, patients, and the public.
The
Journal of Neuroscience Nursing and the
Journal of Infusion Nursing are both honoring MS Awareness Month by offering subscription discounts in March.
Enter promotion code, WFS115GN, and take 40% off the subscription price for either journal.
Last month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the
Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the
Sequential (sepsis-related) Organ Failure Assessment (SOFA) and qSOFA scores.
The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition.
Why the change?
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis:
systemic inflammatory response syndrome (SIRS), sepsis (SIRS in response to a confirmed infectious process),
severe sepsis (sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and
septic shock (sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).
Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case.
What’s New:
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The
Sequential (sepsis-related) Organ Failure Assessment (SOFA) is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have:
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero.
- Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation).
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.
The
qSOFA (Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are:
- Respiratory rate > 22
- Altered mentation (GCS < 15)
- Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse.
Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier. The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.
With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.
It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood.
I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3!
Megan Doble, MSN, RN, CRNP
References:
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent JL, Moreno R, Takala J, et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.
As National Nutrition Month comes to an end, I am reminded how nutrition isn’t just about cutting calories and eating healthy. There is so much more that we don’t think about on a regular basis, unless it affects the patients in our care or our personal lives.
I regularly visit an adolescent sports medicine facility with one of my children. The clinicians there deal with a variety of conditions and issues, ranging from orthopedic injuries and concussions to eating disorders and, in our case, impaired growth related to caloric expenditure through sport.
Some people may see a kid who is fit and active and think “Wow, he is so lucky!” I see a kid who is competitive to the point that his growth charts have taken some sharp declines during a critical adolescent growth period. While I’m proud of his commitment and determination, I also am concerned for his growth and development.
We are fortunate to have a great resource in our area that has helped us turn things around for my son. He is a swimmer and a runner who trains for hours each day, and to meet his nutritional needs for sport and catch-up growth, he must take in over 5,000 calories each day! Sounds easy, right? Actually, it is a challenge and requires quite a bit of hard work. I ask that you let this post serve as a reminder to be open to the struggles of others; sometimes the problems they face aren’t as simple as you may think.
For some related reading on this topic and more on nutrition, explore
Nutrition Today, a journal with articles written by “leading nutritionists and scientists who endorse scientifically sound food, diet, and nutritional practices,” including the following related to sports nutrition:
This topic came up a couple of times recently – once, in a conversation with nurse faculty preparing courses for undergraduate students; the second, during the Keynote Address at the Dermatology Nurses’ Association Convention. The faculty members were questioning which term – patient or client – is appropriate for use in the academic setting. In her Keynote,
Everyday Ethics for Nurses in Everyday Practice, Leah Curtin, ScD(h), RN, FAAN touched on this topic and even dug deeper into the roots of each of the words, encouraging the audience to make their own decisions regarding the appropriateness of each term.
Here’s a closer look at the terms ‘patients’ and ‘clients.’
Patient
- Comes from the Latin word, patior, which means ‘to suffer’
- Defined as ‘one who suffers’
Client
- Comes from the Latin word, clinare, which means ‘to lean’
- Defined as ‘one who is the recipient of a professional service’
Based on the word roots and definitions, some may feel that the term ‘patient’ indicates a hierarchical relationship, where the term ‘client’ signifies a more collaborative relationship. It’s interesting then that many authors, clinician and non-clinician, use the terms interchangeably or even simultaneously. For example, “patient or client self-report measures” or “patient/client safety” is often found in the literature. However, we know that the written word is not how we speak and I’ve yet to hear a colleague ask “Is the patient/client NPO?” or say “The patient/client needs a new IV inserted.”
I was surprised during a search on this topic, to find that this is not a new discussion. In a
1997 article from the Canadian Medical Association, Peter C. Wing, MB, ChB found that use of the term “client” was documented as early as 1970. He also shares results from his survey of 101 people attending an ambulatory back-pain clinic; almost ¾ of those surveyed stated a preference for ‘patient’ rather than ‘client.’
Personally, I can’t imagine referring to a person in my care as a client. It just sounds unnatural to me. Which do you prefer?
POLL QUESTION |
For whom do you care – patients or clients?
|
Create your own user feedback survey
References
Farlex, Inc. (2016, April 8). Retrieved from The Free Medical Dictionary: http://medical-dictionary.thefreedictionary.com/
Wing, P. (1997). Patient or client? If in doubt, ask. Canadian Medical Association, 287-289.
My most memorable mentor has to be my first preceptor after I graduated from nursing school. As a new nurse in the medical intensive care unit, I was pretty nervous and overwhelmed. I had worked in the unit for about a year and a half as a nursing assistant, but I knew how different my role would be as a new RN.
This nurse was literally always teaching. And not just me… anyone who she came in contact with learned from her. She was an expert and I honestly can’t remember a time when she didn’t know something. She sought out new experiences for me and encouraged me to be on the lookout for new experiences throughout my career.
Amazingly, she was able to see patient care from my standpoint as a novice. She started with the basics and was able to help me build upon my knowledge and skills in a way that made sense to me. Later, as I became more confident and comfortable, she would begin her questions to me with “What would you do…” or “How would you know…”
One important quality that stood out about this nurse was her respect for everyone - patients, family members, nurse colleagues, and other members of the healthcare team. She was a good listener, had amazing clinical skills, and a knowledge base that boggled my mind!
This nurse was more than my preceptor, she was a mentor and friend to me. I feel so fortunate to have been mentored by such a wonderful role model. Who is your most memorable mentor?
Reviewed and updated by Myrna Buiser Schnur, MSN, RN: January 25, 2024
Since I began working in a reconstructive surgery clinic several years ago, I have been exposed to a myriad of complex acute and chronic wounds that require advanced treatment modalities to heal, such as Negative Pressure Wound Therapy (NPWT). These devices were new to me, and I quickly realized that they can be a source of great anxiety for both patients and clinicians. I decided I needed more information and education on the topic. In Part 1 of this blog series, I will discuss the basics of NPWT, what it is, how it works, as well as risks and benefits.
What is Negative Pressure Wound Therapy (NPWT)? (Gestring, 2023)
Also known as vacuum-assisted wound closure (VAC), NPWT distributes negative pressure across the surface of a wound continuously or intermittently. The therapy, which emerged in the early 1980’s, includes the placement of a dressing (foam or gauze) onto the wound and is connected to a vacuum pump via tubing. A clear occlusive dressing is placed on top, forming an airtight closed system. Gentle, controlled suction is applied pulling wound debris into a collection chamber. The Food and Drug Administration (FDA) approved the first device for NPWT in 1997. There are a variety of FDA-approved devices now available on the market, many of which are small and lightweight, allowing patients full mobility. Due to varying designs, it is important that you become familiar with the manufacturer instructions for the specific device in use.
NPWT can ssist in wound healing by (Lippincott Procedures, 2023):
- Providing a moist wound healing environment
- Improving nutrient and oxygen delivery to the wound
- Reducing swelling
- Assisting with wound contracture
- Removing exudate and bacteria that can impede cell growth
- Limiting inflammtory agents
- Promoting blood vessel growth and tissue granulation
Which types of wounds benefit most from NPWT? (Lippincott Procedures, 2023; Wound Care Centers, n.d.)
- Surgical wounds, especially those which need to heal by secondary intention
- Following surgical debridement of acute or chronic wounds (i.e., orthopedic, necrotizing infection, post-sternotomy mediastinitis)
- Open abdominal incisions, dehisced surgical wounds
- Burns
- Skin flaps and preparation for skin graft sites in reconstructive surgery
- Traumatic wounds
- Chronic wounds, such as venous insufficiency ulcers, arterial ulcers, diabetic foot ulcers, and pressure injuries
- Wounds at high risk for infection
- Wounds with copious drainage
- Meshed grafts, to either secure the graft in place or improve epithelialization
- Prophylactic therapy to prevent surgical wound infections
How effective is NPWT? (Gestring, 2023)
Compared to traditional forms of wound therapy, advantages of NPWT include:
- Improved wound healing and decreased time to wound closure in diabetic patients, improving quality of life.
- Less frequent dressing changes (every two to five days)
- Dressings that can be individualized to all types of wounds
What are the risks involved with NPWT?
NPWT devices, if used improperly, could cause harm to patietns including:
- Pain
- Bleeding
- Infection
- Enterocutaneous fistula
- Damage to adjacent skin
- Dehydration
What are the factors that increase a patient’s risk for adverse events with NPWT?
- Increased risk for bleeding and hemorrhage
- Anticoagulant or platelet aggregation inhibitor therapy
- Friable or infected blood vessels
- Vascular anastomosis
- Infected wounds
- Osteomyelitis
- Spinal cord injury
- Enteric fistulas
- Exposed organs, vessels, nerves, tendons, and ligaments
Are there any contraindications for NPWT? (Gestring, 2023)
- Exposed blood vessels, vascular grafts, or vital organs
- Untreated malignancy
- Relative contraindications include:
- Ischemic wounds, necrotic tissue with eschar
- Ongoing infection
- Fragile skin
- Adhesive allergy
While great strides have been made to improve the safety of NPWT devices, serious adverse events may still occur. Clinicians should take time to review specific device instructions for use, indications, and contraindications and adequate staff training should be provided. Healthcare providers that understand the principles of NPWT can then collaborate to ensure that each patient is selected appropriately for therapy based on wound type, risk profile and care setting. In
Part 2 of this series, I will review the procedure for applying a NPWT dressing, general patient care, and tips to trouble-shoot the device.
Reviewed and updated by Myrna Buiser Schnur, MSN, RN: January 25, 2024
I have learned quite a bit on my journey to gaining a better understanding of Negative Pressure Wound Therapy (NPWT). In
Part 1 of this series, I provided an overview of NPWT, including what it is, how it works and the risks and benefits. In Part 2 of the series I will review the practical application of NPWT including prescribing orders, procedural steps, general patient care, and tips to troubleshoot the device
. Let’s jump in!
What should the NPWT orders include?
- Wound dressing material (foam or gauze) and wound adjunct (protective non-adherent, petroleum or silver dressing)
- Negative pressure setting (-20 to –200 mm Hg), typically set at –125 mm Hg
- Therapy setting (continuous, intermittent, or variable)
- Frequency of dressing change
What are the steps in applying NPWT? Each device has a specific design and manufacturer’s instructions for use that should be reviewed. The following procedural steps provide a general guide. Please also refer to your facility's policies and procedures regarding NPWT dressing changes.
- Pre-medicate the patient for pain as needed and as prescribed.
- Prepare the wound:
- Remove the prior dressing very carefully to avoid tissue damage and bleeding
- Verify the number of removed pieces of dressing as documented in the patient's medical record.
- Debride the wound, performed by a qualified practitioner
- Cleanse the wound as needed/prescribed (i.e., irrigate with normal saline)
- Assess wound size and depth, presence of tunneling, tissue loss, odor, warmth, edema, drainage, signs and symptoms of infection.
- Use sterile technique for the dressing change
- If using foam, cut foam dressing to size and place into the wound.
- Document the number of foam pieces used; foam acts as a filter to catch blood clots and large tissue particles that might clog the vacuum system.
- If using gauze, apply a single layer of nonadherent gauze across the wound bed. Then apply saline-moistened antimicrobial gauze loosely onto the wound.
- Document the number of gauze pads or rolls used.
- Avoid overpacking the wound as this may delay healing.
- Trim clear occlusive dressing to size, peel back one side of Layer 1 and place adhesive side down over wound. (see photo 1)
- Remove the remaining side of Layer 1 ensuring it creates a tight seal.
- Cut a hole into the clear dressing about the size of a quarter (2.5 cm). (see photo 2)
- Remove Layer 1 from adhesive pad connected to the pump tubing.
- If you aren't using a pre-attached system, place pad and tubing directly over hole affixing it to the clear dressing. (see photo 3)
- Remove Layer 2 from the adhesive pad.
- Connect pad tubing to canister tubing and be sure the clamps are open. Anchor the drain tubing a few inches from the dressing to prevent tension or dislodgement of the tubing.
- Label dressing with date, time, and number of dressings used.
- Turn on power to the vacuum device, set the prescribed pressure settings, and confirm that the dressing and foam shrink down. (see photo 4)
- Ensure alarm limits are set appropriately.
Wound Care Tips (Lippincott Solutions, 2023)
- Use protective barriers, such as non-adherent or petroleum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
- Avoid overpacking the wound too tightly with foam; this prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
- Avoid placing the tubing over bony prominences, skinfolds, creases, and weight-bearing surfaces to prevent tubing-related pressure ulcers.
- Count and document all pieces of foam or gauze on the outer dressing and in the medical record, to help prevent retention of materials in the wound; when possible, only use one piece of foam dressing.
- With a heavy colonized or infected wound, consider changing the dressing every 12 to 24 hours as directed by the prescribing clinician.
General Patient Care (Lippincott Solutions, 2023)
- Assess the patient for wound healing issues, such as poor nutrition (low protein levels), diminished oxygenation, decreased circulation, diabetes, smoking, obesity, foreign bodies, infection and low blood levels.
- Assess and manage the patient’s pain; be sure to premedicate as needed before each dressing change.
- Provide patient education on:
- Alarms and device ‘noise’
- Dressing changes
- Signs of complications (bleeding, infection)
- Patients should seek medical care if they notice:
- Significant change in the color of the drainage (cloudy or bright red)
- Excessive bleeding under the clear dressing, in the tubing or in the canister
- Increased redness or odor from the wound
- Increased pain
- The device has been left off for more than 2 hours
- Signs of infection, such as fever, redness or swelling of the wound, itching/rash, warmth, pus or foul-smelling drainage
- Allergic reaction to the drape/dressing: redness, swelling, rash, hives, severe itching. Patient should seek immediate medical assistance if they experience difficulty in breathing.
Troubleshooting the Device (Lippincott Solutions, 2023)
- Confirm that the unit is on and set to the appropriate negative pressure, that the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure.
- Be sure the negative pressure seal has not been broken and there are no leaks in the system.
- Ensure there are no kinks in the tubing and that all clamps are open.
- Address and resolve alarm issues; reasons for the unit to alarm include: canister is full, there is a leak in the system, battery is low/dead, therapy is not activated.
- Do not leave the device off for more than two hours; while device is off, apply a moist dressing and notify the prescribing clinician immediately.
- Avoid getting the electrical device wet; educate the patient to disconnect the unit from the tubing and clamp the tubing before bathing.
- Check the drainage chamber to make sure it is filling correctly and does not need changing.
Nursing documentation should include the following (Lippincott Solutions, 2023):
- Date and time of dressing changes
- Wound assessment as described above
- Pain assessment, patient tolerance to the procedure, and interventions performed
- Weight of soiled dressing (if appropriate)
- Type and number of dressings used; verification of components removed from the wound
- Patient and family education provided
While I am not an expert in the field of wound care, I am now more confident and better prepared to manage patients receiving Negative Pressure Wound Therapy. I would love to hear your experiences. Let me know if you have any tips or other suggestions that can help nurses and patients safely operate and maintain these devices.
Happy National Nurses Week! As we approach the celebration this year, I’d like to take some time to share all that we have coming up for the week and into the rest of the month. There’s a lot of buzz online about what a Nurses Week gift should look like (Read: Not another water bottle. How about safe staffing?) As a leading web resource for nurses, we’d like to do our part to create a culture of safety this Nurses Week by providing you with up-to-date resources based on the latest evidence and reviewed by our peers. Be sure to check out
all of our Nurses Week plans and take advantage of CE collections, free articles, eBook offers, and some opportunities for fun!
I’m excited to share that right here on our blog, we have a wonderful series of posts from nurse experts who’ve shared their insights and knowledge. I’ve enjoyed working with these colleagues – they’ve inspired me and taught me so much as we put together this series. I think you’ll enjoy it!
Here’s what’s ahead:
On another note, I want to let you know that
Lippincott NursingCenter.com received the Gold Award from the American Society of Healthcare Publication Editors (ASHPE) for Best Use of Social Media for our campaigns for National Nurses Week in 2015! Thank you to all of you for your likes, follows, comments, shares, retweets, etc. You were instrumental in helping us to achieve this goal!
And congratulations to all the winners of these prestigious awards!
Be sure to follow us on all of our social media channels as we head into National Nurses Week 2016! We’ve got some special offers that you don’t want to miss!
Have a great week, everyone!
As health care professionals, there are few things more agonizing than listening to a grief stricken mother describe how her young daughter, bravely fighting cancer, died during a hospital stay as a result of delays and failed communication. Looking at the audience at the Patient Safety Seminar that day, you could see that all of us felt her pain. After all, we got into the medical field to help people, to heal the sick and care for the most vulnerable, but in this case, we failed. Sadly, I have heard versions of that mom’s story many times throughout the years. The specifics change, but the result is the same -- the loss of life or permanent injury as the result of a medical error.
We aren’t perfect, I tell myself, as I hear those excruciating stories. We are human beings and sometimes, despite our best efforts, we come up short. But inevitably, as I let their brave messages sink in, I use those heartbreaking stories to motivate me -- to dig deeper and try harder and to become a more determined advocate for improving patient safety.
The American Nurses Associations (ANA) theme for National Nurses Week this year is
Culture of Safety – It Starts with you. Since the landmark Institute of Medicine (IOM) report,
To Err is Human: Building a Safer Health System was released in 1999, creating a culture of safety has been a major focus in our profession. The notion that medical errors resulting in patient harm are largely preventable and a result of system failures provided the platform for health care culture reform.
The IOM report provided clear recommendations to address medical errors. The government, professional organizations, and health care organizations have all worked towards reducing preventable medical errors. There is a plethora of information on culture of safety, including webinars, how to guides, frameworks, guidelines, etc. While we have made progress, preventable harm occurs in hospitals every day.
So what is a culture of safety? A culture of safety is an environment in which patient care is safe and effective, and patients are free from preventable harm. The complexity of systems in which health care is provided makes this challenging, but
not impossible.
So, how can every nurse take a leadership role in creating and sustaining a high reliability culture of safety?
- Actively engage patients and their family as partners in care.
- Approach care delivery with interprofessional collaboration and teamwork.
- Promote a culture of blame-free reporting of adverse events and near misses; analyze and learn from them.
- Implement evidence-based best practices; remove barriers to ongoing sustainment.
- Maximize the use of technology as intended.
- Improve hand-off communication and transitions of care.
- Maintain a high level of situational awareness in your work area to anticipate problems ie., rounding, huddles.
- Speak-up if you witness or identify unsafe behavior or safety hazards and hold each other accountable to safe practices.
- Establish goals, measure outcomes and promote transparency of data.
During
Nurses Week this year, let us all make a commitment to ourselves, our teammates and those we care for, that we will become better patient advocates. Let us learn from those heartbreaking stories of loss and take whatever steps are needed to create and sustain an environment founded in a culture of safety -- every day and in every way.
Susan Mascioli MS, BSN, RN, NEA-BC, CPHQ, LSSBB
Director, Nursing Quality and Safety
Christiana Care Health System
Safety is something we think about constantly in our daily lives. We look both ways when we cross the street, we buckle our seatbelts when we get into the car, and we put on helmets when we participate in outdoor activities, such as biking, skateboarding and skiing. For many, safety is not an all-consuming concern at work. As health care providers, however, we are exposed to a multitude of dangers every day. According to the United States Department of Labor, Occupational Safety & Health Administration (OSHA), a hospital is one of the most hazardous places to work.
1 Health care workers experience some of the highest rates of nonfatal illness and injury – surpassing both the construction and manufacturing industries.
2 In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses, a rate of 6.8 work-related injuries for every 100 full-time employees.
1
At work, I regularly lift, turn and transfer patients with limited mobility, strength and balance. I often encounter confused and combative patients who pose a great risk to themselves and the clinical staff. The threat of a needle stick injury and the possible exposure to infectious diseases are two dangers that are perpetually at the forefront of my mind. In nursing school, we were taught basic ergonomic techniques to protect our backs. We were instructed on procedures to prevent unintended exposure to blood borne pathogens. But in the fast-paced world of health care, where patient loads are high, many of these safety strategies fall by the wayside. By nature, nurses often put their own health and safety at risk for the benefit of the patient.
3 So, how safe do we really feel at work and what are hospital administrators doing to protect their employees?
In 1979, Congress passed the Occupational Safety and Health Act, which resulted in the creation of the OSHA. OSHA is the government body responsible for ensuring a safe and healthy working environment for employees by setting and enforcing standards and by providing training, outreach, education and assistance.
3 When I began working in the intensive care unit many years ago, I remember having to complete my first annual competency checklist, which incorporated mandatory lectures developed by OSHA. Topics included blood borne pathogens, fire hazards, fall prevention and methicillin resistant staphylococcus aureus (MRSA). Today, those topics have expanded to include latex allergy, equipment hazards, workplace violence, and workplace stress.
4 These topics are just a subset of the hospital-wide OSHA standards spanning every department from dietary to central supply to housekeeping.
One area of hospital workplace safety that has received great attention in the media in recent years is the use of Personal Protective Equipment (PPE). This issue was highlighted in the news when the first laboratory-confirmed case of Ebola was diagnosed in the U.S. in September 2014.
5 Controversy surrounded this story, which began when a man, who arrived from Liberia initially without symptoms, walked into a Texas emergency room complaining of fever and other flu-like symptoms. After being discharged, he was readmitted several days later and diagnosed with the Ebola virus. Personal Protective Equipment was provided to the staff assigned to the infected patient. Despite these safeguards, however, two clinicians were exposed and ultimately contracted the deadly virus. Thankfully, both nurses survived, but fingers pointed to the hospital administrators, placing blame on their inability to properly educate and ensure the safety of their staff. Were they at fault or just inadequately prepared with minimal resources to deal with this seemingly rare occurrence?
Ebola is an extreme example that emphasized the importance of hospital workplace safety and one that forced hospital administrators across the country to evaluate current policies and procedures. All workers, regardless of the industry, have a right to a safe work environment. Have you noticed any areas of your hospital where improvements could be made to increase overall safety? Do you have recommendations or a success story to share? We would love to hear from you – please leave your comments below.
Resources
Occupational Safety & Health Administration (OSHA): Worker Safety in Hospitals
Occupational Safety & Health Administration (OSHA): Hospital eTools
Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation (Joint Commission)
References
1. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Worker Safety in Hospitals: Caring for Our Caregivers. Retrieved from: https://www.osha.gov/dsg/hospitals/index.html
2. The Joint Commission: Improving Patient and Worker Safety. Retrieved from: http://www.jointcommission.org/assets/1/18/tjc-improvingpatientandworkersafety-monograph.pdf
3. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) About OSHA. Retrieved from: https://www.osha.gov/about.html
4. U.S. Department of Labor: Occupational Safety & Health Administration. (2016) Hospital eTools: Intensive Care Units. Https://www.osha.gov/SLTC/etools/hospital/icu/icu.html
5. Centers for Disease Control and Prevention (2016). Cases of Ebola Diagnosed in the United States. http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/united-states-imported-case.html
We’ve all experienced it over the years…the frustration of having some piece of equipment, computer program, patient care process, person, or policy get in the way of getting the job done. Sometimes it’s because the thing or situation that’s standing in our way is broken. Other times it’s because there’s no rule in the playbook that addresses exactly an unusual circumstance. The end result is often the creation of a
work-around…and nurses can be extremely creative!
Work-arounds circumvent established procedures, policies, and processes. In some cases, they truly may be needed to get an essential task accomplished because the current system has not yet caught up to the realities of clinical practice. The work-around may ultimately indeed be the right way, but just continuing to do it informally may be viewed as a much quicker and easier path to travel than the journey to making it a permanent solution. Depending on the nature of the issue and the organizational change process that’s needed, there may be tedious processes to follow, forms to fill out, a chain of command to invoke, a business case to make, committees to form, places to go, and people to see.
In other words, the real solution can appear a far-off, daunting task that requires considerable expenditure of time and energy and quite possibly a measure of stretching way beyond a personal comfort zone into organizational bureaucracy. There’s a very real chance that the proverbial “squeaky wheel” that brings the matter to light could wind up the owner of the issue and be expected to be part of the solution. However, if the work-around makes things look like everything is working just fine, there’s no obvious burning platform as the catalyst for necessary change. The problem may remain invisible to the larger system and go unsolved. If leadership is unaware, there’s no opportunity to submit requests for maintenance or budget for new equipment, system upgrades, or even necessary material or human resources.
Another category encompasses the work-arounds that may simplify the job or allow it to be accomplished faster, but bypass safety measures put into place to reduce risk. Ignoring established safety practices that are perceived as cumbersome is an example. Staff may become so good at these that the work-around escapes detection. These types of work-arounds can evolve to become the usual practice or even the cultural norm. They may be passed along to new staff members as tips or tricks to be more efficient to the point that staff stops seeing the strategy as a work-around at all. Direct observation might be the only way to spot this situation. Nurses who follow the rules can experience considerable moral distress when they discover that co-workers are using such work-arounds inappropriately. They are then placed into the very difficult position of either turning a blind eye (which has significant ethical and even professional regulatory implications), or acting as a whistle blower to management.
My advice is that if a work-around is felt to be necessary, there’s a problem with the current system that must be addressed. That includes those situations where the work-around is done to make the job easier or faster but bypasses safety measures. Perhaps the safety measures could be maintained and risks reduced if the system was re-designed in a way to make it easier to do the right thing while still meeting all of the standards and regulations. Our knee-jerk in healthcare often involves creating a new form to fill-out or coming up with a new tedious process that gives the illusion of a safety improvement, but instead just adds another barrier that people look for ways to overcome. We need to think broadly and be truly innovative. Strategies include researching current best practices, connecting with staff at other organizations to learn how they manage similar issues, and even investigating if there are applicable innovative solutions in industries outside of healthcare.
We do need to make processes associated with nursing practice and healthcare in general safer, easier, more efficient, and more effective. The appearance of a work-around is a red flag for an improvement opportunity. Rather than allow it to persist or remain obscure, bring the situation to light and be an advocate for necessary change. Keep in mind the old adage: if you always do what you’ve always done, you will always get what you’ve always got. When confronted with a work-around, take on the challenge and demonstrate individual leadership, advocacy, and the courage to engage in true problem resolution.
Happy Nurses Week!
Linda Laskowski-Jones, APRN, MS, ACNS-BC, CEN, FAWM, FAAN
Editor-in-Chief, Nursing2016
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware
Don’t you wish it was that easy? You could just pick up the phone, hire Bugbusters, and they’d come out and use their Sci-fi equipment to rid your facility of all those nasty “bugs” or organisms that cause health care-associated infections (HAIs). Unfortunately, it isn’t that easy; there’s no Sci-fi equipment to magically rid your facility of organisms. We’ve made strides, however, towards reducing the incidence of these infections by using a variety of evidence-based best practices.
Progress report
The Centers for Disease Control and Prevention recently published the National and state healthcare associated infections: Progress report using 2014 infection data from national acute care hospitals. This report revealed significant progress towards reducing HAIs:
- Central line-associated bloodstream infections declined by 50% between 2008 and 2014.
- Catheter-associated urinary tract infections showed no change overall, but there was progress made in non-critical care settings between 2009 and 2014, and in all settings between 2013 and 2014.
- Surgical site infection declined by 17% between 2008 and 2014.
- Clostridium difficile infections declined by 8% between 2011 and 2014.
- Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia declined by 13% between 2011 and 2014.
As you can see, we’ve made significant progress, but there’s still much more work to be done. Every day, nearly one in 25 patients in the United States has at least one infection that they acquired during their stay in a health care facility. This shows the need to improve infection control and prevention practices in health care facilities, and other various settings.
Bugbusting best practices
So, what can we do to bust those “bugs” and prevent HAIs in our health care facilities? To start, research shows that when members of the multidisciplinary team are aware of infections and join together to take steps to prevent those infections, infection rates can be reduced by more than 70%. Developing a culture of safety that includes teamwork, evidence-based infection prevention processes, and accountability for preventing infections is key.
Making it real
Make infections real to all members of the health care team, including environmental services personnel, transportation staff, sterile processing department staff, patients, visitors, and volunteers; not just those directly involved in patient care. After all, everyone plays a role in preventing the spread of infection.
Share stories… nothing hits home like a story of a patient who suffered harm as a result of an infection that could’ve been prevented. Take for instance, the story of an elderly patient admitted to a health care facility for knee replacement surgery. The surgical procedure itself went smoothly, but the patient soon developed a surgical site infection, the responsible organism was MRSA. The patient spent months in the hospital for IV antibiotics, prosthetic joint removal, spacer insertion, and eventually an above the knee amputation of the affected leg. The patient, the mother of a staff physician, eventually succumbed to complications of the MRSA infection.
How could a seemingly uncomplicated surgery result in an infection that ultimately resulted in this patient’s death? Was it by the hands of a health care worker who didn’t take time to perform hand hygiene? An operating room team member who failed to follow sterile technique during the procedure? An environmental services staff member who didn’t properly clean surfaces in the patient care area? A sterile processing staff member who didn’t properly sterilize surgical instruments? A visitor who failed to perform hand hygiene before visiting the patient? The patient herself who failed to properly perform personal hygiene after surgery? Any of these scenarios could’ve caused the patient’s infection and subsequent death. When this story was told, it was difficult not to feel accountable.
Zero tolerance
There are many opportunities for infection to spread in a health care facility. It’s important to make sure that everyone is educated about measures to prevent infection, using methods that they understand. Start with the basics...we’ve all heard it before,
hand hygiene is the single most effective thing you can do to keep infection from spreading. Make sure everyone performs hand hygiene properly, every time that it’s indicated.
Develop a culture that has zero tolerance for infection and zero tolerance for failure to follow proper infection prevention practices. Empower patients, family, and other staff to speak up when infection prevention practices aren’t followed. Getting to zero is the only sure way to keep our patients safe from infection.
What infection prevention practices have been successful at your facility? Have you done anything creative to engage staff, patients, and visitors; something outside the box that you’d like to share with us?
References:
Centers for Disease Control and Prevention. (2016). “National and state healthcare associated infections: Progress report” [Online]. Accessed April 2016 via the Web at http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf
Institute for Healthcare Improvement. (n.d.). “What zero looks like: Eliminating hospital-acquired infections” [Online]. Accessed April 2016 via the Web at http://www.ihi.org/resources/Pages/ImprovementStories/WhatZeroLooksLikeEliminatingHospitalAcquiredInfections.aspx
Yokoe, D.S., et al. (2014). SHEA/IDSA practice recommendation: Introduction to a compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infection Control & Hospital Epidemiology, 36(5), 455-459.
Collette Bishop Hendler, RN, MS, CIC
Senior Clinical Editor
Clinical Project Manager, Lippincott Procedures
Wolters Kluwer, Health Learning Research & Practice
For any nurse working in a direct care setting, preparing medications and administering them to patients is part of the daily routine. Mistakes can happen at any point in the process. Administration errors are one of the most serious and most common mistakes made by nurses. The result may lengthen a hospital stay, increase costs, or have life and death implications for the patient. So, what can you do to safely administer medications?
Start with the basics
- Verify any medication order and make sure it’s complete. The order should include the drug name, dosage, frequency and route of administration. If any element is missing, check with the practitioner.
- Check the patient's medical record for an allergy or contraindication to the prescribed medication. If an allergy or contraindications exist, don't administer the medication and notify the practitioner.
- Prepare medications for one patient at a time.
- Educate patients about their medications. Encourage them to speak up if something seems amiss.
- Follow the eight rights of medication administration.
Minimize distractions and interruptions:
- Know that interruptions and distractions have a marked effect on your performance, causing a lack of attention, forgetfulness, and errors.
- Make sure you have all the required supplies and documents available before beginning preparation or administration activities.
- Follow your facility’s policy related to the use of a “No Interruption zone” (NIZ), a practice recommended by the Institute for Safe Medication Practices (ISMP) to enhance patient safety. Your NIZ should be a discreet area where medication tasks are performed. It may be a dedicated medication room or a quiet area sectioned off by visual markers.
- If required by your facility, wear a special vest, apron, sash, lighted lanyard, or other item that indicates that you are administering medications and shouldn’t be interrupted.
- If your facility utilizes mobile devices, temporarily transfer calls and other notifications to another staff member or place the device on pause during the most complex parts of the medication preparation and administration tasks.
Implement these additional safety measures:
- Be especially alert during high-risk situations, such as when you are stressed, tired, or angry or when supervising inexperienced personnel. Monitor and modify work schedules to minimize work- or fatigue-related medication errors.
- Be familiar with all appropriate antidotes, reversal agents, and rescue agents. Know where they are stored on your unit and how to administer them in an emergency situation.
- Be familiar with high-alert medication (such as anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs). Ask another nurse to perform an independent double check and rectify any discrepancies BEFORE administering the drug.
- Be aware of the ISMP’s and your facility’s list of confused drug names, which includes sound-alike (such as Zocor and Cozaar) and look-alike (such as vinblastine and vincristine) name pairs. Take extra precautions when administering drugs from these lists. Your facility may also have extra safeguards in place, such as requiring both the brand and generic name be recorded, including the purpose of the medication with all orders, or setting up computer selection screens to prevent look-alike names from appearing near each other.
- Pay attention to Tall Man lettering, a visual safety feature that highlights a section of a drug’s name using capital letters to help distinguish look alike name pairs from each other, such as BuPROPion (an antidepressant) from BusPIRone (an anxiolytic) or glipiZIDE from glyBURIDE (two different antidiabetics).
- Measure and document a patient’s weight in metric units (grams and kilograms) ONLY to allow for accurate dosage calculations. Also, weigh the patient as soon as possible on admission and don’t rely on stated, estimated, or historical weights.
- For patients receiving IV opioid medication, frequently monitor respiratory rate, sedation level, and oxygen saturation level or exhaled carbon dioxide to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays.
- Administer high-alert intravenous medication infusions via a programmable infusion device utilizing dose error-reduction software.
- Reconcile the patient’s medications at each care transition and when a new medication is ordered to reduce the risk for medication errors, including omissions, duplications, dosing errors, and drug interactions.
- Educate and provide written instructions to the patient and family (or caregiver) regarding prescribed medications for use when at home and verify their understanding prior to discharge.
By being familiar with medications you administer and following safeguards, you can help protect your patients from medication errors.
For more information on medication safety, go to:
CDC: Medication Safety Program
Institute for Safe Medication Practices
AHRQ Patient Safety Network: Medication Errors
US FDA: Medication Errors Related to Drugs
References:
Institute for Safe Medication Practices. (2016). "2016-17 targeted medication safety best practices for hospitals" [Online]. Accessed April 2016 via the Web at http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitals.pdf
Safe medication administration practices, general. (2015). In Lippincott procedures. Retrieved from http://procedures.lww.com.
Nursing 2016 Drug Handbook. (2016). Wolters Kluwer: Philadelphia, Pennsylvania.
Joan M. Robinson, MSN, RN
Clinical Director
Lippincott Solutions
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
Preventing 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 NursingCenter.com and take advantage of a
National Nurses Week CE Collection discount this week.
References
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 https://www.osha.gov/SLTC/workplaceviolence/standards.html
3. The National Institute for Occupational Safety and Health (NIOSH). June 26, 2014 Recent NIOSH Research on Occupational Violence and Homicide, Retrieved from http://www.cdc.gov/niosh/topics/violence/traumaviol_research.html
This 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.
Earlier this month, nurses and nurse practitioners spent some sunny days in Orlando at the Coronado Springs Resort of Walt Disney World. We learned, networked, and enjoyed good food and fun! I must give props to the conference chairpersons, planning committee members, and meeting planners for such well-done back-to-back conferences. And I was lucky enough to attend both!
The keynote sessions were extraordinary. At
Nursing2016 Symposium, Charles Kunkle, RN, MSN, CEN, BC-NA had the audience involved and laughing, while really making us think during his presentation,
No Time to Care: Instilling Compassion Back Into Your Care in 60 Seconds or Less. One key reminder for me was that talking to a person as a human being, not a diagnosis, can make all the difference. Mr. Kunkle quickly did an ER admission scenario two ways – first referring to the patient as “the abdominal pain” through the admission process, then again referring to the patient by name. His lively and dynamic presentation style really added to the impact of his message. Also, Mr. Kunkle reminded us that “only 15% of the message that we deliver comes from spoken word.” So, remember, it’s not what you say, but how you say it. Pay attention to your nonverbal and paraverbal (tone, volume, and cadence) communication.
At the
National Conference for Nurse Practitioners, the thrill of being in the presence of
Loretta Ford, RN, PNP, EdD, FAAN, FAANP was indescribable. Using a Q & A format, conference chairperson, Margaret A. Fitzgerald DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC had a candid conversation with Dr. Ford about her work founding the nurse practitioner profession and her thoughts on the future of our profession. I especially enjoyed her insights for the future, including how “language matters.” She emphasized that the use of the word ‘medical’ is synonymous with ‘physician’ and that we should instead focus on using the word ‘health’ as much as we can. For example, she stated “Let’s reorient from saying ‘primary medical care’ to ‘primary health care.’”
Here’s a look at some other takeaways from the week:
- “One in ten Americans take SSRIs.”
Sophia Chu Rodgers, FNP, ACNP, FAANP, FCCM
ABG Interpretation, Fluid, and Electrolytes
- “Regarding pulse oximetry…remember to treat the patient, not the number.&rdquo
AnneMarie Palatnik, MSN, RN, ACNS-BC, AVP
Skill Assessment: Pulmonary
- “CCF (chest compression fraction) is the total amount of time compressions are delivered relative to the total amount of time of cardiac arrest. The goal is 60%, however, 80% is optimal and achievable when an advanced airway is present.”
Denise Drummond Hayes, MSN, RN, CRNP
The Case of the Vanishing Vasopressin: BLS & ACLS Guidelines Update
- “Joint swelling is the hallmark sign of rheumatoid arthritis that is required for diagnosis.”
Richard S. Pope, MPAS, PA-C
RA in 2016: It’s Not What It Used to Be! Or Is It?
- “You can use any ventilator setting for any patient as long as you understand how it works.”
Eric Magaña, M.D.
Nuts and Bolts of Mechanical Ventilation
- “Mothers taking SSRIs in pregnancy put infants at risk for persistent pulmonary hypertension.”
Dr. Lana Melendres-Groves
Acute Care: Pulmonary Hypertension
- “ST-elevation rules! If you see ST-elevation in a patient complaining of chest pain, assume acute ischemia.”
Dr. Andrea Efre
Acute Care: Chest Pain: Refine Your Assessment Skills and Define Your Differential Diagnosis
- “When someone wants ‘everything done,’ our next question should be ‘what does that mean to you?’”
Debbie A. Gunter, FNP-BC, ACHPN
Talking about Dying Won’t Kill You! How to Talk with Patients about Terminal Illness
Here’s a look at my time at these two Lippincott conferences. Hope to see you next fall at
NCNP2016 Fall and
Nursing Management Congress!
I hope that some of you have been using
My Nursing Care Plan to help you achieve your professional goals and make self-care a high priority. Here’s an update on how I’ve been doing.
Well, even as a clinical editor and being very involved with sharing nursing continuing education activities and attending Lippincott Nursing Conferences, I’ve stayed true to my tendency to procrastinate! With an April 30
th license renewal deadline, I completed my
CE requirements just in time on April 25
th. Fortunately, I did get my renewal done in time and avoided fees, however, I don’t recommend cutting it so close!
I have better intentions to keep up with my CE requirements over the next renewal cycle, though, and have already used
My Planner to plan upcoming CE activities. Also, I’ll be attending both
National Conference for Nurse Practitioners and
Nursing Management Congress this fall. I feel like I’m off to a good start!
At this point in my career, conference attendance and keeping up with my reading of the latest research in nursing and health care is my main avenue for lifelong learning. In the past, my
specialty certifications included CCRN (Acute/Critical Care Nursing) and WHNP-BC (Women’s Health Care Nurse Practitioner). I know that when I return to clinical practice, I will become certified in whatever specialty my career takes me next.
With regard to membership in a professional nursing organization, I’ve taken my own advice and rejoined the
American Nurses Association, as well as the
Pennsylvania State Nurses Association. There has never been a more important time to show your dedication to our profession and I encourage you all to get involved. If you are involved with publishing in nursing, I encourage you to join the
International Academy of Nursing Editors (INANE). I’ve been a member for years and it’s a great network of nurse authors, editors, and publishers – plus, it’s free to join!
Also,
returning to school is definitely in the cards for me in the future. While I know the time will never be perfect, I’m just waiting for it to be a little better! I’ll keep you posted!
This part of the care plan has been a little trickier for me, and I wonder if you feel the same? As nurses, we are so used to taking care of others, that self-care is often less of a priority. I am happy to report that since the beginning of 2016, I’ve had a physical, including my mammogram and some other screening tests. I’ve also been working with my primary care provider and a specialist to diagnose and manage a chronic cough and shortness of breath (likely post-viral or adult-onset asthma).
I’m also getting out there and walking and doing my best to eat healthy, which is not always easy with a teenage son who has
high-caloric needs to keep up with his sports. My next goal is to add some weight training to help maintain and improve bone density, which we know is critical for women as we get older.
And as for “me time” and managing stress, scheduling time for things I enjoy (reading and gardening, especially) and keeping them on the calendar definitely has helped. I admit that sometimes those times get pushed aside for other responsibilities, but as long as I keep trying and do my best, it’s better than my previous attempts.
How about you? What have you been up to? What’s been the most challenging part of the care plan for you? And, if you have any advice for me, I’d appreciate your support!
If you own a Smart mobile phone, chances are you have downloaded a mobile application (app) or have used one at some point. According to a 2015 Pew Research Study, two-thirds of Americans own a Smart phone and more than half have used their phone to get health information.
1 Mobile apps are software applications designed to run on platforms, such as smartphones, tablet computers and other handheld devices. Apps are downloaded onto your mobile device and are designed to provide consumers with quick access to information and tools with or without internet connectivity. As of June 2015, more than 100 billion mobile apps have been downloaded from app stores and the number of mobile app buyers in the United States is projected to reach 85 million in 2019.
2 Apps developed specifically for health care are on the rise. There are over 150,000 mobile health, or mHealth, apps on the market focusing on various areas of wellness, including fitness, general health and drug information, disease management, telemedicine, and clinical workflow, to name a few. These are available for free or for a small fee and are typically intuitive and easy to use, even for those that are not technology savvy.
Fitness apps are perhaps the most widely used mHealth apps available today. Many of these apps have companion external devices known as wearables that help consumers track steps, weight, pulse, and calories. As a runner, I have used several training apps in preparation for long distance races. These assist in mapping routes, tracking training sessions, and calculating distance and speed. Some provide feedback on performance, while others send motivational reminders to users to get out and exercise. These digital coaches can facilitate healthy lifestyle changes and can be very cost effective to the average consumer, but only when integrated into a regular routine.
General health care apps provide a range of capabilities, such as allowing patients to organize documents, appointments, and medications into a personal file that can be easily accessed at provider appointments and by family members. Others allow consumers to have direct access to all of their electronic health records (EHR) integrated into one place that automatically update with new information, such as medical history, medications, allergies, prior surgeries and procedures, vital signs, changes in weight, and glucose readings via a patient portal. These apps facilitate the sharing of medical records with providers in real-time, which may promote patient safety, disease prevention, continuity of care, and patient self-management.
Drug information apps provide clinicians with medication references, such as drug indications, dosages, contraindications, safety information, and prescription interactions. Apps aimed at improving medication compliance provide patients with reminders to take their pills, how many to take, and when to refill a prescription. Disease management apps help clinicians monitor patients’ health status and streamline communication. For example, there are several apps on the market targeting diabetes therapy. Some simply help patients monitor blood glucose levels, while others provide sophisticated data analytics to the patient’s health care provider and team, along with a patient self-management plan. Telemedicine apps support communication between patients and providers and is one of the fastest growing areas of app development. These apps enable patients to connect with clinicians via video or text consultation in real time. Some healthcare providers are able to refer to specialists, order lab tests and prescribe medications through the app. Others allow providers to make a diagnosis and determine if an emergency room visit is necessary.
Finally, clinical workflow improvement apps streamline communications and data management for nurses and other providers within the clinical setting. These are the most advanced apps on the market, often linking multiple health information systems and improving efficiencies in the workplace. Incorporating mHealth apps into the in-patient care setting, however, involves a high level of commitment, coordination, and resources. Questions hospital administrators should consider when developing a strategy involving mHealth include
4:
- Do mHealth technologies enhance workflow, reimbursement, and quality of patient care?
- Which mHealth apps are approved for recommendation to patients?
- When can an mHealth app be recommended to the patient and how would this information be communicated to the health care team?
- Who will provide guidance to the patient on the use of the mHealth app, and who is responsible for monitoring compliance and outcomes?
- What is the evaluation process for new mHealth apps? How will effectiveness be tracked?
- What new skills are needed by clinicians, information technology professionals, and hospital executives to ensure successful implementation of new digital tools?
Integrating mHealth has the potential to improve disease management, communication, and overall patient care. Complete adoption of mHealth, however, will depend largely on:
- Payers’ recognition of the value apps provide in health care management
- Establishment of standards for security and privacy guidelines that protect patient’s personal health information
- Evaluation and regulation of health care apps
- Full integration into health information systems4
Technology has and will continue to rapidly transform every aspect of our daily lives. Managing our health is no exception. As mHealth apps become more sophisticated and increasingly ubiquitous in our modern society, patients and consumers will demand higher quality and functionality. We, as health care providers, need to be armed with the skills to adopt and manage digital tools as they will inevitably become an integral part of how we deliver patient care.
References
-
-
-
AJN Reports (2015). The World of Apps in Healthcare: Opportunities and Challenges for Nurses. American Journal of Nursing. 2016; 115 (11): 18-19.
-
Austin R, Hull S. (2014). The Power of Mobile Health Technologies and Prescribing Apps. Computers, Informatics, Nursing.
Myrna B. Schnur, RN, MSN
Related Reading
In
Part 1 of this series, I provided a general overview of mobile medical applications (apps) that are available on the market in the areas of general health, wellness, disease management, and hospital clinical workflow. There are many potential benefits of mobile medical apps, such as facilitating communication between patient and provider, enhancing efficiency, and advancing the overall quality of patient care. There have been recent reports in the news, however, pointing to the dangers of patients being misdiagnosed via telemedicine websites and mobile apps. Serious patient safety questions arise when mobile medical apps are designed to act as a medical device or provide patients with a medical diagnosis. Should these apps be regulated by the government? Part 2 of this blog series focuses on the current regulation recommendations* surrounding the use of mobile apps as it applies to direct patient care.
The Food and Drug Administration (FDA) is the government organization responsible for protecting the public health by assuring the safety of drugs, biological products, medical devices, food supply, cosmetics, and products that emit radiation.
1 In 2015, the FDA released a document that outlines the use of health care applications and states that apps that act as either a medical device or an accessory to a medical device will need to obtain FDA approval. The intended use of a mobile app determines whether it meets the definition of a “device.” When the intended use of a mobile app is for the “diagnosis of disease or other conditions, or the cure, mitigation, treatment or prevention of disease, or is intended to affect the structure or any function of the body, the mobile app is considered a device.”
2 Intended use is communicated to the consumer through product labeling, advertising, or verbal and/or written statements made by manufacturers. All products that fall under the definition of device are subject to regulations set forth by the FDA before they can be marketed and sold to the general public.
FDA regulation will focus on mobile apps that turn a mobile platform into a regulated medical device, which could pose a risk to a patient’s safety if it did not function properly. Examples include medical apps that:
- Connect to and control medical device(s) in order to actively monitor or analyze medical device data. (i.e., an app that controls the delivery of insulin on an insulin pump);
- Turn the mobile platform into a medical device by using attachments, display screens, or sensors, or by including functions similar to those of currently regulated medical devices. (i.e., an attachment of electrocardiograph (ECG) electrodes to a mobile platform to measure, store and display ECG signals);
- Perform patient-specific analysis and provide patient-specific diagnosis, or treatment recommendations. (i.e., apps that use patient-specific parameters to calculate dosage or create a dosage plan for radiation therapy).
The following medical apps pose low risk to patient safety, and therefore, the FDA will exercise discretionary judgment with regard to regulation. Examples include apps that:
- Help patients self-manage their disease or condition without suggesting specific treatments (i.e., apps that coach patients with cardiovascular disease to maintain a healthy weight, eat nutritiously, and exercise);
- Provide patients with simple tools to organize and track their health information, without recommending a change to previously prescribed treatment or therapy (i.e., apps that log blood pressure, drug intake times, diet, daily routine, or emotional state);
- Provide easy access to information related to patients’ health conditions or treatments (i.e., apps that use a patient’s diagnosis to provide a clinician with best practice treatment guidelines for common illnesses or conditions);
- Help patients document, show, or communicate potential medical conditions to their providers (i.e., apps that serve as videoconferencing portals to facilitate communications between patients, health care providers, and caregivers);
- Automate simple calculations routinely used in clinical practice (i.e. medical calculators for Body Mass Index (BMI), Glascow Coma Scale Score, or APGAR score);
- Enable patients or providers to interact with Electronic Health Records (EHR) systems to view or download data to facilitate general patient health management and medical record-keeping;
- Transfer, store, convert format, and display medical device data, without controlling or changing the functions of any connected medical device.
Mobile apps that are not considered devices under the FDA definition and are not required to undergo regulatory requirements include apps that:
- Provide electronic copies of medical textbooks or references not intended to diagnose, treat, or prevent disease by helping a clinician assess a specific patient;
- Act as educational tools for medical training and may have more functionality than an electronic copy of text (i.e., videos, interactive diagrams), but are not intended to diagnose, treat, cure, or prevent disease by helping a clinician assess a specific patient;
- Provide general patient education and patient access to commonly used reference information;
- Automate general office operations and administrative functions (i.e., coding, billing, accounting, scheduling, payment processing);
- Act as generic aids (i.e., using the mobile platform to record audio, or send HIPAA compliant messages between health care providers in a hospital).
As more and more apps are developed in the field of health care, clinicians will play a pivotal role in how these apps are implemented in the routine care of patients. We need to have a basic understanding of app functionality, which ones are purely informational and which ones act as medical devices. More importantly, it is essential that we fully comprehend the impact these apps will have on the safety of our patients, as we are ultimately responsible for protecting them from harm.
In
Part 3 of this blog series, I will provide an overview of the medical mobile educational tools available to nurses and how clinicians should evaluate which are the most reliable and relevant sources of information.
*Note: This article is a summary of the FDA guidelines and is not meant to be all-inclusive of the recommendations made by the FDA.
References
-
-
Myrna B. Schnur, RN, MSN
Related Reading
Rounding out this blog series on mobile health applications (apps) or mHealth apps, I wanted to touch on apps specifically designed to provide educational tools and quick references for the nursing profession. According to a survey conducted by Wolters Kluwer Health, 65 percent of nurses said they currently use a mobile device for professional purposes at the bedside.
1 The study also found that 95 percent of health care organizations allow nurses to consult websites and other online resources for clinical information at work.
1 A major advantage of mobile apps is that they provide a variety of references in one central location, that is easily attainable, from almost anywhere there is a reliable internet connection. Nurses employed in every clinical setting stand to benefit from resources at their fingertips, particularly those in home and public health settings, where access to evidence-based information may be limited.
As discussed in
Part 1 of this blog series, there are thousands of mHealth apps available to clinicians. The most common are drug manuals, tools to help evaluate lab and diagnostic studies, and differential diagnosis guides
2. Utilization of mobile devices in professional nursing practice may improve efficiency and assist clinicians to:
- Complete professional development;
- Stay up-to-date with the latest research and literature;
- Provide patient and peer education;
- Translate medical terms for patients and family members;
- Compute drug dosages;
- Calculate physiologic assessments, such as Body Mass Index (BMI), Mean Arterial Pressure (MAP), Glascow Coma Scale score, Apgar score, Stroke Scale and many more;
- Organize shift work; and
- Communicate with other health care professionals.
With an ever increasing number of mHealth apps on the market, how can nurses decipher which are useful and contain the most relevant and accurate information? In order to utilize these resources effectively, nurses should be competent in several key areas, including basic computer knowledge and use, information literacy, (IL) and information management
3. Information Literacy (IL) is defined as the ability to recognize when information is needed and to locate, evaluate, and effectively use that information. Therefore, nurses must be able to assess mHealth apps for accuracy, credibility, bias, timeliness, and breadth of information.
3 A study, conducted by Arith-Kindree and Vandenbark (2014), asked nursing students to assess a variety of mobile apps for usefulness. The study found that some apps, while from reputable sources, provided recommendations that were incomplete.
3 Based on the findings from this study, nurses should critically evaluate each app to ensure it is:
- Credible – verify the author’s credentials, publisher’s reputation, and peer-review status;
- Relevant – assess the intended audience, purpose, and publication date;
- Current – check that the content is consistently updated on a regular basis;
- Utilitarian – confirm the app is useful and functions as it was designed; and
- Comprehensive – establish that the information is complete and derived from a trusted source.
Health care apps can serve as useful tools for clinicians at the bedside, however, there are logistical and cultural obstacles that stand in the way of implementation and utilization. This opens up many opportunities for nurses in the field of informatics to develop policies, organizational infrastructure, and competencies for integrating mHealth solutions within health care organizations and communities.
4 Several challenges, however, must be overcome which include:
- Establishing hospital administrator support;
- Overcoming staff resistance to change;
- Training to different learning styles and comfort levels with technology;
- Securing patient confidentiality;
- Cost of infrastructure and maintaining consistent internet access;
- Preventing vital machine failure or malfunction due to interference from handheld devices; and
- Ensuring that mobile devices are not a distraction in the workplace.
Digital tools can potentially make us more efficient, effective, and informed practitioners. We are fortunate to live in an age of innovation where tools are available at our fingertips, any time, and anywhere. Unfortunately, not all mHealth apps are accurate and some cannot be trusted. We, as health care providers, need to develop a critical eye when evaluating the use of new technologies and verify that they are consistent with evidence based practice prior to full integration into the health care delivery system. In addition, more research is needed in the area of mHealth to assess the true impact it could have on workflow, quality, and patient outcomes.
References:
-
-
Baca K, Rico M, & Stoner M. (2015) Embracing Technology to Strengthen Care and Enhance Human Connection. Dimensions of Critical Care Nursing, 34(3), 179-80.
-
Airth-Kindree N & Vandenbark T. (2014) Mobile Applications in Nursing Education and Practice. Nurse Educator, 39(4). 166-169.
-
Austin, R. & Hull, S. (2014) The Power of Mobile Health Technologies and Prescribing Apps. CIN: Computers, Informatics, Nursing, 32(11). 513-515.
Myrna B. Schnur, RN, MSN
Related Reading
In January of 2016, we shared
5 Things Nurses Need to Know about Zika Virus. Since that time, ongoing research and monitoring has increased what we know, and recommendations have been updated based on the latest evidence. Here are five more things that are important for nurses to understand:
1. Is there a test for Zika virus?
Early in the course of Zika virus, a serum real-time reverse transcription-polymerase chain reaction (rRT-PCR) may detect Zika virus RNA in the blood. The virus RNA may remain present in the urine longer than in the blood; the CDC recommends that urine samples be collected less than 14 days after onset of symptoms for rRT-PCR testing. Virus-specific IgM and neutralizing antibodies typically develop toward the end of the first week of illness, so Zika virus serologic testing can be done later in the course of illness. All submissions go through the state or local health department and there are
specific instructions from the CDC on how to collect, prepare, and ship specimens for testing.
2. What are the current recommendations related to sexual transmission?
- Men who have been diagnosed with Zika virus should use condoms or abstain from sex for at least six months.
- Pregnant women with male partners who live in or travel to areas with Zika should use condoms every time they have vaginal, anal, or oral sex, or abstain from sex for during the pregnancy.
- Both men and women should be counselled about contraceptive planning. Women with Zika virus should wait at least eight weeks after symptom onset before conceiving; men with Zika virus should wait at least six months, as it is unknown how long the virus may remain in semen. Women with possible exposure to Zika virus should wait at least eight weeks after being exposed to attempt conception; men should wait at least six months.
3. What is microcephaly?
Microcephaly is a neonatal malformation in which infants are born with a head smaller than normal due to abnormal brain development. In some cases, newborns may develop normally, however, possible associated neurologic complications include developmental delay and seizures, as well as speech, hearing, and vision deficits, and feeding difficulties. Diagnosis can be made by ultrasound late in the second trimester or early in the third trimester, or after a baby is born. Microcephaly is a lifelong condition and treatment depends on the severity of the malformation and associated health problems.
4. Is Zika virus associated with Guillain-Barré syndrome (GBS)?
The CDC is investigating the link between Zika virus and GBS, as the Brazil Ministry of Health has reported an increased number of people who have been infected with Zika virus who also have GBS. GBS is an autoimmune disease which attacks the peripheral nervous system. Weakness of the arms and legs results, and flaccid paralysis often develops. In severe cases, the muscles of the face weaken and affect the eyes, swallowing, and breathing. Many patients with GBS have a history of a recent viral or bacterial infection, so it is possible that a percentage of those infected with Zika virus could develop GBS as well.
5. How should symptoms of Zika virus be managed?
At this time, there is no antiviral or other medication available to prevent or treat Zika virus. Rest, fluids, antipyretics, and analgesics are recommended for symptom management. It’s important to remember that aspirin and NSAIDs should be avoided until dengue virus is ruled out.
References
Centers for Disease Control and Prevention. (2016, July 14). Zika virus. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/zika/
Coyle, A. (2016). Zika virus: What nurses need to know. Nursing2016, 22-24.
O'Malley, P. A. (2016). Zika Virus: What We Know and Do Not Know. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 194-197.
Todd, B. (2016). Zika Virus: An Unfolding Epidemic. AJN, American Journal of Nursing, 59-60.
With Zika virus in the news and on our minds this season, we know some of the best advice for preventing this illness is to prevent infection via mosquito bites. See the infographic below for recommendations to prevent transmission of Zika virus and other mosquito-borne illnesses.
Add this infographic to your website by copying and pasting the following embed code:
You may or may not have yet noticed that we’ve begun implementing more personalized features here on NursingCenter.com. Take some time to explore your very own dashboard of content related to your area(s) of practice! Here’s how…
1.
Login to your NursingCenter account. Don’t have one? Go ahead and
register – it’s FREE!
2. Click your name at the top right of the page.
3. Click “My Dashboard.”
4. See the results!
5. You can even toggle between your practice areas to see additional content!
6. Need to edit your practice area? Just click “Edit” to update your profile.
Hope you enjoy this new feature on Lippincott NursingCenter.com! And remember, you can always
update your profile to reflect your current practice area. Keep all of your selections up-to-date so we can bring you the content that best meets your needs to improve outcomes and develop professionally.
Thank you!
Posted:
8/31/2016 10:46:42 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories: Technology
I recall attending a reception with my parents in the spring prior to starting my Freshman year at the University of Pennsylvania (Penn), School of Nursing in Philadelphia. My mother was talking to another parent and I casually joined the conversation. We found out that she and her daughter, Lisa Morris (Bonsall) were from our same small town on Long Island. We attended different schools and therefore, had never met. Call it coincidence or fate – we became instant friends. We both enrolled in the pre-freshman program in August to prepare for the academic rigors of an Ivy League institution. At the conclusion of the program, we felt we were ready. Contrary to this belief, once the school year ramped up, I for one, found it to be extremely challenging. The course load was very heavy our freshman year and the amount of information we needed to memorize and synthesize was overwhelming at times. We managed to survive our first year, despite numerous distractions: parties, co-ed dorms, football games and sorority initiation.
Sophomore year brought with it the beginning of our clinical rotations and an end to our late night parties. While our non-nursing classmates slept until mid-morning, we were up and out the door by 6 am to get to our clinical site for a full day of patient care. I remember learning the basics of safe nursing practice, medication administration, and disease management. I’ll never forget the nursing process and writing care plans for all of our patients, each encompassing an assessment, diagnosis, planning, implementation, and evaluation. The practical, hands-on education continued through our junior and senior year with opportunities to take advantage of the many liberal arts classes that Penn had to offer. Lisa and I made it through, and we both graduated with a Bachelor of Science degree in Nursing (BSN). It was 1994 and our turn to make a difference.
Lisa decided to stay in Philadelphia and accepted a position in the Medical Intensive Care Unit (MICU) at the Hospital of the University of Pennsylvania (HUP). I headed to the Big Apple to begin my career at the New York University Medical Center as a nurse in the Surgical Intensive Care Unit (SICU). With four years of training at Penn, I confidently thought once again, that I was ready. However, I quickly realized that I had so much more to learn. Each disease and surgical procedure involved many complexities. Every patient’s recovery varied based on multiple factors and comorbidities. I honed my assessment skills and learned to think critically. It was stressful, and I loved patient care, but after a few years in the ICU at NYU, I realized I wanted to do more. I was ready to go back to school and Penn was the obvious choice.
Lisa had come to the same conclusion and had started graduate school at Penn around the same time to pursue an Advanced Nurse Practitioner degree in Women’s Health. I was intrigued by the business of health care and decided to focus my graduate studies on Hospital and Healthcare Management. We both worked full-time, and many night shifts, in our respective ICUs during graduate school. We found ourselves back in the Biomedical Library, spending countless hours studying for exams, writing papers and preparing for presentations. Upon completion of our Master’s degrees, our occupations took off in different directions. Lisa embarked on a career in publishing and writing for Lippincott Williams & Wilkins. I accepted a position in vaccine clinical research at Merck & Co., Inc.
My husband’s job uprooted us from Philadelphia to San Antonio, and we finally settled down in Denver, Colorado. After several years in pharmaceutical research and lots of travel, I took a risk, left industry and began working for a small start-up education company that provided medical simulation training to health care professionals. We developed interactive clinical scenarios around patient disease management. Given her clinical expertise in the MICU, I reached out to Lisa to author several sepsis case studies for us. These cases served as the basis for the critical care curriculum used to train thousands of practitioners across the country. It was wonderful to work with Lisa again and to reconnect after so many years.
Balancing family with a career became more difficult after the birth of my second son, and I decided to take some time off from work to raise my two boys. It was a wonderful four-year hiatus that I will always cherish. Toward the tail end of that break, Lisa had come to Denver to attend a nursing conference. We met for lunch, and I shared with her my desire to return to work. She remembered our conversation and called me a year later with a job offer, as her responsibilities and workload had grown tremendously. I was grateful to have the opportunity to jump back into the workforce, utilizing both my writing and clinical skills. Today, we collaborate on many nursing topics to provide educational resources to millions of nurses around the world.
It is hard to believe that it has been over 20 years since Lisa and I graduated with our bachelor degrees from Penn. I truly believe that it was fate for us to meet and reconnect after college. While we are not at the bedside full-time today, we are still contributing to the nursing profession in very meaningful and impactful ways. Nursing certainly opens up a world of opportunities, but it is up to each individual to take full advantage of them. Personally, there is no doubt that college provided me with an incredible education, but it is the friendships that I made that truly changed my life. For those of you going back to school this fall, enjoy every moment and cherish the people you meet as they may prove to be as important, if not more, that the lessons you receive in the classroom.
Myrna B. Schnur, RN, MSN
Do you have relationships with people who’ve come in and out of your life at just the right times? People who you connect with so deeply, that no matter how much time has passed, you pick up your friendship without missing a beat? That’s how I’d describe my relationship with Myrna.
In the spring of 1990, my parents and I attended an open house at the nursing school I would be attending that fall. The program consisted of separating the parents from the soon-to-be students for different sessions. When we met up again, my parents introduced me to a couple who they had become fast friends with – and who just happened to be from our same home town! It was Myrna’s mom and dad! And so it was our parents who initially introduced Myrna and I. We spent some time talking that day, amazed that we had never met before back at home. We went to different high schools, but literally lived within five miles of each other!
So we started school and became fast friends. Our nursing class was small enough that everyone got to know each other pretty well. Most of our classes were together and no other students at the university we attended had a schedule like ours as nursing students! After graduation, I remained in the Philadelphia area and Myrna had a commitment in New York City, so we were separated for several years. There was no social media at the time and we were both pretty busy starting our careers, so our contact was pretty limited.
Fast forward to 1995/1996 and Myrna moved to Philadelphia, taking a job in the same hospital I was working. She was in the Surgical ICU, I was in the Medical ICU, so our paths did cross occasionally at work, but it was that time together that really sticks with me. We were single, living in the city, meeting for dinners and hanging out together. We both returned to school and while her focus was on management and mine, women’s health, we still managed to take some of our requisite classes together --- research and statistics. You definitely need a good friend during those graduate level courses – I was so grateful for Myrna!
After we finished our degrees, over the next several years, we both settled down, got married, and started our families. I left the bedside and started working as a clinical editor. Myrna moved to Texas, and later to Colorado and explored some other non-clinical opportunities as well --- in pharmaceutical research, and, later, medical simulation.
Myrna came to Philadelphia a few years later on a work trip and we got to spend a little time together and she explained her work in simulation – I was so impressed. Shortly thereafter, she reached out to me: “
Would I like to write some cases for her?” “Of course!”
Fast forward again, now to 2012, I was attending a conference in Colorado. “
Hi Myrna – want to try to meet up?” “Yes, I’ll meet you at the airport!” It had been such a long time since we’d seen each other! So we visited briefly then and a few years later, our team at NursingCenter was looking for another clinical editor to join our team. I knew just who to call.
Last month, I had the pleasure of collaborating with Michelle Berreth RN, CRNI®, CPP, a Nurse Educator for the Infusion Nurses Society, on a podcast discussing
My Nursing Care Plan. It’s always so interesting to speak with other nurses about their career paths and to bounce ideas around together. After breaking down the components of the care plan –
Meeting My Professional Requirements,
Being a Lifelong Learner in Nursing, and
Maintaining Work-Life Balance – we brainstormed some strategies for planning and meeting personal and professional goals, talked about how difficult it is for nurses to master work-life balance, and discussed having others contribute to our care plans. That last idea of Michelle’s is my favorite and I’ll be incorporating that into my next
update of my own nursing care plan. Thanks Michelle!
Please listen in to our conversation! Have a question or something to add? Be sure to leave a comment!
Thank you!
I wanted to be a nurse for as long as I can remember. I started volunteering at a local hospital as soon as I was old enough and when college application time care around I was certain that nursing school was where I wanted to be. After a 4 year program and with my BSN under my belt, I began working as an RN in the medical intensive care unit of a university hospital.
After a few years, I decided to return to school and further my education. While I remember considering a critical care nurse practitioner program, I ultimately decided to study women’s health. It took me about 4 years to get my Master’s Degree – working weekends while attending classes and clinicals during the week. Caring for women (mostly healthy and many pregnant!) in an outpatient setting was a very different experience than caring for critically ill patients in the hospital.
The next stop in my career was as a clinical editor. I just happened to see an ad for a position in a local nursing publication, and although I wasn’t entirely sure what “clinical editor” even meant, I decided to apply for the job and find out. What a change I was in for! I was in an office setting and wearing real clothes. I spent my first 6 months in a film studio helping to produce nursing videos. If anyone had ever said that as a nurse, I could someday be writing scripts on ECGs and I.V. insertion, recruiting talent, and spending time in an edit suite, I never would have believed them!
Of course, there were bumps in this road…financing my education, reality shock, planning and managing personal and family responsibilities, just to name a few. I’ll have to save those for another post! Well – that’s my story, what’s yours?
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: March 4, 2024
Below are the results of a
nursing quiz about lung auscultation. This revealed a need for clarification of common adventitious lung sounds and the commonly associated clinical conditions.
Answer: B. Crackles are heard when collapsed or stiff alveoli snap open, as in pulmonary fibrosis. Wheezes are commonly associated with asthma and diminished breath sounds with neuromuscular disease. Breath sounds will be decreased or absent over the area of a pneumothorax
Different Types of Breath Sounds
Let’s review the most common adventitious lung sounds. Remember, breath sounds are generated by the flow of air in and out of the lungs and should be characterized by pitch, intensity, quality, and relative duration of the inspiratory and expiratory phases.
Wheeze
A
wheeze (also referred to as a sibilant wheeze) is a high-pitched continuous musical (whistle-like) sound, which may occur during inspiration and/or expiration, due to a narrowed or obstructed airway. A longer, higher-pitched wheeze is associated with a higher degree of obstruction. Wheezes are most often heard with bronchospasm in acute asthma exacerbations or flair-ups of acute or chronic bronchitis.
Rhonchi
Alternately, what we often refer to as
rhonchi is the “sonorous wheeze,” which refers to a deep, low-pitched rumbling or coarse breath sound as air moves through tracheal-bronchial passages in the presence of mucous or respiratory secretions. They are often more pronounced during expiration and are more likely to be prolonged, continuous, and less discrete than crackles. Rhonchi will sometimes be cleared by cough.
Stridor
Stridor is a high-pitched, monophonic inspiratory sound typically loudest over the anterior neck as air moves turbulently over a narrowing in the upper airway. The presence of stridor indicates upper airway spasm or partial obstruction and may be present in infection, upper airway abscess, foreign body ingestion, or certain congenital anomalies.
Crackles
Crackles, or
rales, are short, high-pitched, discrete, discontinuous, popping sounds created by air being forced through an airway or alveoli narrowed by fluid, pus, or mucous. These breath sounds may also be heard when there is a delayed opening of collapsed alveoli. Crackles are not cleared by coughing.
Crackles are typically heard during inspiration and can be further defined as coarse or fine.
Coarse crackles are lower-pitched, heard during early inspiration, and sound harsh, loud, or moist. They are caused by mucous in larger bronchioles, as heard in COPD.
Fine crackles are higher-pitched, heard during late inspiration, and may sound like hair rubbing together. These sounds originate in the small airways/alveoli and may be heard in interstitial pneumonia or pulmonary fibrosis.
Lung Sounds and Clinical Conditions
Now, let’s think about test-taking strategies. In this instance, it would be helpful to go through each clinical condition separately and predict what you may hear on auscultation.
Asthma
Asthma is a condition mediated by inflammation. The resulting physiologic response in the airways is bronchoconstriction and airway edema. This response is triggered by an irritant, allergen, or infection. As air moves through these narrowed airways, the primary lung sound is high-pitched wheezing. Initially the wheezes are expiratory but depending on confounding factors or worsening clinical symptoms, there may be inspiratory wheezes, rhonchi, or crackles. For testing purposes, however, expiratory wheezes are associated with asthma.
Pulmonary Fibrosis
Pulmonary fibrosis is a form of interstitial lung disease in which scarring (or fibrosis) is the hallmark clinical feature. This scarring leads to thickness and stiffness in the lungs. The most common adventitious breath sound associated with pulmonary fibrosis is fine bibasilar (lower lobes of both lungs) crackles. This may be hard to distinguish from congestive heart failure. The crackles are the result of the snapping open of collapsed, stiff alveoli.
Neuromuscular Disease
Neuromuscular disorders can cause respiratory problems through several mechanisms as the muscles responsible for breathing are affected. Diaphragmatic weakness can lead to hypoventilation; chest wall muscle weakness can lead to ineffective cough; and upper airway muscle weakness can lead to difficult swallowing and ineffective clearing of upper airway secretions. In general, there are no specific adventitious breath sounds associated with neuromuscular disorders.
Pneumothorax
A pneumothorax is a collapsed lung. There would be loss of breath sounds over the area of a pneumothorax as there is no air movement in the area of auscultation.
So, this leads us to the correct answer. During lung auscultation, crackles are heard in pulmonary fibrosis, which is choice B.
Reviewing what you know and thinking about each response choice can help you focus in on the correct answer. Do you have an easy acronym or pearl for remembering breath sounds, or some test-taking strategies to share?
Breath Sounds References:
Hinkle, J.,Cheever, K., & Overbaugh, K. (2021). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th edition. Philadelphia: Wolters Kluwer Health.
Stewart, J.B.J.D.J.F.B.S. R. ([Insert Year of Publication]). Seidel's Guide to Physical Examination (10th ed.). Elsevier Health Sciences (US).
The fall edition of the National Conference for Nurse Practitioners took place earlier this month in Chicago. It was yet another remarkable conference in a great city. Here’s a look at some highlights from the conference and what I learned.
Words from the Experts
My schedule was full with sessions related to dermatology, pain management, critical care, and more! Here are some of the pearls and tips I learned from the sessions I attended:
“Engage patients. Say ‘What matters to you?’ rather than ‘What is the matter with you?’”
Healing Health Care: The Nurse Practitioner Solution
Tom Bartol, NP, CDE
“The two most powerful tips to prevent premature aging are never smoke and limit UV exposure.”
Identifying and Treating Common and Benign Skin Conditions
Victor Czerkasij, MA, MS, FNP-BC
“Respiratory failure is all about three things. It’s all about the pump. It’s all about the circulation. It’s all about gas exchange.”
Acute Care: Recognizing and Managing Respiratory Failure
Anne Dabrow Woods, DNP, MSN, RN, CRNP, ANP-BC
“Things will speak through the skin that have nothing at all to do with the skin.”
Pediatric & Adolescent Skin Issues
Victor Czerkasij, MA, MS, FNP-BC
“When initiating opioid therapy, have an exit strategy from the very beginning.”
Opioid Prescribing: Safe Practice, Changing Lives
Barbara St. Marie, PhD
“Suboptimal nutrition is a main contributor to postoperative complications.”
Optimizing Outcomes with Pre-Op Evaluation
Monica N. Tombasco, MS, MSNA, FNP-BC, CRNA
“There is a strong placebo effect in treatment of IBS. Why? Because symptoms come and go.”
New Concepts in IBS
Christopher Chang, MD, PhD
“When evaluating pain treatment, go beyond the number...ask about functionality. ‘What can you do now that you couldn't do before?’”
Chronic Pain Management
Yvonne D’Arcy, MS, CRNP, CNS
“The outcome of heart failure is about as severe as most malignancies.”
Comprehensive Management of Heart Failure
Louis Kuritzky, MD
“Zika Virus – why now? It's a novel virus introduced to a population with virtually no immunity."
Emerging Infectious Disease Threats: Dengue Fever, Chikungunya, Enterovirus D65, Avian Flu, and Zika Virus
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC
New (to me) Resources
I enjoy when presenters include websites and tools that I can add to my own list of go-to resources. Here are some that I’ve added to my favorites: style type="text/css">ul{margin-left:16px;}
- Recreating Healthcare — an open and interactive site where visitors can share ideas about health care, and read and comment on the ideas of others.
- TheNNT — quick summaries of evidence-based medicine provided by a group of physicians.
- The Collaborative for REMS Education (CO*RE) — tools and resources for safe opioid prescribing.
- Trauma.org — image databank and other resources for professionals in trauma and critical care.
Posters
Poster presentations often pull me in because it’s great to see the work that others are doing. It’s so important to share and learn from one another and presenting one’s work at a national conference, such as NCNP, is impressive! While all of the posters were well done and informative, what struck me were two common themes that emerged; there were multiple posters related to pediatric care and still more about shared medical appointments. You can take a look at a selection of the posters (as well as other pictures from the conference) here in our
Facebook photo album.
Technology and sharing
As an attendee myself, I found the conference app helpful to keep track of my sessions and fill out evaluations as part of the process for obtaining my continuing education credit. Other features allowed me to learn about exhibitors and even vote on the poster presentations.
Social media was strong at the conference with attendees, conference staff, and exhibitors using the hashtag, #NCNPconf. Attendees shared what they learned and even posted photos of themselves in our selfie booth! Exhibitors also tweeted and shared information about their products and contest winners.
Stay tuned for details for NCNP 2017 (#NCNPconf) next spring in Nashville, Tennessee!
Hope to see you there!
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.
Traumatic 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 that
2:
- Realizes the widespread impact of trauma and understands potential paths for recovery.
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
- Seeks to actively resist retraumatization.
The six key principles of trauma-informed care include
2:
- Safety – make sure your patient and family members feel safe, both physically and psychologically.
- Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
- Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
- Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
- 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.
- 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:
- Ask every patient what can be done to make them more comfortable during their appointment.
- Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
- Give the patient the option to shift their clothing out of the way instead of putting on a gown.
- Provide a pillow for back support for patients who are anxious in the supine position.
- Offer a mirror to see procedures or examinations that a patient cannot see.
- 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:
- Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
- Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.
3. Multidisciplinary collaboration:
- Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
- Keep referral and educational material on trauma available in waiting rooms.
- Engage in inter-professional collaboration to ensure continuity of care.
4. Understanding your own history and reactions:
- Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
- Learn the signs of professional burnout and prioritize good self-care.
5. Screening:
- Decide if your organization will screen for current trauma or a history of traumatic events.
- Consider if screenings will be face-to-face or self-reported by the patient.
- Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
- 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
References:
-
-
This week has demonstrated that the political climate in the United States is not fixed in a stationary position but, is dynamic. Many of you will be asking yourselves what does this mean for healthcare reform, the Affordable Care Act, and for nurses and advanced practice nurses (APNs) in the United States. The bottom line is we just don't know. However, one thing we are sure of is, healthcare needs to be reformed and we must be present at the table when options are being discussed.
So, what can you do?
First, you need to understand your scope of practice and if you live in a state with restricted practice, you need to continue to lobby your congressmen and senators about the value nurses and APNs bring to patients and healthcare delivery.
Secondly, be the voice of reason. There are many things about the Affordable Care Act that have improved access to care and quality of care; we must be able to articulate why those things are important and why they need to stay from a cost-benefit and cost-effectiveness perspective.
Thirdly, educate our healthcare colleagues and healthcare consumers about who we are as a profession and why having a nurse and an APN as part of the healthcare team improves quality, patient-centered care.
And finally, remember our history and the great strides we have made as a profession. The profession of nursing is growing and changing based on the needs of those we serve. We are all Americans and our goal is to improve patient care and outcomes regardless of who is in power.
In conclusion; step up, have a voice, be able to articulate the message, and speak from a position of knowing what you do in practice does make a difference.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Health Learning, Research & Practice
Posted:
11/11/2016 9:03:04 AM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
1 comments
Categories: Inspiration
Last year, during the holiday season, we shared
Three inspirational gifts for nurses. This year, we’ve got some more gift ideas to share with you! Explore the products below and consider which nurse you’d like to surprise this year with a special gift. You may even want to pick up one of these for yourself, or leave some hints for your family and friends!
Offering life- and career-changing moments in nurses’ lives, the 80 true stories in
Reflections on Nursing, from the
American Journal of Nursing, reveal nursing at its most demanding and fulfilling. These inspiring, true stories—written by nurses in numerous care settings—show nursing as both professional and life experience, and often, as an inspired journey. Here’s a look at some of the stories that caught my eye: In the Hand of Dad:
Preemie's struggle becomes one nurse's journey with a father; At Her Mercy:
A nursing instructor finds herself in the hands of a challenging former student; and Nurse, Heal Thyself:
Walking in the patient's shoes.
I picked up my copy of the
Inspired Nurses Calendar earlier this month and have already put it to use! This is the gift that keeps on giving all year! Each month showcases a different story from a nurse that demonstrates our hard work and dedication. You will be reminded daily of what it means to be a nurse. By reading these stories, such as that of a NICU mom who went on to become a NICU nurse or a church missionary nurse now pursuing her DNP, you’re sure to be reminded of your own journey in nursing and your past experiences, and probably ponder, as I do, what the future holds.
Based on the same content used by hospitals and brought to you by the most trusted source in nursing, the
Lippincott Advisor app is an expanding collection of over 2,000 evidence-based, clinical decision support entries on diseases, treatments, signs and symptoms, and diagnostic tests that are updated quarterly. You can take all that you learned in school with you and be able to make clinical decisions at the bedside – safely and confidently.
Have a wonderful holiday season!
Posted:
11/21/2016 8:43:54 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
1 comments
Categories: Inspiration
Nurse leaders + Las Vegas + a Presidential election = a busy conference week! Whew…it certainly was an eventful week as nurse leaders from around the world got together in Las Vegas for Nursing Management Congress 2016!
Preconference workshops
For two days, preconference workshops were in action. The
New Manager Intensive provided fundamentals for success for those new to the role, including calculations – staffing, supplies, and equipment – to effectively and safely run a unit. In addition, new managers brushed up on relationship and communication skills, as well as handling the pressures of leadership through a period of health care reform. The
Experienced Nurse Leader Intensive covered topics related to the business of health care, such as aligning with organizational goals, team development, and improving performance. Other sessions during these two days included a
Certification Prep Course, Creating a World-Class Culture, and
Improving the Patient Experience.
An opening session to remember
This was my first real exposure to Zubin Damania, MD, aka
ZDoggMD, and I am now a big fan! His humor, talent, and passion for improving the patient experience were inspiring. He encouraged us to “reshuffle our deck” and embrace a new era of health care – Health 3.0 – re-personalized medicine with a focus on building relationships. Here’s a brief video clip from his keynote address:
You can find ZDoggMD on
YouTube, Facebook, and
twitter. His “membership-based primary care and wellness ecosystem”,
Turntable Health, is truly breaking down barriers.
So much learning
While I’ve never held a role in nursing management, the knowledge and advice from the experts at NMC are beneficial to all nurses. Here are some of the pearls and tips I learned:
“To be a successful leader, you must be flexible and move quickly in decision making.’”
Opening Session
Jeffrey Doucette, DNP, RN, FACHE, CENP, LNHA
“Until you change people’s minds about their work habits, they’re not going to change their work habits.”
Changing the Culture of Fatigue: A Nurse AND Patient Safety Problem
Mary Lawson Carney, DNP, RN-BC, CCRN, CNE
“Understanding quality across the continuum will lead to improved outcomes across the continuum.”
Reducing Readmissions Across the Care Continuum
Leonard L. Parisi, RN, MA, CPHG, FNAHQ
“Nurses should prepare for the future by keeping their eyes on how nursing care helps patients become and stay healthy and allows the health care system to work smoothly.”
Nursing Workforce Predictions: What’s Really Happening?
Sean Clarke, PhD, RN, FAAN
“It’s the simple solutions that get us where we need to be.”
Getting the Most from People Around You
Andrea Mazzoccoli, MSN, MBA, PhD, FAAN
“The curse of knowledge…We forget what it was like to not know what we know now.”
Talkin’ Bout My Generation: Generations in the Workplace should be Your GREATEST Strength, Not Your Biggest Headache!
Libby Spears
As next year’s planning gets underway, we invite you to look at our
2016 NMC photo album, see
social media highlights, and
submit an abstract!
See you next year!
#NMCongress
Reviewed and updated by Lisa Bonsall, MSN, RN, CRNP, CCRN: February 13, 2024
Mastering hemodynamics can be tricky, but the first step is understanding the terminology. Let’s look at cardiac output and cardiac index – how to calculate them and why they’re important.
Cardiac Output Formula
Cardiac output (CO) is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate.
Stroke volume is determined by
preload, contractility, and
afterload. The normal range for cardiac output is about 4 to 8 L/min, but it can vary depending on the body’s metabolic needs. Cardiac output is important because it predicts oxygen delivery to cells.
How to calculate the cardiac output
If a patient's stroke volume is 75 mL with each contraction and his heart rate is 60 beats/minute, his cardiac output is 4,500 mL/minute (or 4.5 L/minute).
Cardiac Index Calculator
The
cardiac index (CI) is an assessment of the cardiac output value based on the patient’s size. To find the cardiac index, divide the cardiac output by the person’s body surface area (BSA). The normal range for CI is 2.5 to 4 L/min/m
2.
How to calculate the cardiac index
If a patient’s cardiac output is 4.5 L/minute and his BSA is 1.25 m
2, his CI would be 3.6 L/min/m
2. If another patient has a cardiac output of 4.5 L/minute, but he has a BSA of 2.5 m
2, his CI would be 1.8 L/min/m
2.
Both cardiac output and cardiac index are important to let us know if a patient’s heart is pumping enough blood and delivering enough oxygen to cells. We also use CO and CI values to manage certain drug therapy, such as inotropics and vasopressors.
Cardiac Output and Cardiac Index References
Hinkle, J., & Cheever, K. (2021). Brunner & Suddarth's Textbook of Medical-Surgical Nursing, Fifteenth edition. Philadelphia: Wolters Kluwer.
King, J., & Lowery, D. R. (2023). Physiology, Cardiac Output. In StatPearls. StatPearls Publishing.
Warise L. (2015). Understanding cardiogenic shock: a nursing approach to improve outcomes. Dimensions of critical care nursing : DCCN, 34(2), 67–78. https://doi.org/10.1097/DCC.0000000000000095
Happy New Year! Here’s the list of nursing recognition days, weeks, and months for 2017*.
Know of others? Please leave a comment or email
[email protected].
Thank you!
*Dates and links will be updated as they become available.
January
February
March
April
May
June
September
October
November
Let us know how you will celebrate or what plans you have to recognize your colleagues. Leave a comment or email us at
[email protected].
Have a great year!
It’s hard to believe that it’s been a year since we began developing
My Nursing Care Plan! It has been such a fun project for me, as well as a learning experience. Thinking about and organizing the content was challenging, even though, as a nurse myself, I know what my requirements are, what I need to do to stay up-to-date in nursing, and what I
should be doing to balance work and life! The difficulty was putting it down in words and figuring out
how to try and juggle it all. Creating the companion
video and
infographics was something new for me too – but I do love learning new things, especially when it comes to technology – so it was quite a treat to be involved in those projects. Lastly, having a
conversation with Michelle Berreth RN, CRNI®, CPP, a nurse educator for the Infusion Nurses Society (INS), was quite eye-opening and inspiring, but more on that later…
So, what’s happened since my
Mid-Year Update? Not too much…here’s a quick recap and a look ahead to 2017:
- Since I renewed my licenses in 2016, I’m not due for renewal until 2018. I’m proud to say that I’ve already logged in 12 contact hours toward my 30-hour requirement for license renewal for my RN license. I do need, however, to step up my contact hours related to women’s health to meet my 45-hour requirement for my NP license! My goal is to complete 35 contact hours related to women’s health by 12/31/17.
- I’ve decided that before returning to school, I’d like to get back to the bedside. What I really need to think about is “what does that mean?” Do I want to work as a staff nurse or nurse practitioner? In critical care or women’s health? My heart is leaning toward acute care, but I’m also considering inpatient hospice.
- Regardless of what clinical path I decide to take, I’d like to get certified. Something new I discovered last year were ‘-K’ or ‘knowledge’ certifications, specifically for nurses or NPs who don’t provide direct care, but do influence patient care. I will definitely be looking a little closer at this opportunity.
- Work-life balance continues to be a struggle, just as I’m sure it is for many of you. My cough is now under control, and the focus now turns to eating and sleeping right, and exercising more. I’m due for my annual gynecologic exam and mammogram, so I’ll be scheduling those ASAP.
Now, back to my conversation with Michelle from INS. During our discussion, we came up with some insights to consider when using My Nursing Care Plan that I think are important to share.
- Consider asking others – colleagues, family, friends – to contribute to your own care plan.
- Waiting for the right time to get things done isn’t realistic. When is the right time? If you wait for it, it may never come.
- Assess if multitasking really is in your best interest. Remember that it doesn’t work for everyone and it’s okay to do one thing at a time.
- Be present. Whether at work or in your personal life, focus on the task at hand – whether it’s a true task or a personal or professional interaction.
- Evaluate your care plan monthly, preferably about one week before month’s end. See what’s left to do and take a glance at plans for the next month. You can even set a reminder to do this on your phone or email.
What’s your update from the past year? Any goals for 2017 you’d care to share?
More Reading & Resources
You know who I’m talking about, right? Don’t we all know a nurse who seems to hit a vein every. single. time? I think every unit has the go-to nurse when there is a “tough stick” in need of I.V. access. Actually, a few nurses come to mind when I think back to my days in the unit. Back then, we just ‘knew’ who the experts were. Maybe it was (or is) you!
Now, infusion nurses are getting the recognition they deserve. Every year on January 25
th, we celebrate
I.V. Nurse Day to recognize our colleagues who provide specialty care to those patients requiring the expertise of an infusion nurse. Infusion nurses have a special knowledge and skillset, and from acute care settings to home care, and among most specialties, having an infusion nurse as part of your team is important.
Happy I.V. Nurse Day!
We are all leaders, no matter where we work, the patient populations that we care for, or our role in nursing. As nurses, we lead every day – some of us at the bedside or in the clinic, some of us in the classroom, some of us in patients’ homes, some of us in the boardroom – there are too many places to list! Hopefully, you already realize that you are a leader every day, but if you do need a little convincing, through the course of this year we’ll make it clear to you.
So how are you a leader? Ask yourself the following questions…
1. Are you an expert? Think of the things that your colleagues come to you for repeatedly. Maybe it’s a question about a certain diagnosis or patient population. Perhaps you’re the go-to person for placing I.V.s when there is a patient who is a difficult stick.
2. Are you an educator? Do you teach students? Do you ever precept new or new-to-your-unit nurses? Do you teach colleagues from other disciplines about the unit where you work? What about patient education? (We all do this one!)
3. Are you an advocate? Do you speak up for your patients and their families? How about for yourself? Your colleagues? The nursing profession?
4. Are you a role model? Do you take on the charge nurse role? Are you a team player? Are you a nurse that others strive to be like? Do you model healthy behaviors for patients and the public?
5. Are you a voice for our profession? Are you educated about the global issues affecting nursing and health care? Are you a committee member at your institution? Are you a member of a professional nursing organization? Are you involved in local, state, or national boards?
6. Are you a nurse? We know we are trusted by the public – in fact,
we’ve been voted the most trusted of all professions for the past 15 years in a row! How often do family members and friends come to you with a health-related question or advice? The title ‘nurse’ signifies leadership to those around us.
If you answered yes to any of the above, then you are a leader!
Today is the first day of
National Nutrition Month! We have several journals dedicated to the topic of nutrition, plus a vast amount of related content from this blog and our other nursing journals. We are happy to share these selections with you here – enjoy!
General nutrition
Nutrition related to specific disorders
Nutritional concerns in pregnancy
Athletes
Older adults
If nutrition is a topic you are passionate about, please
Consider Writing an Article for Nutrition Today. Thank you!
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: March 4, 2024
Sepsis and septic shock are serious life-threatening responses to an infection that impacts millions of patients worldwide. Early identification and management of these conditions improves outcomes. Patients with sepsis can present in a variety of ways making it very difficult to diagnose. There are multiple tools supported by experts in the management of sepsis that clinicians can utilize to screen patients for sepsis including the Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA), systemic inflammatory response syndrome (SIRS) criteria, National Early Warning Score (NEWS), or Modified Early Warning Score (MEWS) (Evans at al., 2021). These tools require a combination of physiologic and laboratory variables to screen for the presence of sepsis.
Use this infographic as a reference guide for lab results that you need to screen patients for sepsis.
References:
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Critical care medicine, 49(11), e1063–e1143. https://doi.org/10.1097/CCM.0000000000005337
Nehring S.M., Goyal A., & Patel B.C. C Reactive Protein. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441843/
Neviere, R. (2023, September 15). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. UpToDate. https://www.uptodate.com/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis
Ostermann, M., & Joannidis, M. (2016). Acute kidney injury 2016: diagnosis and diagnostic workup. Critical care (London, England), 20(1), 299. https://doi.org/10.1186/s13054-016-1478-z
Samsudin, I., & Vasikaran, S. D. (2017). Clinical Utility and Measurement of Procalcitonin. The Clinical biochemist. Reviews, 38(2), 59–68.
It’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.
As nurses working at the bedside, most of us are familiar with the common lab test, lactate. We know that when cells become hypoxic, lactate levels increase. While working in the intensive care unit, checking a lactate level was routine. Unfortunately, an elevated lactate level is typically a bad sign for the patient, often related to increased organ dysfunction and mortality. In recent years, the blood lactate level has gained wide acceptance as an important marker in the diagnosis of sepsis and septic shock and is useful in evaluating response to fluid resuscitation. An elevated lactate is not only a marker for sepsis and septic shock – it may signal other important clinical conditions as well. So, what is lactate and what exactly does it tell us?
You may also want to review the following resource...
Lactate is an organic molecule produced by most tissues in the human body, with the highest production found in muscle.
1 The body normally produces energy by way of aerobic metabolism, which requires oxygen to break down carbohydrates, amino acids, and fats. Via glycolysis, glucose is converted into pyruvate, which enters the Krebs cycle to produce oxygen and adenosine triphosphate (ATP) or energy. If oxygen isn’t available to body cells, anaerobic metabolism kicks in to produce energy. In this pathway, pyruvate is metabolized by the enzyme lactate dehydrogenase (LDH) into lactate.
2 Lactate leaves the cells, enters the bloodstream, and transports to the liver, where it is oxidized back to pyruvate and then converted to glucose via the Cori cycle.
1,2 Lactate is cleared from the blood, primarily by the liver and, to a lesser extent, by the kidneys and skeletal muscles.
2
Normal and Elevated Lactate Levels
A normal blood lactate level is 0.5-1 mmol/L. Hyperlactatemia is defined as a persistent, mild to moderately elevated (2-4 mmol/L) lactate level without metabolic acidosis.
2 This can occur with adequate tissue perfusion and tissue oxygenation. A level > 4 mmol/L defines lactic acidosis
3, a level high enough to tip the acid-base balance, which may result in a serum pH < 7.35 in association with metabolic acidosis. Lactate can be measured from both venous and arterial blood. Serum samples should be processed within 15 minutes to avoid falsely elevated results. If processing cannot occur within this time frame, the sample should be kept on ice.
Hyperlactatemia and lactic acidosis may occur with an increase in lactate production, a decrease in lactate clearance, or a combination of both.
3 An increase in lactate production is typically caused by impaired tissue oxygenation, either from decreased oxygen delivery or a disorder in oxygen use, both of which lead to increased anaerobic metabolism.
3 Most causes of lactic acidosis are due to significant, systemic tissue hypoperfusion, referred to as type A lactic acidosis. Alternately, in Type B lactic acidosis, the etiology may be related to toxic-induced impairment of cellular metabolism, local hypoperfusion (i.e. regional ischemia) or in many instances, the mechanism is unknown.
Causes of Elevated Lactate
Below are some common causes of lactic acidosis:
Type A:
- Sepsis and septic shock: dysfunction in the microcirculation (where oxygen is exchanged) leads to lactate production, while decreased oxygen delivery contributes to a decrease in lactate clearance.3
- Cardiogenic, obstructive and hemorrhagic shock: may cause decreased oxygen delivery and hypoperfusion.
- Cardiac arrest: ischemia and inflammation following cardiac arrest may cause an increase in lactate.
- Severe lung disease, respiratory failure or pulmonary edema: excessive work of breathing causes anaerobic muscle activity.
- Trauma: hypoperfusion due to blood loss is common in trauma patients and may lead to elevated lactate levels.
Type B:
- Seizures: depending on the type, seizures can produce a significant increase in lactate, but the effect is short-term; once the seizure has resolved, lactate levels typically return to baseline.
- Excessive muscle activity: lactate increases with strenuous exercise due to anaerobic metabolism and may be seen in rhabdomyolysis.
- Regional ischemia: mesenteric ischemia, bacterial peritonitis, acute pancreatitis, extremity compartment syndrome, gangrene and other types of soft tissue infections may elevate lactate.
- Burns and smoke inhalation: smoke inhalation victims are at risk of elevated lactate due to potential inhalation of cyanide and/or carbon monoxide.
- Diabetic ketoacidosis (DKA): due to a change in metabolism; elevated lactate in DKA is not necessarily associated with worse outcomes.
- Thiamine deficiency: low thiamine levels result in anaerobic metabolism and increased lactate production; risk factors for thiamine deficiency include poor nutrition, chronic liver disease, alcoholism, hyperemesis gravidarum, anorexia nervosa, and gastric bypass surgery.
- Malignancy: tumors may cause production of glycolytic enzymes, impaired liver clearance and malnutrition leading to thiamine deficiency.
- Liver dysfunction: the liver is the primary organ responsible for lactate clearance; injury or failure results in decreased lactate clearance.
- Genetic: inborn disorders of metabolism, particularly in the pediatric population, may cause elevated lactate levels.
- Drugs and Toxins that may cause increased lactate:
- Metformin (biguanide)
- Acetaminophen
- (Nucleoside reverse transcriptase inhibitors (NRTI)
- Linezolid
- Beta-2 agonists
- Propofol
- Epinephrine
- Theophylline
- Alcohols (ethanol, propylene glycol and methanol)
- Cocaine
- Carbon monoxide
- Cyanide
Treatment of Elevated Lactate Levels
Treatment of elevated lactate levels should be determined by the underlying cause. If hypoperfusion or hypoxemia is the culprit, focus on improving perfusion to the affected tissues. In shock, treatments include fluid administration, vasopressors, or inotropes. In regional ischemia, surgery may be needed to restore circulation or remove damaged tissue.
1 If drugs, seizures, malignancy, or thiamine deficiency is the cause, stop, reverse, and treat the offending agent.
1 Multiple conditions can contribute to lactic acidosis; therefore it is critical to carefully evaluate the patient’s complete medical history, conduct a thorough physical assessment, and assess other laboratory or diagnostic tests before beginning treatment.
Elevated Lactate References
1. Anderson, L.W., Mackenhauer, J., Roberts, J.C., Berg, K.M., Cocchi, M.N., and Donnino M.W. (2013, October). Etiology and therapeutic approach to elevated lactate. Mayo Clinic Proceedings, 88(10), 1127- 1140.
GI Nurses & Associates Week is March 20-24, 2017!
We wish those of you in this specialty a wonderful week, and we thank you for compassion and dedication. Please enjoy the content below, specially selected to help you in your practice.
For those of us in other specialties, GI disorders can be challenging. Please explore, and share, the content in this collection with your colleagues!
Colorectal Cancer
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Clostridium difficile
Pancreatitis
Have a great week!
Graduating from nursing school and passing your NCLEX boards is a great accomplishment and one to be very proud of, congratulations! Now you face the next step – applying and interviewing for a nursing job. This can be both exciting and stressful at the same time.
Choosing a job that has a good orientation program, however, can help lessen this stress for you. There are a few different types of orientation programs that a health care facility may offer. Understanding the different types can assist you when interviewing. Many of the terms used to describe orientation programs will vary depending on the health care facility. For instance, the health care facility may use the term preceptor program, mentor program, residency program, or nursing orientation. Most times the health care facility will include many of the same components necessary to orient you to your new role in the health care facility. It will be important for you, however, to find out what does the specific term mean to the institution you are applying to. Below, you will find the common meaning behind these terms in a typical acute care hospital setting.
Nursing Orientation
Most hospital-based nursing orientation programs will include a general orientation in the classroom followed by an orientation on the unit you were hired to work on. The classroom will include education from each department in the hospital, as well as education on the use of the electronic medical record (EMR). The classroom orientation can vary from a few days to a few weeks depending on the health care facility. Once the majority of classroom orientation is complete, you will orient with an assigned preceptor or mentor on the unit you were hired to work on. A
preceptor or
mentor is a registered nurse, preferably with a BSN degree, who has been working at the institution for at least two years. The unit orientation can vary in length of time depending on the health care institution. You generally will be on orientation following your preceptor/mentor’s schedule for about three to six months. If you were hired to work in a critical care area, your orientation will most likely be longer and even up to one year depending on the facility.
Many facilities are finding it challenging to recruit experienced competent nurses to work in critical care and specialty areas, such as the Emergency Department (ED) and Operating Room (OR). To meet this challenge, many hospitals started residency programs for new nursing graduates. The
residency program generally requires the newly hired nurse to attend the general nursing orientation, as well education classes on specific skills you will need to work in your area. For example, if you are hired to work in the ED or the OR, you will need education and skill competency on ECGs and Advanced Cardiac Life Support (ACLS), as well as education on other skills needed for working in that specific area. Once the classroom training is completed and skill competency is verified you will orient in that area for a year, possibly longer depending on the facility and your learning needs.
Many new nurses ask what if I do not feel ready to come off orientation? This is a good question; most health care facilities will extend your orientation a month to a few months depending on your learning needs.
Interview questions
No matter what term the facility uses to describe their nursing orientation program there are some general questions you may want to ask when interviewing for the job. The questions include:
- What type of nursing orientation program do you offer?
- What type of education classes will I be taking?
- How long will I be in orientation?
- What support is available to me during and after my orientation?
- Will there be one or many preceptors/mentors assigned to me during my orientation?
- Can you provide a sample of what the orientation schedule may look like?
It is important to remember that the health care facility wants to make your orientation a successful one. A successful orientation program helps ensure your competency caring for patients and improves both nurse recruitment and retention at the facility. You are now ready to begin the interview process, and always keep in mind why you were called to the wonderful world of nursing. Blessings :)
Maureen Kroning RN MSN EdD
Nyack College School of Nursing
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: March 12, 2024
As the influenza season begins to subside, we can take a step back and reflect on best practices. Isolation guidelines in the healthcare 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, that we take proper precautions to prevent the spread of influenza healthcare settings which include acute-care hospitals, long-term care facilities, outpatient offices, and home healthcare settings.
Influenza is transmitted from person to person through large particle respiratory droplets which can travel up to six feet through the air. Transmission may also occur indirectly via hand contact of infectious particles on contaminated surfaces or objects to mucosal surfaces of the nose or mouth. Interestingly, all respiratory secretions and bodily fluids including stool of patients with influenza are consider potentially infectious. In the healthcare setting, adherence to both standard and droplet precautions are necessary in patients with confirmed or suspected influenza. According to the CDC, droplet precautions should remain in place for seven days after illness onset or until 24 hours after resolution of fever and respiratory symptoms. Some healthcare facilities may have a specific policy requiring a longer duration of adherence to droplet precautions. As a general rule, visitors of patients in isolation for influenza should be limited and should be screened for symptoms of respiratory illness, be provided proper personal protective equipment according to the facility policy, and should not be present during aerosol-generating procedures. Finally, most healthcare settings endorse the posting of appropriate signage outside patient rooms identifying the level of transmission-based precautions that are in place with basic instructions on how to adhere to the 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.
References:
Centers for Disease Control and Prevention (CDC), National Center for Immunization and Respiratory Diseases, (2021, May 13). Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm#
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. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: March 12, 2024
As a follow-up to our
previous post on isolation guidelines, here is a list of transmission-based precautions recommended for common pathogens. Standard precautions should be adhered to for all patients in addition to pathogen-specific precautions.
References:
Centers for Disease Control (CDC), National Center for Immunization and Respiratory Diseases, (2021, May 13). Prevention Strategies for Seasonal Influenza in Healthcare Settings: Guidelines and Recommendations. https://www.cdc.gov/flu/professionals/infectioncontrol/healthcaresettings.htm#
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. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Nulens, E. (2018). Isolation of communicable diseases. In Bearman, G (Ed.) Guide to Infection Control in the Healthcare Setting. International Society for Infectious Diseases. https://isid.org/wp-content/uploads/2019/06/ISID_GUIDE_ISOLATION_OF_COMMUNICABLE_DISEASES.pdf
I must admit, when discussions about nurses on boards transpired here in our office, I wasn’t exactly sure what that meant. Nurses provide patient care – it’s what we study, it’s the work we do, and for many, it’s our passion. When I heard the term “nurses on boards,” I immediately thought of managers and administrators. Serving on a board wasn’t something for all nurses to consider, or was it?
A little history
According to the 2014 American Hospital Association governance data,
nurses hold only 5% of board seats in health-related organizations and corporations. Shouldn’t we be involved in the decisions that affect our health care system, our organizations, our profession, our patients, and ourselves? One of the key messages of
The Future of Nursing: Leading Change, Advancing Health report is “Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.” As a result of our minimal representation on governing boards and the Future of Nursing report recommendations, the
Future of Nursing: Campaign for Action set a goal to get an additional 10,000 nurses on governing boards by 2020.
Why nurses need to “get on board”
Earlier this month, Susan Reinhard, RN, PhD, FAAN, chief strategist for the Center to Champion Nursing in America and senior vice president and director of AARP’s Public Policy Institute wrote an excellent piece,
Getting nurses on board, for
Trustee magazine. In her article, Reinhard addresses the gender gap and other barriers to nurses serving on boards. She also shares her path to the boardroom and the real life stories of other nurses serving on boards and how their service made an impact. For example:
“The late Connie Curran, R.N., told the story of listening as her 100-bed community hospital proposed saving money by eliminating weekend hours at its in-house pharmacy. Medication orders could be filled Friday evenings, the thinking went. The other board members, she noted, were not being negligent. But she was the only person whose experience working nights and weekends led to a few unasked questions, such as, ‘What about newly admitted patients?’ The pharmacy stayed open.”
Can you imagine working where the hospital pharmacy is closed on the weekends? This is exactly why nurses are instrumental to serving on committees, commissions, and boards where health care decisions are made. This example illustrates our unique experience and the need for us to be present where decisions are being made at the organizational level and beyond.
Overcoming barriers
As nurses, we know about overcoming barriers. We face obstacles in our day-to-day practice that force us to speak up and advocate for those in our care. In 2009, Prybil identified three barriers to nurses serving on boards:
- Gender – 90% of RNs in the U.S. are women and women are underrepresented on boards
- Belief that nurses aren’t able to weigh in on safety and quality issues
- Potential conflict of interest related to placing an employee in a voting capacity
How can we remove barriers and foster collaboration? Let’s focus on what we know about ourselves and our profession. First, nurses represent the largest segment of the health care workforce; there are 3.6 million of us in the United States. We are a female-dominated profession, and that should not affect our representation among the decision makers. We need to work hard to have our voices heard, and remember that we are skilled communicators and problem-solvers.
We also know the issues, especially when it comes to safety and quality care. We face these issues every day. We use the nursing process repeatedly in the clinical setting to assess, diagnose, plan, implement, and evaluate. This framework can be applied for strategically tackling any hospital-wide, local, national, or global issue. Nurses are knowledgeable and skilled and need to have a “seat at the table.”
Additionally, people trust us – that’s been
proven time and again. We are on the frontlines, not only in the hospitals, clinics, and offices, but also in schools, the community, and so many other settings. And remember,
we are all leaders, no matter the setting or role of our work.
The Nurses on Boards Coalition (NOBC)
The Nurses on Boards Coalition was developed to help ensure that the goal of at least 10,000 nurses are on boards by 2020 is reached. It’s a national partnership of organizations committed to this endeavor.
“Our goal is to improve the health of communities and the nation through the service of nurses on boards and other bodies. All boards benefit from the unique perspective of nurses to achieve the goals of improved health and efficient and effective health care systems at the local, state, and national levels.”
Visit the
NOBC website to be counted if you already serve on a board, or to learn more about this initiative and board membership.
Wolters Kluwer is proud to be a Healthcare Leadership Organization Strategic Partner of the NOBC.
Improving health and wellness of U.S. citizens by placing more nurse leaders on boards
Watch this
video of Chief Nurse, Dr. Anne Dabrow Woods, to learn about improving care of communities so we can improve care and outcomes for individuals. Nurses must have a voice where health care decisions are made; our unique perspective is essential to achieve optimum wellness for our patients.
This video was created for A Community Thrives (ACT), part of the USA Today Network nationwide program that provides the resources necessary for philanthropic missions in our communities to succeed.
Please consider casting your vote for this submission. You may vote once daily through May 12, 2017.
More Information
Nurses on Boards Coalition
Future of Nursing: Campaign for Action
American Nurses Foundation: Nurses and Board Leadership
American Nurses Association: Policy and Advocacy
References
Huston, C. (2008). Preparing nurse leaders for 2020. Journal of Nursing Management, 16(8).
Prybil, L. (2009). Engaging nurses in governing hospitals and health systems. Journal of Nursing Care Quality, 24(1).
It is an exciting time for nursing!
On Friday, April 21, 2017, Rear Adm. Sylvia Trent-Adams, became one of the first nurses to serve as Surgeon General of the United States.
Trent-Adams was a nurse officer in the Army and also served as a cancer research nurse at the University of Maryland. In 1992, she joined the Commissioned Corps of the Public Health Service and was the deputy associate administrator for the HIV/AIDS bureau of the Health Resources and Services Administration. In November of 2013, Trent-Adams joined the office of the Surgeon General as the 10th chief nurse officer of the U.S. Public Health Service (USPHS).
I look forward to seeing Trent-Adams’ impact on public health. Based on what I’m learning from her
biography and her quotes in the articles below, I believe her nursing background will positively influence her decisions and actions.
In a
2014 Profile in American Journal of Nursing, Trent-Adams is quoted as stating:
“Nurses bring common sense to solving problems, which has not been recognized enough,” she said. “Nurses spend more time with the patient than any other health care provider.”
In 2015,
American Journal of Nursing profiled Monrovia Medical Unit (MMU) Team 1, a group who spent 60 days in Liberia operating a 25-bed Ebola unit outside the capital city, with the specific intention to treat health care workers.
Rear Admiral Sylvia Trent-Adams, chief nurse officer of the USPHS, went to Monrovia with the team as commanding officer of the Commissioned Corps Ebola Response. She said the team "did an outstanding job." They provided "high quality care and treatment services, which were often described by our international partners as the best available care in the country," she said. "Each day we strive to 'protect, promote, and advance the health and safety of our nation,' and this mission was no different."
I am proud to see a nurse assume this leadership position. It is an exciting time for nursing, indeed!
Happy National Nurses Week! As we approach this year’s celebration, I’d like to introduce our upcoming blog series related to the theme of balancing mind, body, and spirit. Several nurse experts will share their knowledge and advice around different aspects of self-care for nurses.
I think you’ll enjoy theses daily blog posts, starting
May 6
th, 2017. We welcome any and all feedback or personal experiences that you’d like to share!
Work-Life Balance: The Elusive Golden Ring
Shawn Kennedy, MA, RN, FAAN
Editor-in-Chief,
American Journal of Nursing
Healthy Eating: Food for Thought
Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN
Editor-in-Chief,
Nursing2017
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware
Hit the road…or the mat
Collette Bishop Hendler, RN, MS, CIC, CCRN (Alumnus status)
Senior Clinical Editor
Health Learning, Research & Practice
Wolters Kluwer
Stress: The Elephant in Your Career
Gloria F. Donnelly, Ph.D., RN, FAAN, FCPP
Professor and Dean Emerita
College of Nursing and Health Professions
Drexel University
Editor in Chief,
Holistic Nursing Practice
Protect yourself so you can continue to protect others
Vicki Cantor, RN, BSN, MA
Clinical Editor
Health Learning, Research & Practice
Wolters Kluwer
Are You Soaring Spiritually?
Kathy Schoonover-Shoffner, PhD, RN
National Director, Nurses Christian Fellowship/USA
Editor-in-Chief,
Journal of Christian Nursing
If only I had said something…
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Health Learning, Research & Practice
Be sure to check out all of our
Nurses Week plans and take advantage of CE collections, free articles, a crossword puzzle, and more!
Also, follow us on social media -- We’ve got some special giveaways that you don’t want to miss!
Have a great week, everyone!
In anticipation of Nurses Week, on May 1
st the ANA launched its “
Healthy Nurse, Healthy Nation Grand Challenge” initiative, designed “to help nurses improve their overall health and challenge the rest of the country to do the same.” It’s a worthwhile effort – lord knows we can all use healthier habits in our lives.
As nurses, we work long hours. It can be on our feet doing direct care, attending meetings and writing budgets and working on staffing issues, traveling on public transportation or dealing with traffic to visit patients at home, or teaching the next generation of nurses. In my case, it’s spending hours on a computer, conference calls, and frequent travel to meetings. Then, after work, we go home and take care of others and other things – household bills and repairs, managing growing families, or going to school or even to other jobs, exercising, (notice I put exercise last…) – and then fall into bed wired and exhausted. In the morning, there’s coffee or diet cola to get us up and running and we do it all over again.
Ask yourself:
- When was the last time you went outside just to experience the sun on your face or take a leisurely walk?
- When was the last time you did something just for yourself?
- When was the last time you did something fun with your kids during the week?
- When was the last time you can say that you had a good night’s sleep and woke up feeling rested?
We have the data that show that we need to pay attention to how we take care of ourselves. Research published in
AJN on
health promotion practices of nurses noted that 66% of the nurses reported too many competing priorities; these nurses scored lower on spiritual growth, interpersonal relationships, and stress management. We also know that most of us are chronically sleep-deprived -- in another article in
AJN,
The Potential Effects of Sleep Loss on a Nurse’s Health, the author cites studies that reveal that daily sleep time for nurses was less than six hours, and that many nurses work 15 hours or more a day, or more than 60 hours a week. And we know that fatigue translates into a higher risk for making errors.
Work-life balance is an elusive goal, at least it is for me and many people I know. It’s run, run, run most of the week; catch-up on things we didn’t get to on the weekends and squeeze in time for family and friends. We are often our own last priority when it comes to healthy practices. A health scare a few years ago caused me to rethink how I work, and while I still don’t have ideal work-life balance, I’m doing a few things that are simple and easy to work into a schedule.
Here they are in case they are helpful to you:
- Always eat some kind of breakfast, preferably protein and low carb (you’ll avoid that mid-morning slump. My go-tos: hard-boiled egg, peanut butter on a piece of whole wheat bread, a scoop of cottage cheese with some fruit).
- Walk around the block (or two) at lunch time or, if too busy, before you head home.
- Park further away than you have to – walking even a little is better than none. Take the dog (or invite your partner or a child) for an evening walk
- If feeling very stressed, remove yourself (even if only to the bathroom) and take a few minutes to take a few deep breaths, get a drink of water, and clear your head.
- Listen to music on the way home from work. I find it helps me make that transition and I arrive home more relaxed.
- Don’t check email or social media or use a computer or tablet before bed (I know – it’s hard). Give yourself at least an hour to wind down before sleep.
- Try to get 7 hours of sleep each night.
We make appointments and commitments with other people and consider ourselves dependable and responsible when we keep them. We need to feel the same about taking time for ourselves. Make an appointment with yourself to walk, work out, read, see a movie – anything that will give you time for yourself – put it on the calendar, and honor that commitment just as you would others. You owe it to yourself.
Shawn Kennedy, MA, RN, FAAN
Editor-in-Chief, American Journal of Nursing
What information do you consider when you read a food label? My bet is that for those who do take the time to read the fine print, it’s typically the calorie count, the fat and sodium content, and perhaps even the recommended daily allowance of vitamins and nutrients that take center stage, especially for people who have an eye toward losing weight or making healthier choices. But what about the ingredient list? The ingredients in particular, including the ones with names that sound like compounds best discussed in a chemistry class, are often ignored. And I’m sure we all know people who don’t give any part of nutrition labels even a passing glance. I’ve actually heard friends admit, “I don’t want to know what’s in my food; I just want to enjoy it.” There’s no doubt there’s a very strong emotional connection to foods that we love…but we owe it to ourselves to take a much closer look at exactly what we put into our bodies.
It’s well established that our food choices play a significant role in our overall health and our risk of developing or worsening chronic diseases. Much has changed in relation to the science of healthy eating and disease prevention since many of us studied nutrition in nursing school. Have you kept up with the latest evidence to inform your own food choices or those of your family and patients, or do you place your trust in popular media and advertising claims about diet and nutrition? How do you knowingly separate the healthy food facts from the hype? Unfortunately, the hype comes from advertising dollars that, in a large part, serve to drown out the evidence from legitimate food science research.
I’ve always tried to eat “healthy,” but in retrospect, my diet left a lot to be desired. There’s nothing like a health scare to motivate new learning. My sentinel moment occurred the day I discovered that I had developed a major food allergy to carrageenan. To my great surprise, consuming my favorite brands of coffee creamer, yogurt, ice cream, and sorbet started to reliably induce progressively worsening wheezing, facial flushing, and tachycardia. The reaction that captured my full attention came very close to sending me to the emergency department for treatment. Being a stubborn ED nurse, I self-treated with over-the-counter antihistamines and fully committed to figure out exactly what caused me to react. Through the process of elimination, I found that the common denominator in all four foods was
carrageenan. Eating even a small amount of it reproduced my symptoms quite predictably. Switching to brands of products that didn't contain the offending ingredient and carefully scrutinizing all food labels made eating much less eventful and far more enjoyable.
When I researched carrageenan, I learned that it’s made from red seaweed and is added to food as a non-nutritive thickening agent. Although it's a natural product found in many "healthy" foods, it’s a potent inflammatory mediator that’s been linked to inflammatory bowel disease and colon cancer.
1 Carrageenan is actually used as an inflammatory agent to test the efficacy of anti-inflammatory drugs.
1 Knowing the risk it creates, even for people who don’t have an allergy to carrageenan, I had to wonder why it’s even placed in the products we buy and why it’s so pervasive?
Sadly, I learned that there are many other chemical additives commonly found in our food supply that are suspects in causing a myriad of human health issues. Take artificial sweeteners, for example: a prospective study just published from the Framingham Heart Study Offspring Cohort group revealed that individuals with the highest consumption of artificial sweeteners had a statistically significant higher risk of stroke and dementia, even after other possible contributing factors were adjusted.
2
So, my personal mission began to learn as much as possible from legitimate, high quality, evidence-based health literature about nutrition and food safety. The information I found inspired me to make a personal commitment to eat “clean”— that is to avoid food with chemical additives — and completely change my diet to consume foods derived primarily from whole, plant-based sources. The fewer the ingredients, the better. I’ve learned that plant-based, nutrient-dense foods are the very best to fuel our bodies and prevent disease. Yes, these foods can be prepared in very delicious and healthy ways. Eating like this feels different because most of us were not raised on a clean, plant-based diet. We were raised on high sugar diets with artificial colors, preservatives, and chemical additives because that’s what was advertised on television and we came to believe that these “foods” were somehow good for us.
Changing the way we eat is a very heavy lift. It clashes with the typical societal food norms, family customs, and available choices on many restaurant menus. It’s especially tough to be discriminating with food choices when eating out. Few people really understand how to feed someone on a plant-based diet. For example, I was served only a plate of plain lettuce at one recent function that I attended by those who knew my plant-based preferences. Keep in mind that all manner of fruits, vegetables, seeds, nuts, legumes, grains, and healthy, plant-based oils are part of the repertoire of possibilities.
Eating a clean, plant-based diet is a journey. I’ve found that the more I learn, the easier it is to make good choices. A very broad base of scientific evidence exists to support that dietary choices are firmly connected to personal health. As nurses, we need to expand our knowledge base on this subject and incorporate teaching about the impact of food choices on health into our teaching with patients. Simple steps like choosing to bring fruits, vegetables, nuts, and healthy grains into work for snacks in the break room can make a positive difference (as opposed to the usual tempting fare found on most nursing units). For those of you interested in learning more, I’ve included a reading list of resources that were most helpful to me in shaping my own perspectives. One of my favorite websites,
https://nutritionfacts.org, provides reviews on the latest high quality, peer reviewed, evidence-based research on food, nutrition, and overall health. The information contained on this website has enabled me to better make healthy lifestyle decisions.
As we celebrate Nurses’ Week and beyond, I encourage you to take stock of your own dietary habits and make informed choices that promote optimal health!
Bon appetit!
Linda
References:
1. Borthakur A, Bhattacharyya S, Anbazhagan AN, Kumar A, Dudeja PK, Tobacman JK.
Prolongation of carrageenan-induced inflammation in human colonic epithelial cells by activation of an NFκB-BCL10 loop. Biochem Biophys Acta, 2012;1822:1300-1307. Retrieved at: http://ac.els-cdn.com/S0925443912001032/1-s2.0-S0925443912001032-main.pdf?_tid=0b956676-2db2-11e7-8d56-00000aacb360&acdnat=1493563018_03f88014c2f300c3ba560bb71255bd30.
2. Pase MP, Himali JJ, Beiser AS, Aparicio HJ, Satizabal CL, Vasan RS, Seshadri S, Jacques PF. Sugar- and Artificially Sweetened Beverages and the Risks of Incident Stroke and Dementia: A Prospective Cohort Study. Stroke. 2017;48:1139-1146. Retrieved April 24, 2017: https://doi.org/10.1161/STROKEAHA.116.016027.
Suggested Reading List
- Campbell, T. C., & Campbell, T. M. (2006). The China Study: The Most Comprehensive Study of Nutrition Ever Conducted. Dallas: Benbella Books.
- Fuhrman, J. (2011). Eat to Live. New York: Little, Brown and Company.
- Greger, M., Stone, G. (2015). How Not to Die. New York: Flatiron Books.
- Greger, M. https://nutritionfacts.org Accessed April 30, 2017.
- Robinson, J. (2013). Eating on the Wild Side. New York: Little, Brown and Company.
Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN
Editor-in-Chief, Nursing2017
Vice President: Emergency & Trauma Services
Christiana Care Health System – Wilmington, Delaware
It’s no secret that as caregivers we’re typically not very good about taking care of ourselves. We get home after a long day, evening, or night at work, and then it’s time to shift gears and settle into our second job, taking care of things at home. By the time we actually have time for ourselves, we’re exhausted.
We know the benefits of getting at least 2 hours and 30 minutes of moderate-intensity aerobic activity a week. It helps:
- control your weight
- reduce the risk of type 2 diabetes and metabolic syndrome
- reduce the risk myocardial infarction and stroke
- reduce the risk of breast and colon cancer
- strengthen bone and muscle
- improve mental health and mood
- increase longevity.
But, just how do you fit exercise into an already busy, exhausting schedule? My brother, an exercise physiologist says, that there are plenty of 15-minute opportunities in a day; 96 to be exact, so there’s no reason why you can’t be intentional about reserving at least one or two of them for yourself. It seems pretty achievable when you look at it that way, doesn’t it?
Well it is achievable, and you don’t need an expensive gym membership to do it. Start by taking a 15-minute walk around your neighborhood. Ask a friend or family member to join you, or take the family dog for a walk. It’s a great way to relieve stress, reconnect with others, and get exercise at the same time. On your day off, increase the length of your walk by walking through a local park, around town, or along the beach. You’ll log in exercise time and gain some peace of mind.
To increase strength, endurance, and body tone, take another 15 minutes to practice yoga. You don’t need to venture away from home to establish a regular practice. All you need is a yoga mat and some floor space to get started. There are online videos and apps to guide you through your practice.
Yoga practice consists of different postures, referred to as asanas. During a practice session, you’ll use your breath to help guide you through the different postures, and you’ll focus on using core strength (referred to as mula bandha) to move energy through your body.
Before you get started, you’ll want to familiarize yourself with the different schools of yoga, so that you can choose the one that’s right for you. Some of the schools include:
- Asthtanga, a fast-paced practice, consists of a sequence of postures that provide a vigorous workout.
- Bikram, commonly referred to as “hot” yoga, consists of 26 consecutive postures that are performed in a room heated to about 100° F.
- Iyengar, a slow-paced practice, focuses on stillness and form with each posture.
- Jivamukti, a fast-paced practice similar to Asthtanga, incorporates meditation, chanting, and readings along with the postures.
- Kripalu, or gentle yoga, consists of postures designed to tone muscles, improve blood flow, and energize the mind.
- Kundalini, utilizes rapid breathing, chanting, and meditation to move through slow, deliberate movements.
I’ve been a walker for quite some time, but I only attended my first yoga session about two years ago. My daughter asked me to attend a “hot” yoga session that a friend was teaching. I had no idea what “hot” yoga was, but I thought why not support her friend and give it a try. I thought I’d be calmly sitting on a mat breathing and relaxing. Little did I know that I’d be working up a sweat trying to keep up with the instructor as she led us rapidly through a variety of postures.
I enjoyed the session but it wasn’t until my daughter gave me a gift certificate for a private yoga lesson that I became hooked. Now I’m a regular weekend attender at a local yoga studio where I practice Asthtanga yoga. During the week, I practice at home using an app. Since beginning yoga four months ago, I’ve been able to curb my anxiety, sleep at night, gain flexibility, and increase my core strength.
The beauty of both of these exercise options is that you can do them anytime and anywhere…wherever and whenever you can find those 15 minutes, 15 minutes where you can refocus and simply take care of you.
Collette Bishop Hendler, RN, MS, CIC, CCRN (Alumnus status)
Senior Clinical Editor
Health Learning, Research & Practice
Wolters Kluwer
“I resigned my staff nurse position today,” my young colleague confessed, “after only 7 months. I loved taking care of patients and families, but just couldn’t take it anymore – the other nurses complaining, but never speaking out, the rude behavior and put downs, and the nurse manager who made bad decisions and supported the wrong people – will it be like this in my next job? I feel like such a failure.” I have heard this story at least three times over the past year and I am only an N of 1. Recent studies have documented the alarming percentage of nurses who are leaving their jobs or leaving the profession climbing to 17.2 % in 2016 and costing hospitals an average of $5.2M – $8.1M annually.
1 Reasons cited by nurses for leaving include poor management, and stressful work conditions, including inadequate staffing, verbal abuse, and work-life balance issues.
2, 3 While employing organizations are deciding how to tackle this problem, you need stress relief
now to get you through the day. First, let’s revisit the concept stress, then consider a few simple and creative strategies that you can use to get the elephant out of your workday ---- STRESS!
Stress Revisited
Hans Selye, a Canadian physician, conceptualized the “stress response” and conducted research on how it worked after observing patients’ responses to the stress of hospitalization.
4 “Stressors” are those factors experienced or perceived by individuals as causing harm or distress. “Experienced” or “perceived” is an important distinction since the stressor can be real and direct like a contracting a virus or being robbed at gunpoint or the stressor could be the result of how we view a situation; a putdown for one nurse can be devastating and for another a minor blip in the course of a day’s work. The apathy of her colleagues, rude behavior, put downs, and the passivity of the nurse manager were my colleague’s perceived “stressors.” Stress, on the other hand, is the individual’s reaction or the body’s response to real and perceived threats whether that reaction is manifested physically or mentally. In this case, my young colleague’s reaction was to let the stressors overwhelm her to the point of leaving – remember fight or flight? She could have tried to “change her perceptions,” “change her reactions,” “change her behavior or get help,” instead the stress led to resignation. Depending on the severity of the stress, individuals and organizations always have a measure of control in managing “stressors.” Instead of merely reacting, striving to develop a
deep awareness of how you can plan, craft, and control your responses to difficult situations can be the first step to stress inoculation.
Stress Inoculation
You get to choose how to “vaccinate” your stress. Choose “ingredients” based on your preferences, style, and time – some take no time, others take a commitment of 20 minutes to half an hour per day. Try one strategy per week to find what is right for you. Continue with those you believe are helping you to respond effectively instead of reacting haphazardly and then move on to more structured and serious stress management modalities. Below is a simple formula to begin stress reduction.
It’s your choice!
- Move -- Twenty minutes a day of running, walking, cycling, etc., will help to dissipate the effects of stress. Regular exercise improves cardiovascular function, produces endorphins in the brain that result in improved mood, strengthens muscles, and improves tone. If you are not inclined to run, sign up for yoga or Pilates. These meditative exercise forms stretch and tone your body and improve your posture and flexibility which can become a metaphor for how you respond in stressful situations. Regularly moving the body increases body awareness during stressful interactions. So, if you experience bullying or other negative interpersonal encounters on the job, use your body’s signals to respond – stand taller, face your nemesis or – if you are too rattled – leave the scene, it is your absolute right to remove yourself from such situations. Better yet, dance!
- Rehearse difficult conversations in the privacy of your car – you could even let loose, scream, use profanity – no one will hear you but you, and hearing how you respond or “talk back” can be helpful in changing your verbal responses during stressful situations. Just be cautious; if someone in the next car notices your solitary conversations, just smile, fiddle with the radio and pretend you’re singing. Rehearsals should help your responses become more rational, more focused, less defensive and more “I” oriented. Read up on developing calm, assertive responses or join an assertiveness training group. In time you will be surprised when the assertive responses that you rehearsed become natural and automatic during difficult situations.
- Laugh – Humor provides release and helps put things in perspective. Most importantly, laugh at yourself even at your best efforts. At the urging of my internist, I hired a personal trainer and worked out 2 days a week for 2 years – the result, I spent $3,000 dollars and lost three pounds but I was “toned.” I am still laughing at the result. Get a small group of like-minded nurse colleagues together and watch funny SNL’s vignettes or YouTube videos. My SNL favorites are from the 1980’s particularly Jane Curtin attending assertiveness training class or Roseann Roseanna Danna reporting the news. Humor heals and humor shared is even more healing.
- Reframe difficult situations, that is, change the meaning, the emotional tone, or your viewpoint of a difficult situation and place it in another frame. Remember when Huckleberry Finn, a Mark Twain 5 character, had to whitewash the fence – it was work he did not want to do but he “reframed” and pretended to be having such great fun that all his friends begged to help and he finished in record time. How would you reframe a heavier than usual patient assignment or having to work on a holiday? It is possible to change what we think or how we view any situation. Conjure up at least 3 positive or at least, neutral interpretations of the next difficulty you encounter. Flexing perspective is liberating.
- Imagine – Your imagination can save you from revealing negativity, disapproval or even fear. Use fantasy to get yourself through difficult situations. For example, when attending that meeting you dread with all of those difficult colleagues gathered in one place, imagine that you are all different animals in a zoo. Imagine the sounds they would make when things got tough or how they might gallop or slither from the room. You will get a pleasant look on your face when you are fantasizing and group members will think that you are relaxed and have it together. The rule is to keep your fantasy private.
- Sing in the privacy of your car or the shower. Sing uplifting and inspirational songs that emphasize self-empowerment. Or download the following songs on your phone and sing along or listen on your break. Music reorganizes the brain and the messages sung are uniquely remembered. Here is a selection of empowering songs to get your started. If you are of my vintage, Sinatra’s, “I Did It My Way,” or “I Gotta Be Me,” or a few pop favorites, “Let it Go,” or “Brave,” or “Fight Song.” It you are hip, there is Des’ree’s “You Gotta Be,” and if you are inclined to country music, one of my favorites is Bobby Bare’s, “Drop Kick Me Jesus thru the Goalpost of Life.” In Bobby’s words, “If you have the will, God has the toe.” Make your own song selections and share.
So there is it, a simple formula that will get your started to managing every day stress:
Move + Rehearse + Laugh + Reframe + Imagine + Sing
If your health is at risk or your situation is dire, consult a health professional.
Take care of yourself!
References:
-
2016 National Healthcare Retention & RN Staffing Report Published by: NSI Nursing Solutions, Inc. www.nsinursingsolutions.com. Accessed 4/30/2017
-
Flinkman M, Ulpukka I, Salantera S, International Scholarly Research Notices. August 20, 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762080/ Accessed 4/30/2017.
-
-
Selye H. The Stress of Life. New York: Mc Graw Hill, 1956.
-
Twain, M. Adventures of Huckleberry Finn. Costa Mesa, California: Saddleback Educational Publishing, 1999,2011
Gloria F. Donnelly, Ph.D., RN, FAAN, FCPP
Professor and Dean Emerita
College of Nursing and Health Professions
Drexel University
Editor in Chief, Holistic Nursing Practice
How often have you given your patients advice on preventive health care and screenings and heard that nagging, guilty little voice in your head saying, “Don’t be a hypocrite, don’t forget about
you”? Part of our job as nurses is to teach our patients about preventive health care and recommended screenings to maximize their health, longevity, and quality of life. While we know the importance of these health care services, however, we don’t always translate that into practice for ourselves.
Nurses may not follow recommended preventive and screening practices for a multitude of reasons. Shift work, long hours, limited paid time off, and an unpredictable schedule make it difficult to schedule appointments. As caregivers to the core, the needs and activities of our children, spouses, and parents become our focus during our non-working hours, and our own health care needs tend to take a backseat. But, in order to take care of our patients, as well as our families, we must make our own health a priority. A sick nurse can’t take care of anyone.
So, what exactly do you need to do? To start with, schedule a check-up with your practitioner. Your practitioner will perform a physical examination, provide counseling, and perform or order screening tests and preventive services based on your age, gender, and risk factors. Your practitioner may include the following during your check-up, based on the recommendations by the
U.S. Preventive Task Force:
- Screen for alcohol misuse, intimate partner violence, depression, or high blood pressure
- Order a serum blood test to screen for human immunodeficiency virus or hepatitis C virus
- Order a serum lipid blood test to screen for hyperlipidemia
- Order a dual-energy X-ray absorptiometry scan to screen for osteoporosis
- Order or perform cancer screenings at the appropriate intervals, including breast cancer, cervical cancer, and colorectal cancer screenings
- Order or perform any additional targeted screenings based on your history, the presence of risk factors, and physical examination findings
In addition to the health care screenings, preventive measures can stop certain diseases from occurring in the first place.
The Centers for Disease Control and Prevention recommends the following vaccines for all health care workers:
- Hepatitis B series
- Influenza (annually)
- Measles, Mumps, & Rubella
- Varicella
- Tetanus, Diphtheria, & Pertussis
- Meningococcal
Some of these vaccines may be required at your facility, so they may be given free-of-charge during work hours, which saves you the time and inconvenience of scheduling a separate appointment. If they’re not, ask your practitioner about them at your check-up. It’s important to protect yourself so you can continue to care for others.
Nurses Week is the perfect time to renew our commitment to take better care of ourselves by practicing preventative care measures and making those screening appointments. Be well!
References:
Vicki Cantor, RN, BSN, MA
Clinical Editor
Health Learning, Research & Practice
Wolters Kluwer
Spirituality is a vague concept for many nurses—especially when our primary focus is implementing physical, scientific interventions. As holistic caregivers, we believe nursing care should be for body, mind, and spirit.
Our personal spirituality, however, is easy to ignore
. Some of us don’t think about our spirituality until we are turned upside down by a life crisis. But over time, even without crisis, if we don’t care for our spirits we will suffer consequences.
Paying attention to personal spirituality is especially important for nurses. Researchers and spiritual care experts have found that offering good spiritual care requires the nurse to attend to his or her own spirituality (makes sense, right?) (Baldacchino, 2011; Taylor, 2009; 2011). Furthermore, we regularly experience spiritual distress in our work, which leads to weariness, depression, compassion fatigue, and burnout. Moreover, being spiritually healthy –
soaring spiritually – feels better than spiritual malnourishment. In fact, it feels great!
What is spiritual health? Our spirit is the core of our being, a characteristic of all humanity. While our spirit is accessed through our mind, spiritual health is more than mental health. Spirituality involves the ultimate search for meaning and understanding of the sacred or transcendent. It expresses a universal human capacity to transcend ourselves and
connect with God, other people, and the world around us. It is through spirituality that we find self-fulfillment, peace, and meaning in life and suffering (Lepherd, 2015). A frequently used assessment of spiritual health is the Spiritual Well-Being Scale (SWBS), a general indicator of perceived well-being and spiritual quality of life, with subscales that assess Religious Well-Being (one's relationship with God or “higher power”), and Existential Well-Being (one's sense of life purpose and life satisfaction) (Bufford, Paloutzian, & Ellison, 1991).
What helps nurses’ spirituality? Recently, researchers in Iran found a positive correlation between nurses’ clinical competence and spiritual health, and professional ethics and spiritual health (Tabriz, Orooji, Bikverdi, & Taghiabad, 2017). A U.S. chaplaincy department conducted a randomized controlled study of a spiritual retreat for nurses. Nurses who did the spiritual retreat scored higher at 1 and 6 months on the SWBS and Daily Spiritual Experience Scale than nurses with no retreat (Bay, Ivy, & Terry, 2010). The ancient text of Proverbs in the Tanach (Hebrew Bible) and Christian Holy Bible speak about what makes for spiritual health (kind words, trustworthy words, humility, relationship with God, clean heart), versus a crushed, broken, or weighed down spirit (i.e., Psalm 51; Proverbs 15:4, 16:19-24, 17:22, 18:14, 29:23). Wise king Solomon wrote, “
Keep your heart, for from it flow the springs of life” (Proverbs 4:23, ESV).
How are you caring for your spirit? Do you engage in spiritual renewal? A renewal experience is doing something you enjoy like a walk in nature or a hobby. I find renewal exercising with friends and playing the piano. For nurses of faith, attending a gathering in your worship tradition can be (should be!) a renewal experience.
Meet regularly with friends who will listen to and support you. Two months ago, I reluctantly joined a small group from my church to share time, meals, and service projects. I expected this to be work. To my surprise, even though I can’t attend regularly, the group is renewing me. This week, a young man shared his struggles with me, and I shared mine. He texted me today saying he was praying for me, and that “your absence is felt and we cherish when you are able to attend.” I felt spiritually connected, that someone of like mind cares for me.
That is spiritual renewal in the struggle of life.
Below are ideas for spiritual self-care. As we think about balancing body, mind, and spirit during this year’s 2017 National Nurses Week, take time to care for
your spirit.
Ideas to Help Your Spirit Soar
- Daily quiet time with personal reflection or meditation on spiritual readings.
- Read enlightening materials—spiritual readings (i.e., Bible) or devotional books.
- Plan for times of rest and take your mind off work, off problems, and relax (Sabbath). Consider a one-day or longer “guided spiritual retreat” at a retreat center near you.
- Attend gatherings of your faith tradition.
- Spend time in prayer, talking with the Mystery many call God.
- Join a “share group” of people with whom you have a common interest.
- Do special things you enjoy—go to a greenhouse, art gallery, antique mall, camping or on a picnic, take in a movie with a friend. Be creative!
- Engage in regular physical exercise (walk/run alone or with a friend; join an exercise group).
- Conduct a spiritual self-assessment; heighten awareness of your spirituality (Beckman, Boxley-Harges, Bruick-Sorge, & Salmon, 2007).
- Engage in spiritual direction with a spiritual director or companion consistent with your beliefs (http://www.sdiworld.org).
References:
Baldacchino, D. R. (2011). Teaching on spiritual care: The perceived impact on qualified nurses. Nurse Education in Practice, 11(1), 47–53. doi: 10.1016/j.nepr.2010.06.008
Bay, P. S., Ivy, S. S., & Terry, C. L. (2010). The effect of spiritual retreat on nurses’ spirituality: A randomized controlled study. Holistic Nursing Practice, 24(3), 125-133.
Beckman, S., Boxley-Harges, S., Bruick-Sorge, C., & Salmon, B. (2007). Five strategies that heighten nurses’ awareness of spirituality to impact client care. Holistic Nursing Practice, 21(3), 135-139.
Bufford, R. K., Paloutzian, R. F., & Ellison, C. W. (1991). Norms for the Spiritual Well-Being Scale. Journal of Psychology and Theology, 19(1), 56-70.
Lepherd, L. (2015). Spirituality: Everyone has it, but what is it? International Journal of Nursing Practice, 21(5), 566–574. doi: 10.1111/ijn.12285
Tabriz, E. R.., Orooji, A. Bikverdi, M. & Taghiabadl, B. A. (2017). Investigation of clinical competence and its relationship with professional ethics and spiritual health in nurses. Health, Spirituality and Medical Ethics, 4(1), 2-9.
Taylor, E. J. (2009). What do I say? Talking with patients about spirituality. West Conshohocken, PA: Templeton.
Taylor, E. J. (2011). Spiritual care: Evangelism at the bedside? Journal of Christian Nursing, 28(4), 194-202. doi: 10.1097/CNJ.0b013e31822b494d
Kathy Schoonover-Shoffner, PhD, RN
National Director, Nurses Christian Fellowship USA
Editor-in-Chief, Journal of Christian Nursing
I walk into the room and look at the figure of a 20-year-old college student lying in the bed after a deliberate overdose, intubated and on a ventilator, the steady rhythm of the machine making her chest rise and fall and the steady beeping of the heart monitor somewhat reassuring that my patient was still alive. The parents sitting by her bedside with tears streaming down their faces. The mother speaks to me, “If only I had said something. I thought it was only stress of being in college and having to take final exams; if only I had said something…”.
If only I had said something…these are words none of us wants to say or hear, but too often this is exactly what happens. Frankly, I’ve heard those words too many times in my professional practice. How many times have you wondered if someone you know has a mental health disorder? Maybe, you wonder if you have a disorder? When we look at the statistics, the impact of mental health issues —which is defined as any mental, behavioral, or emotional disorder, excluding developmental and substance use disorders — is sobering. Mental health issues affect 21.2% of adult females and 24.3% of adult males, per the National Institute of Mental Health (NIMH, 2016). None of us are immune to being touched by someone who has a mental health disorder. From generalized anxiety disorder, panic disorder, post-traumatic stress disorder, bipolar disorder, major depressive disorder, and so on, we have all known someone or taken care of someone who has a mental health issue. Perhaps the greatest issue we face is being able to recognize when someone needs professional help or when we need professional help.
Although we, as health care professionals, recognize that managing mental health disorders is as important as managing any other disorder, the stigma in the community that mental health issues are a sign of weakness or that the person can snap out of it, still exist. We must take an active role in educating the community on when a person may have a mental health issue and not just feeling anxious or feeling down about something that happened in their life. People who entertain risky behaviors, such as prescription drug misuse, exercise extremes, compulsive buying, and risky sex may have an underlying mental illness (
http://mentalhealthamerica.net).
The theme of Nurses Week is Nursing: The Balance of Mind, Body, and Spirit and mental health is certainly a part of that initiative. May is also Mental Health Month. The National Institute of Mental Health (NIMH) is leading the initiative on mental health awareness and management by outlining objectives to define mechanisms of complex behaviors, recognizing those who have mental health issues, and when intervention is necessary, and striving for mental health illness prevention.
As nurses, we must speak up when we suspect someone may have a mental health issue and encourage that person to seek professional help. We must have the courage to speak up even if that person is our colleague, in our family, or even ourselves. No more should we hear, “If I had only said something…”.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Health Learning, Research & Practice
Wolters Kluwer
Last month, I had the pleasure of attending the
National Conference for Nurse Practitioners at the Gaylord Opryland Resort & Convention Center in Nashville, Ten. The interest and enthusiasm were palpable at this sold-out show! From the opening session, where attendees were welcomed with live music, to the exhibit hall, where vendors updated us on the latest products and we enjoyed meals with our colleagues, this was the best NCNP yet!
From the Experts
At the conference this year, I was happy to see several sessions related to women’s health, which is my advanced practice area. I learned so much from these experts, as well as those who presented in the acute care and primary care sessions. Here are some things I learned:
“Virtually all cervical cancers are associated with persistent infection with high-risk HPV types.”
Update on Cervical Cancer Screening: Appropriate Use of Pap and HPV Testing
Nancy Berman, MSN, ANP-BC, NCMP, FAANP
“One treatment modality that improves survival in patients with COPD? Oxygen.”
Acute Care: COPD Across the Scale
Kayur Patel, MD, MRO, FACP, FACPE, FACHE, FACEP
“Primary care providers see 80% of patients with skin conditions. We need to know when it’s NOT acne.”
Acneiform-Pediatrics to Adults
Margaret Bobonich, DNP, DCNP, FNP-C, FAANP
“Sepsis is a medical emergency. First step in treatment is VOLUME -- 30mL/kg of crystalloid fluid within the first 3 hours.”
Acute Care: Understanding Sepsis
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
“Nearly 6% of deaths globally are attributable to alcohol (80K in U.S.)”
Alcoholism and Liver Disease,
Christopher Chang, MD, PhD
“Unlike vasomotor symptoms, vaginal atrophy can be progressive and is unlikely to resolve on its own.”
Comprehensive Menopause Management: An Update on Current Strategies
Nancy Berman, MSN, ANP-BC, NCMP, FAANP
“Maternal risk depends on complexity of primary cardiac lesion and if residual lesions or other clinical sequelae exist.”
Making Sense of Heart Disease in Pregnancy
Kismet Rasmusson, DNP, FNP-BC, FAHA, CHFN
“Switching between anticoagulants should be based on the pharmacokinetic profile of each anticoagulant, appropriate laboratory assessment of patient’s coagulation status, and the patient’s renal function.”
Acute Care: Understanding Direct Oral Anticoagulants
John Togami, PharmD, PhC
This is just a sampling of the takeaways I left with. What did you learn? What would you like to learn? Leave us a comment, and we’ll pass it along to the NCNP Planning Panel.
In a previous blog post, we discussed
preload and afterload. You may recall, preload is the amount of ventricular stretch at the end of diastole. Afterload is the pressure the myocardial muscle must overcome to push blood out of the heart during systole. The left ventricle ejects blood through the aortic valve against the high pressure of the systemic circulation, also known as systemic vascular resistance (SVR). The right ventricle ejects blood through the pulmonic valve against the low pressure of the pulmonary circulation, or
pulmonary vascular resistance (PVR).
Understanding Systemic Vascular Resistance (SVR)
SVR reflects changes in the arterioles, which can affect emptying of the left ventricle. For example, if the blood vessels tighten or constrict, SVR increases, resulting in diminished ventricular compliance, reduced stroke volume and ultimately a drop in cardiac output. The heart must work harder against an elevated SVR to push the blood forward, increasing myocardial oxygen demand. If blood vessels dilate or relax, SVR decreases, reducing the amount of left ventricular force needed to open the aortic valve. This may result in more efficient pumping action of the left ventricle and an increased cardiac output. Understanding SVR will help the bedside clinician treat a patient’s hemodynamic instability. If the SVR is elevated, a vasodilator such as nitroglycerine or nitroprusside may be used to treat hypertension. Diuretics may be added if preload is high. If the SVR is diminished, a vasoconstrictor such as norepinephrine, dopamine, or vasopressin may be used to treat hypotension. Fluids may be administered if preload is low.
How to Calculate SVR
SVR is calculated by subtracting the right atrial pressure (RAP) or central venous pressure (CVP) from the
mean arterial pressure (MAP), dividing by the cardiac output and multiplying by 80. Normal SVR is 700 to 1,500 dynes/seconds/cm
-5.
Here’s an example:
If a patient's MAP is 68 mmHg, his CVP is 12 mmHg, and his cardiac output is 4.3 L/minute, his SVR would be 1,042 dynes/sec/cm
-5.
Factors that Increase SVR
Conditions that can increase SVR include (Breitenbach, 2010; Gowda, 2008):
- Hypothermia
- Hypovolemia
- Cardiogenic shock
- Stress response
- Syndromes of low cardiac output
Factors that Decrease SVR
Conditions that can decrease SVR include (Breitenbach, 2010; Gowda, 2008):
- Anaphylactic and neurogenic shock
- Anemia
- Cirrhosis
- Vasodilation
The accuracy of SVR depends on the direct pressure measurements and indirect cardiac outputs from a pulmonary artery catheter which are subject to error. However, SVR can provide critical information when differentiating various types of shock. Understanding SVR will help the bedside clinician better manage medications and hemodynamic instability.
*You may also see systemic vascular resistance index (SVRI); this is calculated by substituting cardiac index (CI) for CO in the equation.
This blog is the first in a new series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition.
Your presence on a board warrants confidence and truthfulness. In our turbulent health care environment, we are faced with old issues and new challenges that require immediate solutions and planning. In the words of Helen Keller, “optimism is the faith that leads to achievement. Nothing can be done without hope and confidence.” That being said, your role on a board places you in a position of influence. Your ideas, positions, and nursing experiences, provides you with a solid foundation to influence, empowered by confidence and truthfulness.
How can you be confident?
- Learn from setbacks, failures, and success.
- Become well versed on the topic of discussion.
- Be aware of your body language.
- Assert views in non-threatening, non-judgmental ways.
- Be articulate and concise when making your points.
Your nursing perspective is valuable to inform stakeholders about the realities of the issue, evidence-based information, new research, and stories. What we communicate may have an impact on colleagues, families, communities, or society. The information and perspective you share may be the foundation for an issue that may have political, economic, and social implications both in the short term and long-term.
How can you be truthful?
- Convey authenticity through openness, humility, and transparency.
- Be diligent in exercising your fiduciary responsibility.
- Represent nursing and other disciplines at board meetings.
- Communicate in a way as to maintain credibility and build relationships.
- When you don’t completely understand an issue, ask for clarification to gain full understanding.
According to
Mary Beth Kingston, Executive Vice President and Chief Nursing Officer, Aurora Health Care, Milwaukee Wisconsin, and past AONE Board of Directors,
"It is important to do 'due diligence', specific preparation prior to board service by learning about the organization, it's work or product and values.”
Call to Action
As you serve or aspire to be on a board, remember it calls for confidence and truthfulness. We hope our column serves as a reflective tool to strengthen your influence when serving on boards.
This month, we celebrate the 20
th anniversary of Lippincott NursingCenter! In June of 1997, the website formerly known as
AJNOnline became Lippincott’s NursingCenter.com. This look back at our evolution has been eye-opening [credit to the Internet Archive,
Wayback Machine]. As a clinical editor on the NursingCenter team since 2002, there is much that I’d forgotten, as well as some previous features that are now inspiring me with new ideas!
Originally launched in 1993 with grant funding from the Department of Health & Human Services, Division of Nursing, NursingCenter.com was one of the very first Internet sites devoted exclusively to nursing. The site began as
AJNNet, an electronic bulletin board system (BBS) for delivering continuing education to nurses in medically under-served areas. In January 1995, the BBS evolved into a full website called
AJNOnline, the first website to deliver full-text nursing journals (including full-text versions of the
American Journal of Nursing and
The American Journal of Maternal/Child Nursing.)
In June of 1997, the site was renamed Lippincott's NursingCenter with more journals and continuing education offerings than any other nursing site. As more even more nursing resources and references were added, the site was completely redesigned and relaunched several times, always with the goal to be the most comprehensive online nursing portal. In April 2000, NursingCenter merged with SpringNet, Springhouse Corporation's award-winning website.
After several more iterations and redesigns, we’ve come to be known as Lippincott NursingCenter. Today, NursingCenter.com continues to expand, offering a growing library of cutting-edge original content to help nurses and students on their professional journeys.
Please join me on a little video journey through our history!
Twenty years ago, when the web was just in its infancy, Lippincott NursingCenter emerged as a premier online resource for nurses. Our authoritative content, created by nurses for nurses, continues to set us apart as an online nursing resource. We are proud of our exclusive content – enewsletters, nursing tip cards and mnemonics, infographics, and blog – that keeps nurses up-to-date clinically and professionally. And our portfolio of resources has grown to include over 6,000 peer reviewed articles from over 70 trusted Lippincott journals and more than 1,900 continuing education activities. Thank you for being a valuable member of our nursing community.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is June’s nurse story, “Hair and Hospice.” Enjoy!
Hair and Hospice
Marcy Hof, RN
Hilton Head Hospital
Thirty-two years ago when I was 21, I got my cosmetology license and began working in a salon. My father had been diagnosed with malignant melanoma and went from hospital to hospital for different treatments and a clinical trial. It was at that time that I realized how valuable nurses are to the world, and how many different aspects of nursing there are. When my dad got to the point where he needed hospice care, I was the only one who could lift him or clean him up. He would tell people to go away and let me help them because I was stronger than my mom and sister. It was only after he passed away that I went to nursing school. I have been an RN for 24 years and today my daughter is in nursing school too! My father would have been so proud!! It is a very rewarding, frustrating, sad, and interesting career that I am glad I pursued!
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit
http://lippincottsolutions.com/inspirednurses. Be sure to check our blog every month for a new inspired nurse’s story.
The majority of healthcare providers in the United States (US) first became familiar with Zika virus in early 2016 when it gained national attention following a large Zika virus outbreak in Brazil in 2015. With this outbreak, a concurrent increase in rates of microcephaly and ocular abnormalities in newborns was observed, suggesting an association between the two (Martines, 2016). Subsequent, retrospective analysis of a Zika outbreak in French Polynesia in 2013-2014 further supported the association between Zika virus infection and neurologic birth defects in newborns (Martines, 2016). The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) first issued public health alerts in January 2016 and February 2016 to increase public awareness, mobilize resources, and expand knowledge of Zika virus. A priority of these efforts was preventing infection in pregnant women and women of reproductive age to avoid birth defects resulting from transmission of Zika virus to the fetus.
Since the initial public health alert, the CDC has provided
extensive guidance and resources for healthcare providers based on current knowledge of Zika virus. Although the virus can be asymptomatic in adults, we know that it can cause significant morbidity and mortality to a fetus when contracted in utero, most significantly microcephaly and fetal demise.
Since the initial advisories of 2016, scientists and healthcare professionals have gained a better understanding of both transmission and the pathophysiologic effects of the virus. The CDC has an extensive system of surveillance, and a registry to monitor cases in the US as well as a registry of all pregnant women with Zika virus infection (the US Pregnancy Zika Virus Registry [USPZR]). All serologic testing for Zika virus is monitored through the CDC allowing for
accurate and detailed surveillance.
From the perspective of the healthcare provider, some of the more significant benefits of the CDC efforts have been the provision of straightforward guidelines for prevention and screening, and anticipatory guidance specific to pregnant women and women of reproductive age. Nurses play a critical role in educating patients and families and can be instrumental in reducing fears by providing patients with the accurate and up-to-date information necessary to remain healthy and reduce the risk of Zika virus infection and spread.
What We Know about Zika virus in 2017 (CDC, 2017):
- Zika virus is spread primarily through the bite of the Aedes species of mosquito which are known to bite during both day and night.
- Zika virus can be passed from a pregnant woman to her fetus and is linked to neurologic birth defects, specifically microcephaly.
- Pregnant women should not travel to geographic regions with risk of Zika.
- Zika virus can be passed sexually from a person who has Zika virus to his or her sex partners.
- Pregnant women living with partners who have Zika virus or have traveled to regions with Zika virus should not have sex with their partner, or should use barrier protection/condoms during pregnancy.
- Women of reproductive age (those reproductive planning and those at risk for unplanned pregnancy) should receive counseling similar to that of pregnant women in respect to risk reduction of Zika infection.
- During the first week of infection, a person can spread Zika virus by being bitten by a mosquito that subsequently bites another person exposing them to blood containing Zika virus.
- Most cases of Zika virus are asymptomatic; if symptoms are present, they may include fever, malaise, maculopapular rash, conjunctivitis, headache, and arthralgia.
- There is no specific treatment or vaccine for Zika virus.
- There has been mosquito-borne transmission of Zika virus in the continental US; the first confirmed case was August 1, 2016 in Miami, Florida.
Summary of CDC recommendations for the care of the pregnant woman (CDC, 2017):
Major Recommendations |
- Pregnant women should not travel to areas with risk of Zika infection.
- Pregnant women should use condoms/barrier protection with any sexual partner that lives in or has traveled to areas with risk of Zika.
|
Prenatal Care
|
- Screen for potential Zika virus exposure at all prenatal visits. Examples of screening tools and testing algorithms can be found on the CDC website.
- If exposure screening is positive, screen for symptoms (fever, rash, arthralgia or conjunctivitis) and/or fetal abnormalities on ultrasound.
- Symptomatic women with possible Zika exposure should undergo serologic and/or urine testing for Zika virus.
- Zika virus testing of asymptomatic women with potential Zika exposure varies based on region of travel.
Zika virus testing includes:
- Zika virus nucleic acid testing (NAT) (i.e. RNA) in urine and serum
- Serum Zika virus and dengue virus immunoglobulin M (IgM)
- If IgM is positive, equivocal, presumptive or possible, must confirm with serum plaque reduction neutralization test (PRNT) which tests viral specific neutralizing antibodies to Zika.
|
Management of pregnant women with Zika virus infection
|
- Consider serial ultrasound every 3-4 weeks to evaluate for fetal abnormalities
- Amniocentesis on a case by case basis
|
Management of pregnant women with potential exposure and no serologic evidence of Zika infection |
- Ultrasound to evaluate for fetal abnormalities.
- If fetal abnormalities present, consider repeating Zika virus NAT and IgM testing.
- If no fetal abnormalities, continue routine prenatal care and risk management for Zika virus exposure.
|
Postnatal recommendations in women with positive or presumptive Zika virus infection during pregnancy |
- Live birth: infant serum and urine testing for Zika virus NAT and Zika/Dengue IgM as well as Zika virus NAT and immune-histochemical (IHC) staining of umbilical cord and placenta; test CSF if available.
- Fetal losses: Zika virus NAT and IHC staining of fetal tissues.
- Breastfeeding is recommended. Zika virus has been found in breastmilk but there have not been reports of infection associated with breastfeeding; the benefits are thought to outweigh the theoretical risks of transmission via breast milk.
|
When a pregnant woman passes the Zika virus to her fetus during pregnancy, it can lead to congenital Zika syndrome (CDC, 2017b). While the full extent of potential health effects from Zika virus is unknown, we know that congenital transmission can lead to brain abnormalities including severe microcephaly, eye abnormalities, congenital contractures (clubfoot or arthrogryposis), hypertonia restricting movement soon after birth and hearing loss (CDC, 2017a, CDC, 2017b). There is guidance from the CDC for healthcare providers on
neuroimaging of infants with congenital Zika syndrome as well as specific guidance for the management of infants with Zika virus infection
for the first 12 months, regardless of the presence of birth defects. The CDC is also responsible for the development of
Zika Care Connect, which provides a network of referral sources and specialty healthcare services helping to facilitate access to resources for families affected by Zika virus.
Zika virus is a classic example of an emerging infectious disease in the US. The response from the CDC and WHO has been critical in making the public aware of this threat and successfully mobilizing resources to provide healthcare providers with the most current, scientifically-based evidence available. Nurses are often the first clinical contact a patient will have with the healthcare system. We are in a position to educate and decrease fears associated with Zika virus, which was an unknown threat to most in the US less than 2 years ago. A major focus of education should be prevention, including educating patients on taking measures to prevent being bitten by mosquitos and efforts to reduce risk by informing patients of travel precautions to areas with risk of Zika infection for pregnant women, women of reproductive age and women and their partners trying to conceive. With this, we can contribute in public health efforts to prevent the spread of an emerging virus which poses serious health risks and the potential for catastrophic effects on newborn morbidity and mortality.
References:
Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases, Division of Vector-Borne Diseases, (2017a). Zika Virus. Retrieved from: https://www.cdc.gov/zika/index.html June 2017.
Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases, Division of Vector-Borne Diseases, (2017b). Zika, CDC Interim Response Plan, May 2017. Retrieved from: https://www.cdc.gov/zika/public-health-partners/cdc-zika-interim-response-plan.html
Martines, Roosecelis Brasil et al. (2016). Pathology of congenital Zika syndrome in Brazil: a case series. The Lancet, 388(10047), 898-904.
Megan Doble, MSN, RN, CRNP, FNP-BC, AGACNP-BC
Summer is a great time to catch up on reading - the days are longer, some of us take some time off from work, and things seem to slow down a bit. If you're like me, you've got a list of reading recommendations from friends and colleagues that you've been planning to read "someday." Well, as I prepare for a little beach time, I'm organizing and prioritizing my reading list. Have you read any of these titles? Or are any on your to-read list?
For students and new nurses transitioning to practice...
Anatomy of a Super Nurse: The Ultimate Guide to Becoming Nursey
Kati Kleber, BSN, RN, CCRN
This is a revised version of Becoming Nursey: From Code Blues to Code Browns, How to Care for Your Patients and Yourself, which I’ve read several times. I look forward to catching up on the new additions that Kleber added to this must-read for students and new nurses.
Intensive Care; The Story of a Nurse
Echo Heron
As a new RN in the ICU, I can remember reading this book and its sequel,
Condition Critical; The Story of a Nurse Continues, many times! These true stories that are recounted in this book shed a light on what is happening every day in the lives of nurses and the patients we care for.
For inspiration...
Reflections on Nursing
American Journal of Nursing
These personal accounts from actual nurses are inspiring and demonstrate the true work that nurses do every day. Reading these stories will help you remember why you became a nurse.
Nightingale's Vision: Advancing the Nursing Profession Beyond 2020
Sue Johnson, PhD, RN, NE-BC
Just released, this book features a look at the status of each recommendation from the 2010 Institute of Medicine (IOM) Future of Nursing report. As “an essential reference to guide nurses in the advancement of their profession in the next decade and beyond,” it sounds like a must-read for all of us.
Strictly for pleasure...
My Sister’s Keeper
Jodi Picoult
This one is recommended by a nurse friend, and while I remember being interested when this movie was released, I never did see it. Picoult is the author of 28 novels, and I am planning on picking up this one, and maybe a few others, soon.
Firefly Lane
Kristin Hannah
This is my favorite book and I’ve read it several times – and I will be bringing it along on my vacation again! A tale of friendship – and its ups and downs – that may remind you of some relationships in your own life. There is a sequel,
Fly Away, that you’ll want to check out too!
What other books do you recommend?
Last week, I had the pleasure of speaking with Dr. Patrick Robinson, the Dean of the School of Nursing and Health Sciences at Capella University. Dr. Robinson has a wealth of experiences and achievements in academia and nursing leadership, as well as clinical expertise caring for HIV/AIDS patients. We spoke about his journey in nursing, along with the work being done at Capella University and the Nurses on Boards Coalition to prepare nurses to be leaders in health care.
Some highlights from our conversation include words of wisdom from Dr. Robinson’s own mentor, Joan Shaver, PhD, RN, FAAN, Dean of the School of Nursing at the University of Arizona. In fact, when presented with a problem or challenge, Dr. Robinson often asks himself, “What would Joan do?” Here are three takeaways from this advice:
- Don’t be afraid of resistance.
- Let people grow naturally.
- People have a spectrum for tolerance for change.
You’ll also be inspired by Dr. Robinson’s advice for ‘creating your leadership playbook’ and pursuing lifelong learning. Here are the three foundational ‘plays’ in his own playbook:
- People and their growth matter.
- If you’re going to be there, be present; and realize that you’ll need to be somewhat selective in what you take on.
- Ego will be one of your greatest assets and one of your greatest liabilities – pay attention to it!
Take some time to listen to our full conversation
here.
Thank you, Dr. Robinson for this inspiring conversation and for the important work that you do!
About Dr. Robinson:
F. Patrick Robinson, PhD, RN, FAAN is currently Dean of the School of Nursing and Health Sciences at Capella University. He obtained his bachelors and masters in nursing from Indiana University and holds a PhD in Nursing Science from Loyola University Chicago. He completed a post-doctoral fellowship in biobehavioral nursing research at the University of Illinois at Chicago. Prior, he served as Senior Vice President of Academics for Orbis Education, Dean of Curriculum and Instruction at Chamberlain College of Nursing, Executive Assistant Dean of the University of Illinois at Chicago College of Nursing and Chair of the Department of Health Management and Risk Reduction at the Niehoff School of Nursing at Loyola University Chicago.
Prior to his academic career, Dr. Robinson held positions as an HIV/AIDS case manager, HIV/AIDS clinical nurse specialist, director of a HIV/AIDS specialty clinic and dedicated HIV/AIDS inpatient unit. Dr. Robinson has a distinguished record of service to the HIV/AIDS care community and served as President of the national Association of Nurses in AIDS Care and as an officer of the HIV/AIDS Nursing Certification Board. He maintains certification as an AIDS nurse (ACRN) from the HIV/AIDS Nursing Certification Board and is a Certified Nurse Educator (CNE) through the National League for Nursing. In 2006, he was named distinguished alumnus of Indiana University School of Nursing and was awarded the Frank Lamendola Memorial Award for exemplary leadership in HIV/AIDS care. Also in 2006, the American Association of Colleges of Nurses named him an Academic Nursing Leadership Fellow. In 2008, he was honored by the Illinois Board of Higher Education and the University of Illinois Council on Excellence in Teaching and Learning for distinguished achievement in teaching. In 2010, he was awarded the Life Time Achievement Award from the Association of Nurses in AIDS Care for sustained contributions to the field of HIV nursing. DeVry, Inc. named Dr. Robinson the inaugural recipient of the Doing Well By Doing Good award in 2011 in recognition for his contributions to community service. In 2014, Indiana University School of Nursing honored him as part of its centennial anniversary as one of the top 100 Alumni Legacy Leaders. Previously, he served as executive vice chair of the board of directors of Howard Brown Health Center, one of the nation’s premier LGBT health centers. Dr. Robinson is a fellow of the American Academy of nursing (FAAN) and currently serves on the advisory council for the National League for Nursing Foundation.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is July's nurse story, “Meant to be a Nurse.”
Meant to be a Nurse
Adriana Pirez, BSN, RN
Saint Luke's Cornwall Hospital, Medical/Surgical Unit
All my life I've wanted to be a nurse. The inspiration was in my family, as my aunt Mercedes was the nurse coordinator for a private hospital in my native country of Uruguay. She married a doctor and one of their sons became a doctor too.
On Sunday's when we would gather at grandma's house, as a little girl, I remember hearing conversations about new drugs in the market to fight illnesses, and many stories my cousin would tell about his experiences as a new doctor doing an internship in a local hospital ED. I was mesmerized by their stories, their intelligence and mostly for their love and dedication to their professions. It took me a long time as a woman, a mother, and a wife, in my forties to realize that that dream of being a vocational nurse could be possible here in the U.S. So, after working for years in different hospitals as a unit secretary and a registrar for the Emergency Department, I enrolled in a nursing program at my local community college.
Finally, after so many struggles, lack of support and discrimination from some professors for me speaking with an accent and being different, I maintained a positive attitude, and transferred to a new nursing program in a prestigious Christian College in Rockland County, NY. In 2013, I graduated with honors. It wasn’t always easy, but I would do it all over again – nine years, three colleges and a huge debt in student loans.
Today, I work in my local hospital, the one where the nurses in that ED inspired me even more. I love the smiles on my patients when they see me coming on my second day of my shifts. Their smiles and their trust in my care is the greatest support I can get, knowing that nursing is in my heart and in my Christian soul, and that I was truly meant to be a nurse.
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit
http://lippincottsolutions.com/inspirednurses. Be sure to check our blog every month for a new inspired nurse’s story.
Lippincott Professional Development (LPD) is the 2017 winner of American Nurses Credentialing Center’s (ANCC) Premier Program Award. We are very honored to receive this award which is given to very few organizations that compete each year. The Premier Prize is a public acknowledgement of continuing education (CE) providers that foster leadership, collaboration, and organizational change to overcome barriers to learning, and to improve nursing professional development and/or patient outcomes. The ANCC award also recognizes the innovation used to tackle the challenges of providing lifelong learning to professional nurses inside and outside our organization.
LPD is committed to developing CE that meets the specific and unique learning needs of nurses who work in a variety of settings, specialties, and who perform a variety of roles. LPD collaborates with professional nursing organizations on research, strategic planning, and identification of learning needs of their members to develop relevant CE activities. LPD strives to include innovative delivery mechanisms in its CE activities. Because of the need to engage nurses with different learning styles, we have developed learning activities that include innovative and interactive strategies.
I’m pleased to share photos of our team receiving the ANCC Premier Award on July 18th, 2017.
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Continuing Education
Lippincott Professional Development
Wolters Kluwer
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 Formula
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?
- Convert pounds to kilograms: 210 pounds ÷ 2.2 kg/pound = 95.45 kg
- Calculate height in meters:
- 6 feet, 3 inches = 75 inches
- 75 inches x 2.54 cm/inch = 190.5 centimeters (cm)
- 190.5 cm ÷ 100 cm/m = 1.905 meters
- Square the height (1.905 x 1.905) = 3.63 m2
- Calculate BMI by dividing the weight by the height (m)2
- 95.45 kg ÷ 3.63 m2 = 26.3 kg/m2
Example 2: What is the BMI for Mr. Smith weighing 210 pounds and 5 feet, 4 inches tall?
- 210 pounds = 95.45 kg
- Calculate the height in meters:
- 5 feet, 4 inches = 64 inches
- 64 inches x 2.54 cm/inch = 162.56 cm
- 162.56 cm = 1.625 meters
- Square the height (1.625 x 1.625) = 2.64 m2
- Calculate BMI:
- 95.45 kg ÷ 2.64 m2 = 36.2 kg/m2
Example 3: What is the BMI for Mrs. Williams weighing 110 pounds and 5 feet, 8 inches tall?
- 110 pounds = 50 kg
- Calculate height in meters:
- 5 feet, 8 inches = 68 inches
- 68 inches x 2.54 cm/inch = 172.72 cm
- 172.72 cm = 1.727 m
- Square the height = 2.98 m2
- Calculate BMI:
- 50 kg ÷ 2.98 m2 = 16.8 kg/m2
What does a BMI Score Mean?
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/m
2 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
BSA Formula
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
- Calculate weight in kilograms: 210 pounds ÷ 2.2 = 95.45 kg
- Calculate height in centimeters: 6 feet, 3 inches = 75 inches x 2.54 cm/inch = 190.5 cm
- Multiply height by weight and divide by 3600
- (190.5 cm x 95.45 kg) ÷ 3600 = 5
- Take the square root of 5 = 2.24 m2
Example 2: Mr. Smith
- Weight in kg = 95.45 kg
- Height in cm: 5 feet, 4 inches = 64 inches x 2.54 cm/inch = 162.56 cm
- (162.56 cm x 95.45 kg) ÷ 3600 = 4.3
- Take square root of 4.3 = 2.07 m2
Example 3: Mrs. Williams
- Weight in kg = 50 kg
- Height in cm: 5 feet, 8 inches = 68 inches x 2.54 cm/inch = 172.72 cm
- (172.72 cm x 50 kg) ÷ 3600 = 2.39
- Take square root of 2.39 = 1.55 m2
How to Use a BSA Score
The average adult BSA is 1.7 m
2 (1.9 m
2 for adult males and 1.6 m
2 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 m
2 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 m
2, has a cardiac output of 4.3 L/min, his cardiac index would be 1.92 L/min/m
2 (4.3 L/min divided by 2.24 m
2). If Mrs. Williams, whose BSA is 1.55 m
2, has the same cardiac output of 4.3 L/min, her cardiac index would be 2.77 L/min/ m
2. While 4.3 L/min falls within the normal range for cardiac output, Mr. Jones’ cardiac index of 1.92 L/min/m
2 is below the normal range of 2.5 – 4.0 L/min/m
2. 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 vs BSA formulas was helpful. We would love to hear your feedback for ways in which you use BMI and BSA in your daily practice.
BMI vs BSA References
-
-
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is August’s nurse story, “A Better Life.”
A Better Life
Helene Vossos, DNP, PMHNP-BC, ANP
Stewart Marchman ACT Behavioral Services
As nurses, we must recognize how vulnerable mental health patients often feel, which can impact their access to mental health services.
As a mental health nurse, I participated in an "Open Access Model" to "walk in" appointments in an outpatient clinic that improved access to mental health services from 54% up to 94%. Many of our inpatient, outpatient, home health care and homeless patients lack communication skills and resources, and all nurses can help make a difference when coordinating their care. As a case study, we talk about Miguel, who is a 32-year-old immigrant from Puerto Rico, homeless in Florida, has a history of schizophrenia and is a new resident. He came to the states by boat, "for a better life." His history includes three previous self-inflicted stabbings to his abdomen and chest when he was out of medication and when "the voices were loud and commanding."
Historically Miguel was in contact with emergency department nurses, medical-surgical nurses, OR nurses, case manager nurses, mental health nurses and nurse practitioners for the past three years. All of these nurses are "mental health nurses" by proxy, as they all touched his life, saving him and helping him to maintain stability and get the health care services he needs by providing "walk-in" status during open-access for mental health services, and have provided a translator as well as additional assistance in maintaining appropriate medication and continuing outpatient services. Nurses save lives in all ways of collaboration, caring and research translated into clinical practice!
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit http://lippincottsolutions.com/inspirednurses. Be sure to check our blog every month for a new inspired nurse’s story.
National Clinical Nurse Specialist Recognition Week, is September 1-7, 2017! We wish all Clinical Nurse Specialists a wonderful week, and we thank you for knowledge, skills, hard work, and dedication. The content below has been specially selected to help you in your practice. Have a great week!
Specially-priced CE collection:
Clinical Nurse Specialists
5.0 contact hours/$19.99
That's a savings of over $35!
Every 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!
References
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.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse, Wolters Kluwer
As many of you know, I am a practicing acute care/critical care nurse practitioner in a hospital in the Philadelphia area. Recently I was called to a rapid response on a medical floor. The patient was an elderly gentleman who was admitted for a urinary tract infection the day prior and now had a temperature of 103° F, a systolic blood pressure of 80/50 mm Hg (normally 130/72), a respiratory rate of 26/min and has gone from being awake, alert and oriented to being lethargic. This scene plays out every day in our healthcare system; so how did the nurse know to call for the rapid response team to come evaluate the patient? She used the qSOFA (Quick Sequential Organ Failure Assessment) tool which identifies patients who are at risk for a poor outcome. Based on the nurse’s quick, critical thinking, the patient was evaluated and the diagnosis was changed to septic shock secondary to a urinary tract infection and he was transferred to the critical care unit for management and he survived. The nurse was the hero in this situation because she recognized this patient was in septic shock.
Sepsis, learning from the past
Sepsis is thought to occur in 750,000 people in the U.S. each year and it’s one of the leading causes of mortality and critical illness worldwide (Angus, 2013; Dieter-Lessnau, 2015). Sepsis is not a new diagnosis but, the guidelines on how to best recognize and manage it have been refined over the years as we learn more about this devastating diagnosis. In 2016, the definition of sepsis was changed to better reflect new knowledge on the pathophysiology of sepsis. For years, we have used the Systematic Inflammatory Response Syndrome (SIRS) criteria to identify patients with sepsis; however, new research has determined that the SIRS criteria was unhelpful because a SIRS response occurs with many other conditions and does not indicate dysregulation as once thought (Singer, et al., 2016; Rhodes, et al., 2017).
A new sepsis definition
As a result, a new definition of sepsis was established and was described in
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis 3) in 2016 (Singer, et al., 2016). In 2017, The
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock were published (Rhodes, et al., 2017). Sepsis is now defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, et al., 2016; Rhodes, et al., 2017). Septic shock is defined as a subset of sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality (Singer, et al., 2016; Rhodes, et al., 2017). The term ‘severe sepsis’ has been eliminated from the definitions.
Early recognition is key
We know that early recognition of a patient with sepsis and septic shock is the first step in sepsis management. What tools are available to nurses to identify a patient who is likely to have a poor outcome due to organ dysfunction potentially related to sepsis? New definitions and guidelines have identified two tools that can be used by healthcare professionals to help identify a patient at risk for poor outcomes.
The qSOFA tool is a resource to be used outside of a critical care unit, such as in the emergency department or a medical/surgical unit, or primary care/urgent care, to identify these types of patients.
The qSOFA tool looks at 3 variables:
- Respiratory rate greater than or equal to 22/min
- Altered mentation
- Systolic blood pressure less than or equal to 100 mm Hg (Singer, et al., 2016; Rhodes, et al., 2017).
The SOFA tool is used with critical care patients to identify a higher risk of patient mortality. Any change in 2 points or greater is equal to a higher risk of mortality. The variables evaluated in the SOFA tool are:
- Respirations
- Coagulation
- Liver function
- Cardiovascular system
- Central nervous system
- Renal system
Post-Sepsis Syndrome Reality
Patients who live through an experience of sepsis often have post-sepsis syndrome and exhibit long-term physical, psychological, and cognitive disabilities which result in health and social implications (Iwashyna, 2010). It is imperative that nurses recognize this syndrome and educate their patients and their families and other members of the support network, about this condition.
Nurses, you are an integral part of the interdisciplinary team
Without a doubt, nurses are key in sepsis early recognition, management and education because you are with the patient 24 hours a day. Having access to the latest evidence-based clinical practice guidelines and using them for clinical decision support is crucial to improving patient outcomes.
Sepsis Alliance has an assortment of valuable resources for healthcare professionals and patients on sepsis. Wolters Kluwer is proud to partner with Sepsis Alliance to improve knowledge on this devastating, but preventable, condition.
References
Angus, D. C. (2013). Severe sepsis and septic shock. New England Journal of Medicine, 840-851.
Dieter-Lessnau, K. (2015, Oct. 8). Distributive shock. Retrieved July 20, 2016 from Medscape: http://emedicine.Medscape.com/article/168689-overview#a3
Iwashyna, T., et al. (2010). Long-term cognitive impairment and functional disability among survivors of sepsis. JAMA,304(16):1787-1794.
Rhodes, M.B., Evans, L.E., Alhazzani, W., et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
SepsisAlliance.org
Singer M., Deutschman, C.S., Seymour C.W., et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
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…
Collaboration
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.
Communication
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.
Cooperation
I 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.
The Surviving Sepsis Campaign (SSC) is the leading organization responsible for educating healthcare professionals on the most current scientific evidence on the timely and appropriate treatment of sepsis. This ultimately allows us to positively impact sepsis-related morbidity and mortality.
Over the past year and a half there have been several major updates to best practices in the field of sepsis. In 2016, Singer, et al., published “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” which provided updated definitions and clinical criteria for Sepsis and Septic Shock with the elimination of the terms
severe sepsis and
SIRS. The new terminology defines sepsis as life threatening organ dysfunction caused by a dysregulated host response to infection and septic shock as a subset of sepsis in which underlying circular and cellular/metabolic abnormalities are profound enough to substantially increased mortality (Singer et al. 2016). Clinically, the septic shock subset are those patients with refractory hypotension despite adequate fluid resuscitation requiring vasoactive medications to maintain a mean arterial pressure (MAP) > 65 mmHg.
In March 2017, the Surviving Sepsis Campaign (SSC) published updated guidelines on the management of Sepsis and Septic Shock. This document, titled “
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016” provides updated recommendations to the version published in 2012 and includes 93 statements on early management of sepsis and septic shock. A major difference evident in the new guidelines is a movement from protocolized management to a more individualized, “patient-centered” approach guided by dynamic variables and ongoing evaluation of clinical response to treatment (DeBaker & Dorman, 2017).
As the scientific and medical community’s understanding of sepsis and the pathobiology driving this life-threatening condition grows, it is essential that the APN stays abreast of changes to management based on the most up-to-date information.
Below is a summary of the recent SSC guidelines (Rhodes, et al., 2017) with a focus on material most pertinent to our practice as APNs.
- Initial Resuscitation
- Fluids
- Begin fluid resuscitation with crystalloid fluids immediately for sepsis-induced hypo-perfusion. Ideally, aim for at least 30 mL/kg completed within the first 3 hours from time of diagnosis.
- Crystalloids are the fluid of choice for initial fluid resuscitation.
- Recommendations against hydroxyethyl starches or bicarbonate therapy as an agent to improve hemodynamics or reduce vasopressor requirement.
- Following initial resuscitation, hemodynamic assessment should be used to guide further fluid administration using invasive and non-invasive measures.
- Include clinical exam and evaluation of available physiologic variables including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output.
- Evaluate fluid responsiveness by the following means:
- Dynamic variables:
- Passive leg raise
- Pulse or stroke volume variations induced by mechanical ventilation
- Lactate clearance
- Discontinue fluid administration if response is no longer beneficial.
- Target a mean arterial pressure (MAP) of 65 mmHg in those with septic shock.
- Vasoactive Medications
- Initial vasoactive medication of choice should be norepinephrine.
- Consider the addition of vasopressin (at 0.03 units/min) or epinephrine to reach target MAP or to decrease the dose of norepinephrine.
- Consider arterial catheter placement for the monitoring of blood pressure in those requiring the use of vasoactive medications.
- In the absence of response or if clinical assessment does not lead to clear diagnosis, consider evaluation for other types of shock (DeBaker & Dorman, 2017).
- Diagnosis/Source Control – obtain both as soon as possible with early antibiotic therapy.
- Goal to identify or exclude anatomic source requiring emergent intervention as soon as possible; this includes removal of intravascular access if possible source of infection.
- Obtain at least two sets of blood cultures prior to initiation of antibiotics in all patients with suspected sepsis or septic shock if it will not delay initiation of treatment.
- Antibiotic therapy
- Initiate one or more empiric broad-spectrum antibiotics as early as possible and within 1 hour (maximum) of recognition of sepsis or septic shock to cover all suspected pathogens.
- Evaluate daily for potential de-escalation/narrowing of antibiotics based on pathogen identification and clinical improvement.
- Limit combination therapy (double coverage) to patients with septic shock.
- Do not continue antibiotics for severe inflammatory states (i.e. systemic inflammatory response syndrome [SIRS]) with no infectious etiology.
- Duration of antibiotic treatment should be 7-10 days.
- Extend for slow clinical response, undrainable foci, staph aureus, or neutropenia.
- Shorten course for quick clinical response, adequate source-controlled, GU/UTI or simple pyelonephritis.
- Consider procalcitonin measurement to support de-escalation of antibiotics in patients with sepsis and to support discontinuation of antibiotics in those who ultimately have limited clinical evidence of bacterial infection.
- Although there is low quality of evidence and a weak recommendation by the SSC, many institutions have adopted use of this biomarker in the management of sepsis.
- Blood products
- Limit red blood cell transfusions to those patients with hemoglobin concentration < 7 g/dL. Consider higher threshold in select clinical populations (i.e. acute hemorrhage/ongoing active bleeding, acute coronary syndrome with ischemia, symptomatic anemia).
- Mechanical ventilation
- In all mechanically ventilated patients with sepsis:
- Utilize lower tidal volume strategy using predicted body weight.
- HOB 30-45 degrees.
- Spontaneous breathing trials in those ready for weaning.
- Minimize sedation and set targets for titration end points.
- In patients with sepsis-induced acute respiratory distress syndrome (ARDS):
- Target tidal volume = 6 mL/kg
- Upper limit goal for plateau pressures of 30 cm H20
- Higher PEEP strategy
- Recruitment maneuvers for those with sepsis-induced severe-ARDS and refractory hypoxemia
- Consider prone positioning if paO2/FiO2 ratio < 150.
- Conservative fluid strategy
- Glucose Control
- Begin an insulin administration protocol for patients with sepsis and two consecutive blood glucose readings > 180 mg/dL.
- Target glucose ≤ 180 mg/dL, rather than upper limit ≤ 110 mg/dL
- Nutrition
- Begin early enteral nutrition rather than parenteral nutrition or combination in critically ill patients with sepsis or septic shock (Rhodes et al. 2017).
- If early enteral feeds are not possible, begin IV dextrose and advance enteral feeds as tolerated rather than initiating parenteral nutrition during the first seven days of critical illness. This may include trophic or hypocaloric feedings and advance as tolerated.
- Gastric residual volumes should only be considered when there is enteral feeding intolerance or high risk of aspiration, rather than routinely.
- Stress Ulcer prophylaxis
- Begin in those patients with sepsis and septic shock AND risk factors for gastrointestinal bleeding; may use either proton pump inhibitor or histamine-2 blocker.
- VTE prophylaxis
- Initiate pharmacologic prophylaxis unless contraindicated. Rhodes et al. (2017) recommends LMWH rather than UFH in absence of contraindications to LMWH, in combination with mechanical prophylaxis in absence of contraindications.
- Communication
- Discuss goals of care and prognosis with patients and family as early as feasible, incorporating end-of-life planning and palliative care principles, when appropriate.
References:
De Backer, D. and Dorman, T. (2017). Surviving Sepsis Guidelines. A Continuous Move Towards Better Care of Patients With Sepsis. The Journal of the American Medical Association, 317(8).
Rhodes, M.B., Evans, L.E., Alhazzani, W, et al. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Critical Care Medicine, 45(3).
Singer M, Deutschman CS, Seymour CW, et al. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). The Journal of the American Medical Association, 315(8).
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: April 22, 2024
Sepsis is a life-threatening, medical emergency affecting approximately one million persons annually in the United States (NIH, 2023). Patients hospitalized with sepsis are eight times more likely to die during hospitalization (Hall et al., 2011). Early identification and treatment are the cornerstones of sepsis management. As nurses, we are in a position to directly impact sepsis-related morbidity and mortality. We are on the frontline in the care of the hospitalized patient. Being cognizant of the subtle clinical changes indicative of impending clinical decline is critical for timely interventions and avoidance of poor clinical outcomes.
In 2016, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)” was published (Singer et al., 2016). As nurses, there are several key points from this publication that we should be familiar with. First, the terminology related to sepsis has changed, but the basis of the definition of sepsis has not. Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection;” the term severe sepsis has been eliminated; and septic shock is defined as a “subset of sepsis in which underlying circulatory, cellular and metabolic abnormalities are profound enough to substantially increase mortality” (Singer et al., 2016). Clinically, those in septic shock have been given the standard fluid resuscitation (30 mL/kg) with refractory hypotension/hypoperfusion requiring vasoactive medications to maintain a mean arterial pressure (MAP) greater than 65 mmHg. Furthermore, Systemic Inflammatory Response Syndrome (SIRS) is no longer part of “sepsis” terminology. Previously, sepsis was considered SIRS with an infectious etiology.
As with many medical conditions that we see on a regular basis, there are continual advances in the understanding of the disease, both from a medical and scientific perspective. With these advances come changes to best practice recommendations. It is essential that nurses stay well-informed of these developments. The latest update to the Surviving Sepsis Campaign’s International Guidelines for Management of Sepsis and Septic Shock was released in 2021 (Evans et al., 2021). Below is a summary of recommendations based on the most recent literature on sepsis with a focus on what is most pertinent to our practice as nurses.
Tips for nurses taking care of patients with sepsis (Evans et al., 2021; SSC, 2019)
Recommendation: Sepsis and septic shock are medical emergencies, treatment and resuscitation should begin immediately.
Recommendation: For patients with sepsis-induced hypoperfusion or septic shock administer at least 30 mL/kg of intravenous (IV) crystalloid fluid within the first 3 hours of resuscitation.
- Tip: Crystalloids refer to IV fluids with a balanced electrolyte composition, such as normal saline or lactated ringers solution (as opposed to colloids, such as albumin or hetastarch).
- Tip: This initial fluid bolus is often referred to as a fluid challenge.
- Tip: In those patients diagnosed with sepsis, the nurse plays a critical role in monitoring appropriate administration of fluids as the patient transitions between levels of care (i.e., emergency department [ED] to floor; floor to intensive care unit [ICU]).
Recommendation: Measure lactate level; if elevated (greater than 2 mmol/L), ensure that a repeat level is obtained within 2-4 hours. In patients with sepsis or septic shock, resuscitation should be guided to decrease serum lactate in patients with elevated lactate levels.
- Tip: Lactate (or lactic acid) is a byproduct of glycolysis in anaerobic metabolism.
- Tip: In the septic patient, think of elevated lactate as a sign of tissue hypoperfusion.
Recommendation: Obtain two or more sets of blood cultures prior to the administration of antibiotics; at least one set should be peripheral, the other from a vascular access device, if present.
- Tip: Bacteremia is common in patients with sepsis; collecting cultures prior to administration of antibiotics gives us the best chance of identifying the correct organism before antibiotics have a chance to affect the growth of pathogens.
- Tip: A “set” of blood cultures is collected in 2 separate bottles, one anaerobic culture bottle and one aerobic culture bottle.
Recommendation: Administer broad-spectrum antibiotics (covering gram-positive and gram-negative organisms) within one hour of diagnosis or in those with high clinical suspicion for sepsis or septic shock.
- Tip: Controlling the source of infection, either with antibiotics or intervention for those infections amenable (wound drainage, debridement, removal of potentially infected device, cholecystectomy), is the foundation of treating patients with sepsis or septic shock.
- Tip: Failure to control the source of infection could lead to persisting or worsening sepsis or septic shock and the inability to stabilize your patient.
- Tip: If a patient is not getting better, think “Do we have adequate source control?”
Recommendation: Administer vasoactive medications if a patient remains hypotensive or if lactate remains elevated following initial fluid resuscitation. Vasoactive medications should be titrated to a mean arterial pressure (MAP) greater than 65 mmHg.
- Tip: Norepinephrine (Levophed) is typically the first vasopressor that is initiated. This is typically started at 2-5 mcg/min and titrated to a MAP greater than 65 mmHg.
- Tip: The second vasoactive medication added is typically vasopressin at 0.03 U/min or 0.04 U/min. This medication does NOT get titrated and can be added in an attempt to decrease the dose of norepinephrine.
Recommendation: In taking care of a patient with sepsis, it is imperative to reassess hemodynamics, volume status and tissue perfusion regularly.
- Tip: Frequently reassess blood pressure, heart rate, respiratory rate, temperature, urine output, and oxygen saturation.
- Tip: Dynamic measurements such as passive leg raising (PLR) are recommended to assess for fluid responsiveness. PLR mimics endogenous volume expansion (equivalent to a 300 mL fluid bolus) and can be thought of as a preload challenge. It is used to predict if a patient will respond to additional fluid boluses. Follow these steps to perform PLR (Mikkelsen et al., 2023):
- Position the patient in the semi-recumbent position with the head and torso elevated at 45 degrees.
- Obtain a baseline cardiac output (CO) measurement.
- Lower the patient's upper body and head to the horizontal position and raise and hold the legs at 45 degrees for one minute.
- Obtain subsequent CO measurement.
- The expected response to this maneuver in those that are fluid responsive is a 10% or greater increase in CO. Although not considered a validated measure, blood pressure is often used as a surrogate marker of CO in evaluating response to the PLR.
New Recommendation: The quick Sequential Organ Failure Assessment (qSOFA) score should
not be used as a single screening tool for sepsis or septic shock.
- What is the qSOFA?
- If your patient has 2 of the following criteria, be concerned for sepsis.
- Respiratory rate greater than 22 breaths/min
- Altered mental status
- Systolic blood pressure of 100 mmHg or less
- What’s new?
- qSOFA was a recommended tool in the 2016 guidelines.
- Found to be poorly sensitive; may not capture sick patients
- The Surviving sepsis campaign guideline (Evans et al., 2021):
- Although the presence of a positive qSOFA should alert the clinician to the possibility of sepsis in all resource settings, given the poor sensitivity of the qSOFA, the panel issued a strong recommendation against its use as a single screening tool.
- Studies suggest that only 24% of infected patients had a qSOFA score of 2 or 3, but these patients accounted for 70% of poor outcomes (Seymour et al., 2016).
- The panel concluded that the qSOFA could be used to alert clinicians of the possilbity of sepsis but shouldn’t be used as a single screening tool.
Remember, sepsis is a medical emergency and should be treated as one. Early identification and management of sepsis improves patient outcomes. Nurses have the capacity to make a difference both clinically and system-wide. Actively participate in hospital-wide performance improvement programs and share your experiences and expertise. You can have a global impact on how we manage sepsis and septic shock in the future.
References:
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
Hall, M. J., Williams, S. N., DeFrances, C. J., & Golosinskiy, A. (2011). Inpatient care for septicemia or sepsis: a challenge for patients and hospitals. NCHS data brief, (62), 1–8.
Jones, A. E., Trzeciak, S., & Kline, J. A. (2009). The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Critical care medicine, 37(5), 1649–1654. https://doi.org/10.1097/CCM.0b013e31819def97
Mikkelsen, M.E., Gajeski, D.F., & Johnson, N.J. (2023, December 8). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock
National Institutes of Health (NIH): National Institute of General Medical Sciences. (2023). Sepsis Fact Sheet. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx.
Seymour, C. W., Liu, V. X., Iwashyna, T. J., Brunkhorst, F. M., Rea, T. D., Scherag, A., Rubenfeld, G., Kahn, J. M., Shankar-Hari, M., Singer, M., Deutschman, C. S., Escobar, G. J., & Angus, D. C. (2016). Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 762–774. https://doi.org/10.1001/jama.2016.0288
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
Surviving Sepsis Campaign (SSC) (2019). SSC Hour-1 Bundle Updated. http://survivingsepsis.org/News/Pages/SCCM-and-ACEP-Release-Joint-Statement-About-the-Surviving-Sepsis-Campaign-Hour-1-Bundle.aspx.
This blog is the second in the series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition.
In this turbulent era in healthcare, we are all called to be cognizant of our input and its potential impact on our society and nursing, specifically in inner cities, rural America, suburban America, U.S. territories, and internationally. Sharing your input on important decisions often requires taking an ethical stance. The decision-making lenses that we use are impacted by our personal and professional core values, experiences, backgrounds, and preparedness. The
American Nurses Association Code of Ethics and
Nurses on Boards Coalition’s Board Core Competencies may serve as a guide as you take a stance for building a healthier America.
10 Key considerations in ethical decision-making for a positive outcome:
- Do your homework on the topic.
- Be objective; consider all perspectives before drawing your own conclusions.
- Maintain curiosity and an eagerness to explore all relevant ideas and approaches.
- Seek out the perspective of all stakeholders; listen with an open mind.
- Consider the social determinants of health.
- Express empathy; consider the implications of the decision on others.
- Provide evidence-based rationale to substantiate your position.
- Strive for the best possible outcomes for the benefit of all.
- Communicate your position with clarity, and be succinct.
- Engage in reflective practice.
According to Pam Rudisill, DNP, RN, MSN, NEA-BC, FAAN, Senior Vice President and Chief Nursing Officer at Community Health Systems (CHS) in Tennessee, AONE, Past President,
"Nurse leaders are faced with challenges and opportunities every day that impact patient outcomes and quality of life for patients and their families. It is a moral imperative of the profession that our collective thoughts and actions model the highest ethical standards. The same principles chief nurse executives use in everyday practice are applicable to service on a board. The Code of Ethics developed by the American Nurses Association serves as a guide to assure nursing responsibilities are consistent with quality of care and ethical decision making.
Call to Action:
Your role and confidence as a nurse leader in taking an ethical stance is critical as you serve or aspire to serve on a board. We hope our column serves as a reflective tool to strengthen your ethical influence when serving on boards and in other leadership roles.
References :
American Nurses Association (2015). Code of Ethics. http://www.nursingworld.org/codeofethics
International Council of Nursing (2012). The ICN Code of Ethics for Nurses. Geneva, Switzerland. http://www.icn.ch/who-we-are/code-of-ethics-for-nurses
Nurses on Boards Coalition (2017). Board Core Competencies. http://www.nursesonboardscoalition.org
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: April 14, 2024
Sepsis is a medical emergency. It is a complication of the body’s response to an infection that can lead to life-threatening tissue damage, organ failure and death (CDC, 2023). According to the Centers for Disease Control and Prevention (CDC), each year, at least 1.7 million adults will develop sepsis and at least 350,000 of those affected will die (CDC, 2023). By increasing awareness of the early signs and symptoms of sepsis and risk factors for developing sepsis, we could improve survival and decrease complications. Like many life-threatening conditions, time is of the essence. Early detection and treatment of sepsis is the cornerstone of managing this medical emergency. In the United States (US), the total annual costs associated with hospitalization and skilled nursing for patients who are treated for sepsis are estimated at $62 billion (Buchman et al., 2020). It is the most expensive condition treated in US hospitals (Torio & Moore, 2016). To increase awareness and improve outcomes related to sepsis, we summarized key teaching points to communicate with patients and the public about this medical emergency.
Here are the top 10 things to teach patients and the public about sepsis:
- Any type of infection can lead to sepsis. The four most common are lung, urinary tract, GI tract, and skin infections (CDC, 2023).
- Most cases of sepsis begin outside of the hospital (CDC, 2023).
- Sepsis affects approximately 1.7 million people in the US annually; 1 in 3 patients that die during hospitalization were impacted by sepsis (CDC, 2023).
- Sepsis is the result of an abnormal inflammatory response that the body has to an infection. The overwhelming inflammatory reaction is what leads to the symptoms of sepsis and the associated organ failures.
- Risk factors for developing sepsis are age (those older than 65 and those under one-year old are highest at risk); weakened immune systems due to medication or disease; chronic illness, such as diabetes or COPD; people with recent severe illness or hospitalization; and people who survived sepsis (CDC, 2023).
- Early signs and symptoms of sepsis include fever, chills, fast heartbeat, confusion, shortness of breath, rapid breathing or severe pain (with no obvious cause).
- There are no specific diagnostic tests for sepsis. Diagnosis is based on clinical examination which is why it is critical to seek prompt medical attention if there is any concern for sepsis.
- Taking measures to prevent infection, such as hand washing, vaccinations, and smoking cessation (since chronic lung disease is a risk factor), can help prevent infections that could lead to sepsis.
- There are likely genetic components and other biological factors that make some people more susceptible to developing sepsis in response to an infection. Ongoing research continues to help us understand sepsis and the optimal treatment supporting the goal to improve early diagnosis and improve outcomes.
- Seek medical attention if you have an infection and any signs or symptoms of sepsis. Early identification and treatment are critical in improving survival and reducing complications.
Improving public awareness of sepsis can save lives. By educating patients and the public, you can make a difference by encouraging someone to seek treatment for this medical emergency that can potentially be overlooked and mistaken for other less threatening illness. Are there any other important items you routinely educate your patients and families about to improve awareness of sepsis? If so, please share your expertise with us.
References:
Buchman, T. G., Simpson, S. Q., Sciarretta, K. L., Finne, K. P., Sowers, N., Collier, M., Chavan, S., Oke, I., Pennini, M. E., Santhosh, A., Wax, M., Woodbury, R., Chu, S., Merkeley, T. G., Disbrow, G. L., Bright, R. A., MaCurdy, T. E., & Kelman, J. A. (2020). Sepsis Among Medicare Beneficiaries: 3. The Methods, Models, and Forecasts of Sepsis, 2012-2018. Critical care medicine, 48(3), 302–318. https://doi.org/10.1097/CCM.0000000000004225
Centers for Disease Control and Prevention (CDC). Sepsis Questions and Answers. https://www.cdc.gov/sepsis/basic/qa.html
Centers for Disease Control and Prevention (CDC). (2023, August 24). What is Sepsis? https://www.cdc.gov/sepsis/what-is-sepsis.html
Centers for Disease Control and Prevention (CDC). (2023, September 11). Get Ahead of Sepsis – Know the Risks. Spot the Signs. Act Fast. https://www.cdc.gov/patientsafety/features/get-ahead-of-sepsis.html
National Institutes of Health (NIH): National Institute of General Medical Sciences. Sepsis Fact Sheet. Updated January 2017. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx .
Torio, C.M. & Moore, B.J. (2016). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013. Statistical Brief #204. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. https://www.ncbi.nlm.nih.gov/books/NBK368492/#sb204.s2
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is September’s nurse story, “I’m Just Like You.”
I’m Just Like You
Angela Townsend, BSN, RN
Home Health
When I was 17, I was diagnosed with Type 1 Diabetes. It was at that moment when I decided to become a nurse. I've found that my own personal experience having a chronic illness has not only increased my understanding and passion for teaching others with diabetes, it has allowed me an empathy towards my patients that I never thought possible. I teach my patients about their illnesses and let them know, "hey, I have to do this too." It has made my experience as a nurse in an ever-changing world of medicine, so much more rewarding!
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit
http://lippincottsolutions.com/inspirednurses. Be sure to check our blog every month for a new inspired nurse’s story.
Las Vegas is different this week. And that’s no surprise. This city has been shocked by the largest mass shooting in modern U.S. history. Some of us were here that day; some of us flew in on Monday. All of us are safe. All of us are deeply saddened. All of us want to do something to help.
Nursing Management Congress 2017, our annual conference for nurse leaders, is taking place this week at The Mirage Casino & Resort. Conference staff and attendees came to Las Vegas to continue our tradition. And while it’s been a different mood here this week, we will not let the actions of one person stop us from learning, networking, and supporting one another. We’re nurses. We are here and we are here to help.
What we’ve been doing
Upon arrival here, our conference chairperson, Pamela Hunt, BS, MSN, RN, NE-BC, immediately contacted University Medical Center to see how our large group of nurse leaders could best serve their network. Because of the overwhelming response from local businesses and volunteers, our services have not been required on-site. Like many all over the world, we have been thinking and praying for the victims and their families, and all the first responders and health care providers.
“
We are truly saddened and heartbroken at the recent events and tragedy in Las Vegas. While we continue to hold the victims and families in our thoughts and prayers – we are a resilient and dedicated group of nursing professionals who have gathered for a week of learning, education and networking. Our goal is to remain committed to providing strategies for improving the quality and cost-effectiveness of care delivery as nursing best practices. And no one will take that from us.”
-Pamela Hunt, BS, MSN, RN, NE-BC, Nursing Management Congress2017 Chairperson
In a sad coincidence, the topic of the keynote address was Orlando Active Shooter: Lessons Learned. We all listened closely to this sobering presentation from Michael L. Cheatham, MD, FACS, FCCM, Chief Surgical Quality Officer, Orlando Regional Medical Center. Dr. Cheatham emphasized the importance of preparation and drills, focusing on being ready
when, not
if, the next mass casualty occurs.
Here are some things other things I learned:
- There have been 273 mass casualty events this year as a result of gun violence.
- During a mass casualty event, the Health Insurance Portability and Accountability Act (HIPAA) allows sharing of names and conditions to identify victims.
- While we know gun violence is a public health crisis, the Dickey Amendment prohibits the use of federal funds to study this issue.
- Stop the Bleed is an initiative to train the public how to help in a bleeding emergency.
In coordination with the Mirage Casino & Resort, a blood drive was organized to be held here at the conference. We are proud of the nurse leaders who are lining up to contribute to this cause! As nurses, we know how important it is to have an adequate supply of blood products for a typical shift. I can only imagine the number of units of blood that have been transfused at UMC over the past several days.
What you can do
Thousands of people attended the outdoor concert on Sunday, October 1, 2017. There were also many witnesses including hotel guests, entertainers, and employees in the tourism industry During a cab ride from the airport to Nursing Management Congress, Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN, Executive Director, Continuing Education, listened to her taxi driver share her experience driving many frightened concert-goers away from Mandalay Bay. The driver kept repeating “I was in shock.”.
Unlike many other mass casualty events that had a local impact, the survivors and witnesses who were tourists in Las Vegas will be heading home to their communities around the U.S. They may present to your health system, clinic, or office for health care in the coming months. They may experience post-traumatic stress disorder (PTSD). Will you be able to recognize it?
The
National Institutes for Mental Health identifies four diagnostic criteria for PTSD (National Institute of Mental Health, 2016):
- At least one re-experiencing symptom (flashbacks, bad dreams, frightening thoughts)
- At least one avoidance symptom (staying away from places that are reminders of the trauma, avoiding related thoughts and feelings)
- At least two arousal and reactivity symptoms (startling easily, feeling tense, sleeping difficulty, angry outbursts)
- At least two cognition and mood symptoms (trouble remembering key features of the trauma, negative thoughts about self or the world, guilt or blame, loss of interest in enjoyable activities)
It is critical for all of us to be prepared both for the occurrence of mass casualty events and for the care of patients who are affected as a result. Recognize the importance of preparation and drills. Make sure your institution has a Hospital Incident Command Center. Ask questions. Get involved. Be prepared.
Reference
National Institute of Mental Health. (2016, February). Post-Traumatic Stress Disorder. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
Lisa Bonsall, MSN, RN, CRNP
Senior Clinical Editor, Lippincott NursingCenter.com
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Continuing Education
Earlier this month, we had a great showing of advanced practice nurses for our fall
National Conference for Nurse Practitioners (NCNP). It was one week after
Nursing Management Congress2017 and one week after the
deadly mass shooting in Las Vegas. Being in town for both conferences was an experience – as we shifted gears for a different group of nursing professionals and also remained a presence in a city that was dealing with tragedy and starting to heal.
As a frequent attendee at NCNP, I often attend a wide variety of topics and speakers. With my background in critical care and women’s health, I am interested in both the acute care and primary care sessions. I had the opportunity this time to meet and learn from new experts and I found myself picking up on a certain theme, which I didn’t realize when I originally registered and picked my sessions! I think you’ll pick up on this as you read through some of these clinical and professional pearls that I picked up at the conference…
“Isn’t it time that nursing is referred to as one of the STEM [science, technology, engineering, and mathematics] professions?”
Keynote Address: Finding Your NP Voice
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
“A high HDL cholesterol is only as good as a low LDL.”
Dyslipidemia: Going Beyond the Current Treatment Options
Joyce L. Ross, MSN, CRNP, CLS, FNLA, FPCNA
“One in four heroin users started with prescription opioids.”
New Trends in Street Drugs and Legal Highs Part 1
Andrea Efre, DNP, ARNP, ANP-BC
“The opioid OD triad: unresponsive/coma, respiratory depression/failure, and CNS depression (mioisis).”
New Trends in Street Drugs and Legal Highs Part 2
Andrea Efre, DNP, ARNP, ANP-BC
“When calculating the anion gap, for every one gram decrease in albumin from normal, add 2.5 to anion gap.”
Understanding Sepsis
Sophia Chu Rodgers, FNP, ACNP, FAANP, FCCM, FAANP
“Repeated doses of ibuprofen and acetaminophen can prolong the duration of a viral illness.”
Antimicrobial Update: A Focus on Respiratory Infections
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
“Adverse drug reactions are responsible for an increase of two days for hospital length of stay.”
Pharmacogenomics and Chronic Pain: Putting Science Back Into the Treatment of Pain
Brett Badgley Snodgrass, MSN, FNP-BC
“Herbal and dietary supplements are at least the fourth most common cause of drug-induced hepatic disease necessitation liver transplant.”
5 Things I Wish I Knew Last Year
Louis Kuritzky, MD
“Prescribing cascade refers to when a new problem arises that is associated with the side effect of a medication and additional medications are added to treat it.”
Polypharmacy: What the Nurse Practitioner Should Know
Audrey M. Stevenson, PhD, MPH, MSN, FNP-BC
The theme I’m referring to above is drug information. These pearls are just a handful from the sessions I attended. There were also sessions on pharmacologic management of dementia, biologics, hormone replacement, direct oral anticoagulants, sleep medications, medical marijuana, opioid prescribing, non-opioid analgesics, and pharmacologic management of obesity. Wow!
I also attended back-to-back sessions on street drugs and spent some time with the Drug Enforcement Agency in the Exhibit Hall. The current
opioid epidemic in the United States is not just a big city problem; it’s happening no matter where you are, among all ages, and it’s a big concern. Think about the prescribing you do on a daily basis. Drug approvals, indications, and warnings are constantly changing, and we must keep our knowledge up-to-date. Now, think about the number of drug overdoses you see, or patients and families that you know are dealing with addiction. These numbers are rising and, as nurse practitioners, we have a responsibility to appropriately assess and manage pain, and prescribe responsibly.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is October’s nurse story, “Beautiful Colors.”
Beautiful Colors
Leeann Vidt, R.N. supervisor
Oakmont Center for Nursing
As all life must come to an end, some families find it difficult to face emotionally. I observe them looking scared to talk with or touch a dying loved one, so I will often enter the room, sit on the bed, and take the patient’s hand in mine, then I will ask them if they think the fall leaves are beautiful with all those wonderful colors. They always answer, yes, and look at me puzzled. I then tell them that those leaves are actually dying and that something so beautiful should not be feared. I tell them the greatest gift to give their loved one is loving memories. I ask starter questions, such as what their favorite vacation or holiday spent together was. As they answer with smiles across their lips, I quietly exit the room and close the door. Nothing warms my heart like hearing the laughter behind that door. And then after the patient passes, I am thanked for making the passage from this life a better memory for them. I tell them that their loved one left within a circle of love, just as they had lived.
This is why I love nursing. To be able to help someone change such a scary situation into a sweet memory, makes those difficult, stressed shifts well worth my nursing cap.
To see all 2016-2017 stories or to share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit
http://lippincottsolutions.com/inspirednurses. Be sure to check our blog every month for a new inspired nurse’s story.
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.
As 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.
References:
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 : https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
Office on Women's Health. (2016, December). White Paper: Opioid Use, Misuse, and Overdose in Women. Retrieved from Women'sHealth.gov: https://www.womenshealth.gov/files/documents/white-paper-opioid-508.pdf
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: http://www.planagainstpain.com/resources/usnd/
Many of you know I still practice on the weekends as a nurse practitioner for Penn Medicine Chester County Hospital and I’m adjunct faculty for Drexel University in Philadelphia. I am currently teaching a course on using evidence in practice and this week is focused on using change theory to implement evidence. Change – one of the hardest things for us to do. We become stuck in doing things the way they have always been done. All you have to do is look at your current practice setting and see others who resist change. Courage and perseverance are the necessary ingredients to implement change. How many of us really have the so-called “right stuff” to make changes in our own practice settings?
As I look back on our nurse practitioner profession, I am amazed at the courage and perseverance it took for Drs. Loretta Ford and Henry Silver to step out of the so-called “healthcare norm” and decide there needed to be a better way to provide care. A nurse and a physician worked together to change practice. They did not do this for recognition. Rather, they did it to improve access to quality care for those who were in need. They implemented change in a healthcare system by using courage and perseverance.
Why did you become a nurse? Why have many of you gone on to be advanced practice nurses? Were you afraid of making a change? When I think about why I became a nurse practitioner, it was because I saw an opportunity to connect the art and science of nursing and medicine in my own practice to improve patient care. I am sure many of you have a similar story.
This is Nurse Practitioner Week and I want to thank each of my NP colleagues for the work you do each day. You emulate what Drs. Ford and Silver did over 50 years ago; you meet each day with courage and perseverance to implement change and improve patient outcomes one patient at a time.
Sincerely,
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse, Wolters Kluwer, Health Learning, Research & Practice
Adjunct Faculty, Drexel University
Nurse Practitioner, Penn Medicine Chester County Hospital
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is November’s nurse story, “It’s My Pleasure.”
It’s My Pleasure
Katie Fadell-Mann, RN
Ebenezer Lake City Care Center
My Dad was a double lung transplant recipient in 2006. What inspired me to be a nurse was seeing the difference his nurse made in his care. His nurse, Sara literally did not leave his side for the first two days after his surgery. When I asked where I could send a gift to for her to thank her for all she had done, she said, "There's no need, it's my pleasure to take care of your Dad."
I started going to school for nursing a few months later.
As nurses, we all know the importance of handwashing. We understand that germs can spread disease, and that hand hygiene can help defend against it. But still, 78 percent of all healthcare professionals tested in a recent
study presented at a conference of the Association for Professionals in Infection Control and Epidemiology (APIC) didn’t wash up to the standards of the World Health Organization’s guidelines for reducing the risk of spreading infection to patients. So, why so many slackers?
Perhaps sinks or hand sanitizer dispensers aren’t always in the most convenient locations in hospitals. And if they are conveniently located, there might not always be soap or sanitizing gel in those dispensers. Or maybe it’s just that we’re rushing from one emergency or critical situation to the next, and taking time to stop and wash our hands consistently doesn’t get prioritized. Or simply because, given those same circumstances, we merely forget.
It seems so obvious, yet the importance of handwashing wasn’t always known. In 1847, a physician working in a Viennese maternity hospital with two separate clinics, one run by physicians and one run by midwives, discovered that babies delivered by physicians had nearly triple the infant mortality as babies delivered by midwives. The reason was that the doctors coming into the hospital to deliver babies had just finished up duties in the autopsy ward, thereby infecting mother and child with numerous germs acquired from their deceased patients. Once doctors were instructed to wash their hands with an antiseptic solution before delivering babies, the mortality rate plummeted.
Getting Nurses to Wash Their Hands
Solutions to promote more frequent handwashing can run the gamut for many hospitals. Implementing one of several newfangled, automated hand hygiene monitoring devices such as video-monitored direct observation systems, electronic dispenser counters, and automated hand hygiene monitoring networks can work for some. And while there is empirical proof that these types of monitoring systems work, with the budgetary constraints many hospitals face, adoption can be cost-prohibitive and therefore not an option.
While there is no universal solution, many hospitals have taken steps to further encourage handwashing by investing in alcohol-based hand rub solutions (significantly more
efficient in reducing hand contamination than antiseptic soaps), both by installing wall-mounted dispensers and by providing individual containers for each healthcare worker. Changing posted messages around the hospital from, “Wash Your Hands to Protect Yourself” to “Wash Your Hands to Protect Your
Patients" can be helpful, along with peer pressure and personal incentives like drawings for free monthly manicures (yes, we all know the toll that constant handwashing can have on our skin and nails).
New incentives
It’s apparent that handwashing keeps us healthier, but what isn’t noticeable is the additional, subtle psychological effect handwashing has on us all as well. The Dalai Lama tells us, “as human beings we all want to be happy and free from misery… and we have learned that the key to happiness is inner peace.” So, what if you could achieve inner peace and happiness through the simplest of daily activities – like handwashing?
A study from the University of Cologne in Germany examined how the act of washing one’s hands can positively affect us after a bad experience or stressful event while also making us feel more optimistic after recent failure. Earlier research from the University of Michigan also found that handwashing can be physically and emotionally cleansing, suggesting that this simple act can make us feel more comfortable about decisions we’ve made or actions we’ve taken.
Personally, when I finish a workout at the gym, the first thing I do is wash my hands. Somehow, this simple ritual of washing my hands afterwards provides a sense of finality and accomplishment. The workout ritual, however, is far more complex (at least for me).
The act of seeking cleanliness has two distinct meanings to us humans. The first is the obvious physical hygiene benefits. The second is more psychological in nature. Psychological studies have shown that the simple act of washing one’s hands can help you feel more optimistic, less doubtful, and even a bit morally superior – as “clean” people have been found to be more judgmental towards other people’s bad
behavior. Think Lady Macbeth.
So, maybe now as we endeavor to wash our hands for the hundredth time today, recalling the Nightingale Pledge and our duty to protect our patients’ safety, we can also reflect on our own goals for self-improvement, including eating healthier, trying to exercise more, and being kinder to others and to our planet, knowing that this simple act of handwashing might be a more logical path to happiness and inner peace. Or, at least we can tell ourselves that.
References:
Brun-Buisson, C., Girou, E., Legrand, P., Loyeau, S., Oppein, F., (2002, August 17). Efficacy of
handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial. Retrieved from NCBI, US National Library of Medicine National Institutes of Health https://www.ncbi.nlm.nih.gov/pmc/articles/PMC117885/
Johnson, N., Niles, M. (2016, June 2). Hawthorne Effect in Hand Hygiene Compliance Rates. American
Journal of Infection Control, Volume 44(Issue 6), S28-S29. Retrieved from AJIS
http://www.ajicjournal.org/article/S0196-6553(16)30209-7/pdf
Kaspar, K. (2012, April 10). Washing One’s Hands After Failure Enhances Optimism but Hampers Future
Performance. Social Psychological and Personality Science, Volume 4(Issue 1), 69-73.
Retrieved from http://journals.sagepub.com/doi/full/10.1177/1948550612443267#articleCitationDownloadContainer
Psyblog (n.d.). 6 Purely Psychological Effects of Washing Your Hands. Retrieved from
http://www.spring.org.uk/2013/10/6-purely-psychological-effects-of-washing-your-hands.php
Deborah Baldwin
Wolters Kluwer Health
Here we are in mid-December and influenza season is in full swing. In fact, while flu activity was low during October 2017,
activity has been increasing since the start of November, with more cases of influenza A viruses, specifically influenza A(H3N2). In the United States, flu season typically ranges from late fall through early spring and while many who get the flu recover without sequelae, serious illness and death can occur, especially in high risk patients, including:
- older adults
- young children
- pregnant women
- those with certain chronic medical conditions, such as:
- chronic lung diseases, such as asthma and chronic obstructive pulmonary disease (COPD)
- diabetes
- heart disease
- neurologic conditions.
So, how can you stay healthy and keep those around you healthy this flu season?
The best way to avoid getting and/or spreading the flu is to get vaccinated! The
CDC recommends that everyone six months and older get an injectable flu vaccine this season. And here’s why…
- While there are certain high-risk groups, anyone can get very sick from the flu, including otherwise healthy people.
- As a health care provider, you can get sick from coworkers or patients who have the flu.
- If you get the flu, but don’t feel sick, you can still spread the virus.
- By getting vaccinated and protecting yourself, you are also protecting your family and friends, and your patients.
Educating Patients: Be ready to answer some of these frequently asked questions
How does flu spread?
Flu viruses spread through droplets when people with the flu cough, sneeze, or talk. The droplets can reach the mouths or noses, or be inhaled into the lungs of others, up to six feet away. A person can also get the flu by touching a surface or object that has flu virus on it and then touching his or her own nose or mouth.
What are the symptoms of the flu?
The flu usually comes on suddenly with a wide range of symptoms:
- Fever and chills, although not everyone with flu develops a fever
- Cough and sore throat
- Runny or stuffy nose
- Muscle or body aches, headaches, fatigue
- Vomiting and diarrhea (more common in children).
When is a person with flu contagious?
Most healthy adults are contagious starting one day before symptoms appear and up to five to seven days after feeling sick. So, it is possible to spread the virus before someone feels ill and even if no symptoms are present.
What if someone has an egg allergy?
Often, a question arises regarding ability to get the flu vaccine if a person has an egg allergy. According to the CDC,
“People with egg allergies can receive any licensed, recommended age-appropriate influenza vaccine and no longer have to be monitored for 30 minutes after receiving the vaccine. People who have severe egg allergies should be vaccinated in a medical setting and be supervised by a health care provider who is able to recognize and manage severe allergic conditions.”
Our Role as Health Care Providers
As health care providers, it is our responsibility to keep our knowledge up-to-date and educate patients, so they can make informed decisions about vaccination. How do you stay informed? And how do you approach the
conversation on vaccination?
References:
Centers for Disease Control and Prevention. (2017, December 11). Influenza (Flu). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/flu/index.htm
Flannery, B., Reynolds, S., Blanton, L., SAntibanez, T., O'Halloran, A., Lu, P.-J., . . . Fry, A. (2017). Influenza Vaccine Effectiveness Against Pediatric Deaths: 2010–2014. Pediatrics, 1-9.
HealthDay. (2017, December 8). Influenza Picking Up in U.S., Predominantly A(H3N2). Retrieved from Lippincott NursingCenter.com: https://www.nursingcenter.com/healthdayarticle?Article_id=729211
The
Centers for Disease Control and Prevention offers the SHARE method to approach the conversation on flu vaccination. This is a great way to help patients make informed decisions.
Reference:
Centers for Disease Control and Prevention. (2017, December 11). Make a Strong Flu Vaccine Recommendation. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/flu//professionals/vaccination/flu-vaccine-recommendation.htm
This blog is the third in the series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition.
In September, we attended the American Hospital Association (AHA) Advocacy Day in Washington D. C.. Prior to our attendance on the Hill, we attended a board meeting that consisted of physician and nurse executives. The agenda and conversations concerned practice issues. Participants were expected to be informed to provide evidence around the topics being discussed.
We observed one strategy that constantly refocused the group and highlighted ideas – storytelling. Storytelling is an effective way to manage sensitive issues and influence people’s emotions to redirect the topic and to influence others.
What are the benefits of telling a brief story on a board?
- Storytelling provides context and meaning to the situation or topic.
- Storytelling brings out creativity.
- Storytelling rekindles the passion for the topic.
- Storytelling generates empathy for the agenda item.
How do you create a compelling or powerful story?
- Keep it short (about three minutes).
- Start with the context.
- Use metaphors.
- Include an element of surprise.
- Appeal to the emotion.
- Make it tangible and concrete.
- Use a style appropriate for business.
- Be culturally aware.
- Acknowledge the composition of the board to ensure sensitivity and appropriateness of the story.
According to Mary Ann Fuchs DNP, RN, NEA-BC, FAAN, Vice President of Patient Care, System Chief Nurse Executive, Associate Dean of Clinical Affairs at Duke University, and AONE Board member, “Storytelling is a very effective strategy that helps to build relationships, demonstrate effective communication and engage others in issues important in health care and especially to the health of our country.”.
Call to Action!
Inform and engage others through storytelling to bring relevant perspective and connectedness to board topics, and to bring about good outcomes.
References:
Nurses on Boards Coalition (2017). Board Core Competencies. http://www.nursesonboardscoalition.org
Schawbel, D. (2012, August 13). How to Use Storytelling as a Leadership Tool. Retrieved from Forbes: https://www.forbes.com/sites/danschawbel/2012/08/13/how-to-use-storytelling-as-a-leadership-tool/2/#429048d8789e
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is December’s nurse story,
Giving Care to “Throwaways.”
Giving Care to “Throwaways”
Carol Hodge, Retired
While working as the Director of Nursing in a Medicaid only nursing home, I had the pleasure of taking care of the many "throw-away" people in the county. These were the homeless, prostitutes, and drug abusers, as well as others who needed long-term care but did not have the resources to pay for it. When a patient, an elderly former prostitute, was admitted to the hospital, I visited her, finding her in a room alone and unresponsive. I sat and talked with her for a while even though I did not get any response or acknowledgement. We weren’t particularly close, so I wasn’t expecting much from our visit. But as I left the room, I heard a weak cry. I turned around, and she was looking straight at me with a tear sliding down her face. It was a moment that confirmed I was on the path that had been chosen for me. I will never forget that day. And now that I am no longer able to work in my chosen career, I know it was truly the hardest job I have ever loved. God Bless our nurses!
Happy New Year! Here’s the list of nursing recognition days, weeks, and months for 2018. Have something to add? Please leave a comment or email [email protected].
Thank you!
January
February
March
April
May
June
September
October
November
Let us know how you will celebrate or what plans you have to recognize your colleagues. Leave a comment or email us at
[email protected].
Have a great 2018!
“Nurses work hard and do hard work.”
I recently had the privilege of speaking with John W. Bluford, lll
Founder and President of the Bluford Healthcare Leadership Institute and President Emeritus of Truman Medical Centers. Mr. Bluford and I discussed the important work of the
Nurses on Boards Coalition and how nurses can be leaders in health care.
Listen in on our conversation and hear specific examples from Mr. Bluford of how he has seen the voice of nursing impact change. Mr. Bluford offers some great advice regarding the need for nurses to understand the financial aspects of health care, since we already know our profession as the “business of caring.”
Thank you, Mr. Bluford, for joining me in this conversation and all your important work!
Take some time to listen to our full conversation
here.
John W. Bluford, III, MBA, FACHE has a distinguished career in hospital and health system administration. Mr. Bluford is President of the Bluford Healthcare Leadership Institute and former President and CEO of Truman Medical Centers. He is also former Chairman of the American Hospital Association, the National Association of Public Hospitals, and the Missouri Hospital Association. He currently serves on the Board of the National Center for Healthcare Leadership. His extensive career began with his role as a Centers for Disease Control and Prevention (CDC)-trained Epidemiologist, later leading Pilot City Health Center in Minneapolis to become the first JCAH-accredited community health center in the county, and then becoming CEO of Hennepin County Medical Center. Mr. Bluford has received numerous awards and achievements and has presented nationally and internationally on topics related to healthcare leadership and change management. His full biography can be read here.
Influenza season is in full swing and the headlines are troubling. For example,
CDC Confirms Widespread and Intense Flu Season All Across the US,
CDC official on why the flu is near-epidemic, peaking early this year, and
Severe flu brings medicine shortages, packed ERs and a rising death toll in California, are a just a few headlines causing distress for many. According to the Centers for Disease Control and Prevention, the most important method to prevent the flu is getting the flu vaccine every year. Keep in mind, that recommendation is not just made for your own protection.
Herd immunity, or community immunity, makes it less easy for communicable diseases to spread, especially to those for whom vaccination is contraindicated. It’s an indirect way to protect individuals through vaccination of the public. Herd immunity protects everyone, but it is especially important for those who can’t get vaccinated – for example, those with life-threatening allergies to any part of the influenza vaccine.
An example of a disruption in herd immunity occurred in the not-so-distant past. If you recall, back in 2015, a measles outbreak began in California when an unvaccinated child was hospitalized with rash. The child’s travel history included a recent visit to a Disney theme park, and within two months, about 125 additional cases were connected with visits to Disneyland (Gould, 2017).
So, what’s the problem? Of late, vaccine safety is being questioned by many and the controversy is getting more attention than the diseases they are intended to prevent. Also, many of us weren’t alive when certain communicable diseases – those for which vaccinations are currently available and recommended – even existed. Most of us haven’t been affected by the crippling effects of polio or the devastation from diphtheria.
While influenza may not seem like a scary illness to some, it can be devastating for others. According to the
Centers for Disease Control and Prevention, 6,486 laboratory-confirmed influenza-associated hospitalizations have been reported since October 1, 2017, and 7% (the epidemic threshold) of deaths for the year (up to and including the week ending December 23, 2017) were attributable to pneumonia and influenza. Twenty influenza-related pediatric deaths have been reported during the 2017-2018 influenza season thus far (Centers for Disease Control and Prevention, 2018).
When it comes to vaccination, remember that by protecting yourself, you are protecting so many others. As nurses, we are in a key position to educate our patients and the public. Use these tools for
Staying Healthy This Flu Season and be sure to
SHARE the Flu Vaccine Recommendation.
References
Centers for Disease Control and Prevention. (2018, January 12). Influenza (Flu). Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/flu/index.htm
Gould, K. (2017). Vaccine Safety: Evidence-Based Research Must Prevail. Dimensions of Critical Care Nursing, 145-147.
U.S. Department of Health & Human Services. (2017, December). Community Immunity. Retrieved from Vaccines.gov: https://www.vaccines.gov/basics/work/protection/index.html
I had the pleasure of speaking with Jessica Emmons, a recent Certified Registered Nurse Anesthetists (CRNA) program graduate who, like many of us, has quite an interesting story to tell of her journey into nursing and to her latest career stop, as a nurse anesthetist. Jessica began her adult life as an accountant and when she was looking for a change, others in healthcare described nursing as an “enviable world.”
During her 12 years as an emergency room nurse, Jessica also worked as a vascular access nurse, where she experienced significant autonomy and decision-making responsibility. As she developed her leadership skills and was sought after for more responsibility, she realized that remaining at the bedside was important to her. She shadowed a colleague in the operating room and had a “wow experience” that drew her to becoming a CRNA.
Please listen in on our conversation to learn more about Jessica, including the human piece of her work as a CRNA, what a typical day is like, and what she means by saying “You never hear about the overly prepared or overly clean nurse on the 5 o’clock news!” Jessica also tells us about the importance of the trust established with a patient in her care and shares an example of providing care to a patient who was not expected to awaken after surgery. Lastly, Jessica has some great advice to anyone considering application to a CRNA program and joining this group of 52,000+ advanced practice nurses!
Happy National CRNA Week!
A 2017 graduate of the Nurse-Anesthesia Program at Drexel University, Jessica Ann Emmons, MSN, CRNA is employed full time with United Anesthesia Services, P.C. and is based out of Paoli Hospital. Her graduate research focused on the second victim phenomenon, and the need for structured peer support after unanticipated adverse outcomes. She continues to speak and present this information at conferences and state meetings in the hopes of creating awareness about this vital topic. In 2003, Jessica earned her ASN from Gwynedd-Mercy College, launching a nursing career and leaving the business world behind. Prior to starting her specialization in anesthesia, Jessica was an emergency department nurse, vascular access specialist, and worked in the neuro-cardiac intensive care unit. Jessica resides in the borough of West Chester, PA with her husband, Will, and their three daughters. In her spare time, Jessica enjoys cooking, bicycling, and quilting, although never all three at once.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the January 2018 inspired nurse story,
Like Angels and Fairies.
Like Angels and Fairies
Chinazo Echezona-Johnson
Services for the underserved ∙ Vice President of Nursing Services
I did not want to be a nurse. I always wanted to be a lawyer. But then something extraordinary happened. My mom went into labor prematurely, and since there was no one to watch me, I had to go with her to the hospital. While in the waiting room, the nurses played with me and kept me company until my father arrived. In my eight-year-old mind, the nurses looked like fairy-tale characters because they were so kind and caring. They were also immaculately dressed in starched white uniforms, polished white shoes and white caps. They looked like angels and fairies to me.
It was a difficult delivery for my mother, but the love and care she and my baby brother received was magical. I did not see the birth, but when I could finally come in and hold my new little brother, I saw many nurses comforting, mothering and supporting other women in various stages of labor, delivering or recovering from childbirth. These kind nurses did not complain – not even when people were yelling at them. They kept their composure and professionalism at all times and it was at that point that I decided I must become a nurse. And today, after 24-years practicing as an Obstetrical and Gynecology nurse, I can still remember the caring nurses who took care of my mother and brother – those magical nurses who changed my life.
As caregivers, educators, and advocates, we must understand the differences between palliative care and hospice care so that we can ensure that patients and families are getting appropriate care and services at the appropriate times.
Both palliative care and hospice care require an interdisciplinary approach, with a focus on relieving pain and managing physical and psychological symptoms, while improving quality of life. What differs is that palliative care should begin at the time of diagnosis, when possible, and can be offered at the same time as curative treatments. Hospice care is appropriate for those with a prognosis of six months or less and excludes concurrent curative treatment.
Listen in as Dr. Anne Woods and Lisa Bonsall go more in-depth on the differences and similarities between the two, and why it’s so important for nurses to be part of related conversations with patients, families, and the interdisciplinary team.
In the fall of 2017, after returning from Nursing Management Congress2017 and the National Conference for Nurse Practitioners, both of which took place in Las Vegas immediately following the
mass shooting at the Route 91 Harvest Festival, I received an invitation from my state nurses association to an active shooter training. I felt compelled to attend this training and vowed to write about what I learned here on this blog. I attended the training session and took extensive notes of the valuable lessons I learned. Well, time passed, and that to-do item got pushed down on my list, which both embarrasses me and teaches me a valuable lesson.
Time goes by. While we don’t forget tragedies, over time we do get caught up in the everyday chaos of our lives and think “I’ll get to that later.” On February 14
th, the 18
th school shooting occurred in the United States since the beginning of 2018. That’s 18 school shootings in 45 days. Unacceptable. We can’t put this on the back burner any longer.
There are many famous quotes about not being able to change others (or the world) without making changes to oneself. So, I challenge you to think about what you can do to address issues related to gun control, mental health, and protecting students, staff, and teachers. What I can do right now is share what I learned from the Pennsylvania State Police back in December of 2017 and share a list of resources to help us all be prepared for an active shooter incident.
Pennsylvania State Nurses Association Active Shooter Training: December 4, 2017
Here are some key takeaways from this presentation:
- Many victims say, “I didn’t know what to do,” or “I was just waiting my turn to be shot.” The important lesson here is to tell people in an active shooter situation to do something. Time is a valuable commodity, and by doing something, one takes some time away from the shooter.
- 63% of active shooter incidents are in commerce or an education environment, but no place is off limits.
- Active shooter incidents typically evolve quickly and end (historically) within 10 to 15 minutes; 36% end before the police arrive.
- Be prepared:
- Mental preparation – Chaos and panic will occur. As best as you are able, trust your instincts, breathe, and remain calm.
- Sounding the fire alarm is NOT recommended. The potential negative consequences outweigh the benefit.
- People are complacent with fire alarms.
- People won’t think “active shooter.”
- Role of police – Police officers are there to neutralize the threat, not treat injured.
- Three options (you may have to do all three):
- Run – If you have an opportunity to escape, do so.
- Hide – Don’t let anyone in.
- Fight – Fight for your life with whatever you have. There is power in numbers and the shooter is typically not looking for a fight.
It is incumbent upon you to be mindful of these things and know how to react if you are involved in an active shooter situation. Think, if you were to be involved in an active shooter situation tomorrow, would you be able to answer the following:
- Are you prepared?
- How would you react?
- Are others prepared?
- Do you know what to expect?
- What is your ability to protect?
The final thoughts of the presentation? “Be prepared and plan to survive.”
Important Resources
National Association of School Nurses: Violence in Schools
Active Shooter Resources from the FBI
U.S. Department of Homeland Security Active Shooter Preparedness
National Institute of Mental Health
More Reading
Plunging Forward in the Aftermath of the Las Vegas Tragedy
Is there a Cure for Gun Violence?
Active shooter on campus! [CE]
Active Shooters: What Emergency Nurses Need to Know
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the February 2018 inspired nurse story,
Heart to Heart.
Heart to Heart
Cameron Mitchum
Medical University of South Carolina ∙ Nursing Professional Development Specialist
Some years ago, I was working in the hospital's ICU float pool, caring for a young man with traumatic brain injury received from a fall. The physicians had declared him brain dead. He was only 16 years old. He had run away from home several years before, so after many hours, his mother was finally located, but unfortunately couldn’t make the journey across the country in order to say good-bye to her son, so asked if I would stay with him until he went into the operating room.
After my shift ended, I stayed with him as a visitor until he went into surgery. I stroked his hand, talked to him, and told him his mother loved him. Later I called his mother and told her about his last few hours. We cried together, and I gave her the number of our chaplain support services.
Two nights later, I was asked to pick up a shift in the cardiovascular ICU. When I walked into the room of a new patient, I asked him how he was doing. He had just been extubated, and he replied, "Let me tell you, I'm doing great! I feel like a new man!” This patient was a high school principal and had received a heart transplant two days prior. I sat down, and we talked for a while, trying not cry. While I never knew for sure, I suspected that this vibrant man had received that young 16-year old boy's heart. At a time in my life when I wondered if I should look at other career options, this experience moved me in ways I still can't fully comprehend. The wonder of nursing care hit me full force that night, and my decision to stay in nursing was firm and never regretted.
At some point, we have all likely witnessed behavior from one colleague toward another that was disrespectful, impolite, or downright rude. The topic of workplace incivility calls to mind several examples from my own experience, where I had to step in to shield a colleague from the cruel words or actions of another nurse.
The most troubling example that I have seen in my career behavior directed toward a new graduate nurse, who was transitioning from a successful career in business to the emergency department. This nurse brought years of experience as an adult in the workplace, rich experiences as a parent, several advanced degrees, a calm demeanor, and an easy-going personality. As an adult learner and career-changer, this nurse was highly motivated, eager to learn the rules of the unit, quick to master tactile skills, and asked excellent questions. There was one problem; this nurse made an early enemy, for unknown reasons, with a nurse who was one of the most out-spoken nurses in that department. This seasoned nurse was in a position of power, and was deeply involved with the day to day management of the unit. When it came to room assignments, scheduling, patient assignments, or breaks, there was no doubt who her least favorite nurse on that unit was.
Please, picture both of these nurses. Would it surprise you to learn that the new graduate nurse was a man? I am happy to report that thanks to supportive colleagues, this lateral violence did not drive out the new nurse. He persisted, developed, and flourished in that department, despite being treated with derision by the nurse who bullied him. It has been ten years since he joined that team, enthusiastically seeking guidance and mentorship from those more experienced than he was at that time, only to be repaid with disrespect and rudeness from a fellow nurse in a position of power. In the ensuing years, he has generously offered help and mentorship to assist other new graduates as they transition into the new and sometimes overwhelming role of nurse.
Our beloved profession can be taxing on the body and spirit. With all of the pressures we face in our units every day as we take care of patients with increasingly complex comorbidities, there is no room for the added stress of lateral violence. As nurses and members of the profession most trusted by the American public, we are not here to push each other down, but to help one another up. What we permit, we promote, and it is incumbent on all of us to draw a line in the sand and say “enough” when it comes to workplace incivility.
Jessica Ann Emmons, MSN, CRNA
We know the value of nurses, and we demonstrate our knowledge and skills to our patients, their families, and the public every day. Now, with a new global campaign launched in collaboration with the
World Health Organization and
International Council of Nurses, we have a larger voice uniting us and validating the work that we do.
On February 27, 2018,
Nursing Now kicked-off with activities across the globe, including
a passionate speech by HRH Duchess of Cambridge, Kate Middleton, who, at the London launch, was announced as Patron of the Nursing Now campaign. The Campaign Board, along with its partners, will work over the next three years to improve healthcare by enabling nurses to do what we do best – promoting health and preventing disease. Based on the findings of the
Triple Impact of Nursing report (improve health, empower women, strengthen local economies), the campaign will run as a program of the Burdett Trust for Nursing.
The
five main programs of the campaign are:
- Universal Health Coverage – ensuring quality health care for everyone
- Evidence of impact – building up evidence of the contributions of our profession
- Leadership and development – supporting nurses as leaders in policy and practice
- Sustainable Development Goals – ensuring health, gender equality, and economic growth
- Sharing effective practice – disseminating and improving access to collections of effective practice.
This short excerpt from Nursing Now’s
vision gives great insight into the goals of the campaign:
“The changing needs of the 21st Century mean nurses have an even greater role to play in the future. New and innovative types of services are needed – more community and home-based, more holistic and people-centred, with increased focus on prevention and making better use of technology. These are all areas where nurses can play a leading role. However, maximising nurses’ contributions will require that they are properly deployed, valued and included in policy and decision-making.”
Nurses – we are a key component in solving today’s healthcare challenges. Let’s get involved! Here’s how:
Nurses, it’s time to lead the charge and make a difference on a global scale. Together we can tackle the healthcare challenges that exist today. This is a big step for our profession. I encourage everyone to learn more about
Nursing Now and get involved!
by Leslie Nikou
INSider Associate Managing Editor, Infusion Nurses Society
Like many moms, her typical day starts with a personal wake-up call from her toddler daughter, tending to her infant son, taking a quick run with her dogs, then tackling the day’s to-do list. Sometimes that includes laundry and cleaning the house, and sometimes it includes conference calls, writing, or meeting with survivors of sexual assault and other types of abuse. Elizabeth Smart is a typical mom with an inconceivable story.
Abducted at knife point from her home in 2002 at age 14, then raped, drugged, and abused for 9 months, the story of Elizabeth Smart’s ordeal gripped the nation. Incredibly, after witnesses spotted Elizabeth walking with her captors on a public street, she was safely returned to her family in March 2003.
Elizabeth largely credits her parents with aiding her recovery by creating a sense of normalcy when she returned home. While they were sensitive to her needs, they didn’t treat her any differently than her siblings, and slowly guided her back into teenage life. After finishing her education, Elizabeth became a staunch advocate for change related to child abduction and founded the Elizabeth Smart Foundation in 2011. She considers herself one of the “lucky ones,” not only because she survived, but because she was able to go home.
She wants to lend her voice to other victims and their families worldwide by creating “something that would help shed a light on the brave work done in fighting crimes against children…(and) provide a place of hope, action, education, safety and prevention for children and their families, wherever they may be.”
1 Elizabeth strongly believes that empowerment is a key component to victims’ survival. She says a traumatic experience might alter the direction of our lives but it does not have to define who we are. Regardless of your background, how you were raised, your financial situation, or whatever impactful event you have experienced, “there is nothing that another human being can do to you that can diminish your worth as an individual.”
In addition to promoting the National AMBER Alert system and other child safety legislation, Elizabeth’s foundation has propelled her into public speaking events across the country. While the actual events of her abduction have been chronicled in best-selling books and made-for-TV movies, the focus of Elizabeth’s talks is not just about what happened to her, it’s about hope, survival, and recovery. She reminds her audiences not to compare themselves or their personal traumas to anyone else’s, because everyone’s situation is unique. There is no “one-size fits all” formula to healing, but learning to love yourself again is one of the first steps.
Elizabeth Smart will bring her inspiring and powerful words to INS 2018 this May as the meeting’s keynote speaker. Listen to our podcast in its entirety at
www.learningcenter.ins1.org/p/INS2018Keynote. For more information about Elizabeth Smart and her foundation visit
www.elizabethsmart.com.
#INSROCKS2018
INS 2018 is heading to the shores of Lake Erie and the bustling city of Cleveland, Ohio. This year’s annual meeting will include 4 days of thought-provoking educational sessions, peer presentations, round-table discussions, and so much more! We have lined up nearly 4 dozen speakers from all facets of the industry to bring you the latest evidence-based information in the infusion specialty.
Highlights for attendees will include a chance to test their infusion IQ in an interactive quiz show, ask infusion nurse-experts about the top-10 most common questions and answers, and collaborate in a 2-hour boot camp on immunoglobulin therapy. Accompanying the education, attendees can roam the jam-packed exhibition hall, experience a special event at the Rock & Roll Hall of Fame, and enjoy countless networking opportunities with colleagues.
Can’t make it to Cleveland? Take advantage of our Virtual Infusion Education located in the INS LEARNING CENTER. The INS Virtual Infusion Education platform is designed to deliver conference programming directly to your home or office. Programming is presented to a live audience and streamed simultaneously. The program is recorded and available on-demand.
This year’s virtual conference, “Infusion Nursing: Why We Do What We Do,” will be streamed live on Tuesday, May 22. It will feature expert infusion nurses and provide foundational information about fluids and electrolytes, and pain management strategies. The day will conclude with a mother’s testimony on the impact infusion nurses have had in her family’s life.
Whether you plan to experience INS 2018 in person or virtually, this year’s meeting is a must! Visit
ereg.me/INS2018 for a complete schedule and registration information.
Johanna Dwyer, DSc, RD
Editor-in-Chief,
Nutrition Today
Registered dietitians and community nutritionists have long understood that America’s nurses are essential allies in promoting nutritional health, and preventing and treating diet-related disease. Multidisciplinary collaboration is essential in providing best care and improving outcomes. It takes communication and teamwork to educate patients and the public, so they can make informed decisions about their nutrition and healthcare.
Those of us at
Nutrition Today are in the midst of celebrating Nutrition Month and want to share some of our favorite recent articles that our nursing colleagues may find useful as well. Here’s a sample, and please feel to drop by the
Nutrition Today website and download the articles listed below. Enjoy free access through May 31, 2018!
Healthy Eating Over the Lifetime
Mediterranean Diet and prevention of Chronic Diseases
Here’s an authoritative primer on the Mediterranean diet pattern and all its components.
Red Meat and Health: Getting to the Heart of the Matter
Don’t miss this update on red meat and health, and its role in the diet.
Food Insecurity: It is More Common Than You Think, Recognizing It Can Improve the Care You Give
A case study is presented to demonstrate an approach to manage patients with food insecurity.
Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach
Read this excellent summary of the new thinking about responsive parenting and how mother and child interact in feeding.
Making the Case for Nutrition Screening in Older Adults in Primary Care
Identifying those at risk must be a priority.
Creating and Sustaining a Healthy Food Environment in Hospitals Contracting with a Food Service
Learn how nurses and dietitians can work together to help those working to make hospital food that both tastes good and is healthy.
Nutrition in Disease
Food Sensitivity versus Food Allergy
This primer on food sensitivity and allergy provides new information that is shaking up the field.
Nutrition for Persons Coping with Serious Mental Illness
Review nutritional counseling tips for those who work with these patients.
Heartburn: Lifestyle Modifications and Over-the-Counter Medications
Discover everything you need to know about heartburn and how to manage it.
Psyllium Is Superior to Wheat Dextrin for Lowering Elevated Serum Cholesterol
Different fibers have different physiological effects. This article explains how and why they differ.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the March 2018 inspired nurse story,
A social butterfly.
A social butterfly
Sharon Vaughn
Vanderbilt Children's Hospital
This story is about a young man who was born with the most severe type of Spina Bifida known in the medical field. His parents were given the prognosis before he was even born, but still chose to carry the pregnancy to term, knowing the baby may not live very long. Today he is cared for by his mom, and requires total care for all of his activities of daily living. And even though this family has had a lot to deal with in caring for him, their strength and love for him and one another is amazing.
I first encountered this child when I was working in the neurosurgery clinic at Vanderbilt Children's Hospital when he came in for his appointments. As soon as he was checked in, he would start talking and yelling for me to come and pick him up and carry him around the clinic so he could be a “social butterfly” and flirt with all of the other nurses while looking for his favorite nurse practitioner.
This child, along with his family, made a lasting impression on my heart and has changed my outlook on nursing. They have shown me that anything can be accomplished, no matter what life deals you. I am so proud to be called a nurse, and I hope to continue to make small differences in the lives of my patients, like this one.
To share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit http://lippincottsolutions.lww.com/landing/inspired-nurses.html. Be sure to check our blog every month for a new inspired nurse’s story.
Last week, I had the pleasure of attending the
National Student Nurses’ Association (NSNA) 66th Annual Convention. It was great to get back to Nashville – such a cool city – but even more impressive to see over 3,000 nursing students from around the country come together to learn, network, and share their work and experiences.
Opening & Educational Sessions
The Opening Ceremony, Awards, and Keynote Address kicked off with local student and musician,
Trevor Martin, performing the National Anthem and then entertaining us with his rendition of
Country Road. Then the NSNA officers, along with special guests, recognized the many sponsors and supporters of the organization and our profession, and presented several distinguished awards. Dr. Pamela Cipriano, President of the American Nurses Association (ANA) and past NSNA president, gave the Keynote Address, focusing on the conference theme of using insights, inspiration, and ingenuity in one’s education and career. Throughout the days of the convention, there were focus sessions and plenary sessions for both students and faculty. Also, each morning, our colleagues from
Lippincott PassPoint hosted the NCLEX® Mini Review, which was a hit with the students, many of whom will be taking the NCLEX in the coming months!
Exhibit Hall
Most of my time was spent in the Exhibit Hall with Wolters Kluwer colleagues sharing information about NursingCenter, and Lippincott’s books and nursing education products. Many schools of nursing and health systems were also exhibiting, and it was refreshing to see such interest in the nursing students of today. Colleges and universities had information on advanced degree programs and opportunities, while the health system representatives that I spoke with were highlighting their innovative orientation and preceptor programs.
While many of the students who approached us at our booth came to learn about NursingCenter, there were quite a few who also came to tell us about themselves! Regional, state, and school student leaders told us about the work they were doing and the upcoming events they would be hosting.
Swag
I am guilty of having a strong attraction to nurse swag and I know I am not the only one! Our
Nursing Pocket Cards were a hit and it was great to share that we have a growing collection of these online.
Student groups were selling apparel & accessories to fundraise and there were some very clever t-shirt captions, like these:
Posters
My favorite part of this experience was viewing the posters. The sheer number of posters being presented amazed me! Also, students stood by their posters, poised and ready to discuss the work they had done. From sharing experiences studying abroad and the importance of understanding global issues in health care and nursing, to tackling clinical topics such as sepsis and veteran suicide, the future of these students is bright and promising! Tomorrow’s nursing leaders are on their way!
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the April 2018 inspired nurse story,
Just Call Me “Boots.”
Just Call Me “Boots”
Theresa Faught
Viva Pediatrics Home Health
When I was nine, I was sent to Itasca Presbyterian children's home to live after my mother was committed to a mental hospital. My father was no longer able to care for me as he was suddenly left to care for his own eight children, plus three of his young stepsons.
Two months later I became very ill with a fever of 107. I had passed out, but when I awoke, I was alone and in a hospital bed with my right arm taped down to a board. Realizing I couldn't get my thumb into my mouth, I began to cry. A young woman in a white mini-dress and boots suddenly entered my room and then asked why I was crying. When I told her, she immediately went to work un-taping and re-taping my IV to the board so I could bend my arm to reach my thumb! She then told me I could call her “Boots” and patted me gently on my head before leaving my room. I felt I was in heaven and that she was my own personal angel. As I drifted back to sleep I kept thinking that when I grow up, I want to be just like her. So, wherever you are Boots, I want you to know that the reason I became a nurse is because of you!
It’s almost
National Nurses Week! We have a lot planned to celebrate, so be sure to take advantage of our new CE collection on
Innovation in Health Care (6.5 contact hours!), watch a special
video from some of our nurses (including me!), and explore
articles, CE, and blogs related to inspiration, innovation, and influence.
Be sure to check out all of our
Nurses Week plans and also follow us on social media -- We’ve got some special giveaways that you don’t want to miss!
As we do each year, we’ll be sharing a blog series related to this year’s theme,
Nurses Inspire, Innovate, and Influence. Each day, one of our nurses will share what this theme, or an aspect of it, means to them. I hope you enjoy theses daily blog posts, starting May 6
th, 2018. Save this page and check back here daily during Nurses Week!
Nurses: Inspirational Innovators
Shawn Kennedy, MA, RN, FAAN
Editor-in-Chief,
American Journal of Nursing
Brenda Nevidjon, Oncology Influencer
Tahitia Timmons MSN, RN-BC, OCN
Clinical Editor,
CEConnection
Renewing Our Inspiration
Jessica Ann Emmons, MSN, CRNA
Clinical Editor,
Lippincott NursingCenter.com
Many Faces of Innovation: One Nurse’s Perspective
Myrna B. Schnur, MSN, RN
Clinical Editor,
Lippincott NursingCenter.com
Inspiration in Nursing: The Secret Sauce of Moving Forward
Lynne Centrella Rudderow, MSN, RN, CRNP, WHNP-BC, CCE
Clinical Editor,
Lippincott NursingCenter.com
Think Differently about Innovation in Nursing
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director of Continuing Education
Wolters Kluwer - Health Learning, Research & Practice
Have the Courage to Influence
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Wolters Kluwer - Health Learning, Research & Practice
Have a wonderful Nurses Week – thank you for your hard work, knowledge, skills, compassion, & dedication!
Shawn Kennedy, MA, RN, FAAN
Editor in Chief,
American Journal of Nursing
ANA’s theme for this year’s Nurses Week – “Inspire. Innovate. Influence.” – is perfect, I think. It’s what we’ve always done, from our earliest beginnings and in every setting. Here are some of my favorite examples (and the articles from the
AJN archives will be free to read for Nurses Week! Click on the pdf version for the best reading experience.)
Florence Nightingale was the first to organize nursing and implement unheard of care measures (the most important being cleanliness and fresh air– how radical!). Simplistic and common sense, but until she and her cadre of nurses marched into Scutari Hospital and instituted these measures, no one had thought to do them in a consistent way. And when the Army wouldn’t agree to her proposed changes, she used her contacts and influence to make her case and win over public sentiment.
Lillian Wald was a visionary leader and is considered the founder of public health. Her community health model is an example of how we’ve come full circle – community health centers are now considered the ideal way to develop healthy communities and deliver preventive care. Wald was newly out of nursing school when she and friend Mary Brewster founded the Henry Street Settlement visiting nurses in 1893, after they saw the dire need for health care among immigrants. They began with nine nurses; by 1916, there were 250 nurses. Visiting homes and providing care to the sick, teaching mothers about infant and child care, and promoting general hygiene was the hallmark of their practice. They added a clinic, a children’s playground and camp. Later, the Visiting Nurse Service of New York became independent, but
Henry Street, now in its 125
th year, still offers a full array of social services to over 60,000 people annually.
Wald also began school nursing, after she convinced the New York City School Board that nurses in school could reduce absenteeism. She placed
Lina Rogers, a Henry Street nurse, in a school to teach basic hygiene and treat minor ailments. At the end of the trial, the school board hired 12 more nurses.
Mary Breckenridge founded the
Frontier Nursing Service in 1925, when maternal and infant mortality in the Appalachian region was dismal. She and two other nurse midwives on horseback visited 800 families each, providing care and teaching health. The overall maternal death rate from 1925-1954 averaged 34 per 10,000; in her area, it was 9.1 per 10,000 births.
But you don’t have to go back in history to find innovators. The American Academy of Nursing recognizes the key roles nurses play in improving care and so has created a program –
Edge Runners - to highlight nurses who’ve been creative in addressing challenges. From creating independent birthing centers to reducing pneumonia in ventilated patients or creating a clinic for racetrack workers, nurses have been at the forefront of care improvements. A recent addition to this group has been
Sarah Szanton, whose innovative program (the home health team consists of a nurse, occupational therapist and a handyman) has enabled older people to remain safely in their homes.
Today’s health care system is being disrupted by many changes, from telehealth, digital documentation, to a changing patient population requiring changing models of care – just the right time for innovative thinking. Look around – what’s in your setting that needs nursing ingenuity? What innovations have you or your colleagues implemented or thought about implementing? Maybe it’s your turn to join the ranks of nursing innovators. There’s no better time than now.
Myrna B. Schnur, MSN, RN
Clinical Editor,
Lippincott NursingCenter.com
Innovation is a word used almost excessively in our society where technology permeates every aspect of our lives. Nowhere is this more evident than in the field of healthcare which has benefited from centuries of new discoveries. Medical innovations such as novel drug therapies that have eradicated diseases, emerging device technologies that have extended lives, electronic medical record systems that have enhanced communication, and advances in process, service delivery, and education that have improved the overall quality of patient care. I have had the privilege of working and experiencing many innovations throughout my 25-year nursing career.
Chapter 1
Beginning in the cardio-thoracic intensive care unit (CT-SICU), I was immediately drawn to the challenging environment where a multitude of technological advances were utilized daily. Each open-heart surgery patient typically arrived to us from the operating room intubated, along with intravenous lines, an arterial line, pulmonary artery (PA) catheter, one or more mediastinal chest tubes, pacing wires with or without an external pacemaker, and a foley catheter. The immediate post-operative period was a delicate balancing act that required careful titration of vasoactive medications and administration of precise amounts of fluid to allow the heart to pump without disrupting fragile coronary grafts. For patients who suffered from complications, additional devices were utilized. We frequently encountered the use of nitric oxide, intra-aortic balloon counter-pulsation, left-ventricular assist devices, bi-ventricular assist devices, extra-corporeal membrane oxygenation (ECMO), and continuous hemofiltration and dialysis. Surrounded by cutting-edge technology was overwhelming at times, and I often felt like a technician managing the machines, desperate to keep each fragile patient alive. It was far from boring, and I grew immensely as a clinician during those years.
Chapter 2
While attending graduate school, I had an opportunity to participate in a team hired to implement a new electronic medical record (EMR) system throughout the university hospital. For most of us working at the bedside, this change in process appeared only as an added bureaucratic burden to our routine. I had no idea at the time how important this technology was and how EMRs would shape healthcare today. The Task Force consisted of nurses from a variety of medical specialties. We assisted health care providers in entering patient orders and educated each staff member to accurately document the medications that were administered as well as each procedure performed. In the intensive care unit, we piloted a program that continuously captured vital signs. We added inputs for physical assessments, titration of vasoactive medications, and changes in ventilator settings. We conducted audits, collected clinician feedback and played an important role in providing input on flow and design to the information technology department. The new system would transform communication among the multidisciplinary team and emerge as a driver in data collection, reimbursement, patient safety, and quality improvement.
Chapter 3
After graduate school, I thought I would pursue a career in EMR systems implementation. The experience proved to be extremely rewarding and the field was swiftly expanding. However, another opportunity presented itself. Instead, I would land in the world of pharmaceutical research working on the early human papilloma virus (HPV) vaccine phase II clinical trials. In terms of innovation, this vaccine would be the first to prevent HPV infection that is responsible for cervical, vaginal, and several other cancers. Again, I was one of several clinical nurses on the team responsible for coordinating the study and ensuring the integrity of the data. The path that a new therapeutic agent moves along on its journey to product approval can be rigorous and long; however, the ultimate public health impact is profound.
Chapter 4
A new stage in my life brought me out west where I made the riskiest career move, or so it seemed at the time. Enamored with the world of high-tech, I interviewed with a start-up company whose goal was to bring simulation technology to the forefront of medicine. Founded on the principles of haptic, or “touch” feedback, the company developed simulations based on endovascular procedures such as coronary angiography, angioplasty and stenting. Working with talented computer engineers, the clinical team developed complex simulations for a variety of medical devices. To expand our reach beyond the cardiac catheterization lab, we created simulations focused on quality improvement initiatives such as sepsis, stroke, heart failure, and ventilator-associated pneumonia to name a few. Each simulated scenario began with a patient history, diagnostic studies and relevant laboratory results. The clinician would use this information to formulate a procedural or treatment strategy. This was followed by a fully immersive experience requiring the practitioner to walk through the scenario, perform the procedure, monitor vital signs, administer medications and manage the patient status. The human patient simulator was pre-programmed to respond appropriately to each action and treatment choice. A debrief was conducted to review both the individual and team performance.
Simulation training is an innovative methodology that has evolved over the last two decades to provide practitioners with an opportunity to learn how to use new devices, to manage complex patient diseases and to experience rare complications in a safe, risk-free environment. It also promotes collaboration and improves communication among health care teams. The National League of Nursing (2015) has advocated simulation as a teaching method to prepare nurses for practice and supports the study conducted by the National Council of State Boards of Nursing which concluded that high-quality simulation experiences could be substituted for up to 50% of traditional clinical hours across the prelicensure nursing curriculum (Alexander, et al., 2015).
I had not thought much about innovation in my career until I was asked to write about it for National Nurses Week. I realized that innovation had been interwoven into several chapters of my life and career as a nurse. And conversely, nurses have played an integral role in every area of health care innovation, not limited to those discussed here. Nurses possess an exceptional skill set allowing them to adapt quickly to novel therapeutics, to translate clinical information into technology requirements, to work in a variety of settings including research, and to create high-tech educational platforms that would alter the delivery of training for future generations to come. Nurses are uniquely positioned to influence change, to take on leadership positions to bridge the gap between technology and clinical practice. We, as a profession, are reminded that we have a responsibility to positively guide the impact of innovation to improve safety and the quality of patient care.
Tahitia Timmons MSN, RN-BC, OCN
Clinical Editor,
CEConnection
For National Nurses Week, I had the opportunity to interview Brenda Nevidjon, MSN, RN, FAAN. Brenda is the current Chief Executive Officer at the Oncology Nursing Society (ONS). Prior to being the CEO at ONS she was faculty at Duke University School of Nursing in Durham, NC. She has spent over twenty years being an influential voice in oncology nursing through her writing and leadership. She has numerous publications, including four books, twenty book chapters and over 20 journal articles. Throughout her career she has been a mentor for nurses who wanted to have a voice in leadership, their work, and publishing.
Like many, Brenda’s path in nursing did not follow the route she had planned. With a master’s degree in psychiatric nursing, she thought she would eventually become a clinical psychologist. However, the opportunity to work at one of only three bone marrow transplant sites in Europe changed her plans to oncology. When she returned to the United States, this experience enabled her to become the head nurse at Duke Comprehensive Cancer Center’s cancer research unit. During her career, leadership has also been an integral part of her nursing path. She was the first nurse and woman to be named as chief operating officer of Duke University Hospital.
Brenda has served on numerous cancer-related boards, including the Institute of Medicine’s National Cancer Policy Forum Board, the Association of Community Cancer Centers and the International Society of Nurses in Cancer Care. When the Cancer Moonshot was started in January of 2016, led by U.S. Vice President Joe Biden, she was involved with meetings to ensure the voice of oncology nursing was present. She was also an ignite speaker in the breakout session, “Putting the Patient at the Center of Access and Care” at the Cancer Moonshot Summit.
Brenda personally influenced and helped my early days as an oncology nurse with a book she edited titled
Building a Legacy: Voices of Oncology Nurses. In the preface, she talked about how important it is for nurses to tell our stories and that editing the book had been a “gift.” When I became an editor, I reread her preface and reflected on the concept of the gift of stories (our words) and what an important influence they are in nursing.
In keeping with the 2018 theme of "Nurses: Inspire, Innovate, Influence" I decided to ask Brenda these questions:
What keeps you inspired when things are difficult?
“The vision of the Oncology Nursing Society since the 1990s has been to lead the transformation of cancer care. This is a north star for me when things are difficult. I believe that oncology nurses must be equal partners in the cancer care environment, in clinical practice, research, and education. Ensuring that our voice and expertise are integrated throughout the cancer care continuum keeps me working for our members and the patients for whom they care.”
What is the most innovative idea or thing you have heard about in oncology recently?
“Sometimes the simplest of things can be innovative. As more immuno-oncology agents are being approved, concerns about side effects management have become a focus. Some of these side effects present like the ones we see from chemotherapy, but the treatment is not the same. Realizing that patients may go to urgent care clinics or emergency rooms, staff developed a wallet card for nurses to give patients, so they can inform caregivers in those settings about the agent they are taking. Treating the side effect properly will avoid complications that could be life threatening. So far, we have distributed over 60,000 of these free wallet cards.”
Who has been the biggest influence on your nursing career?
“There is no one influence on my career, but as a young unit manager, the chief nurse of the hospital saw my potential and provided me the courage to leave and reach for an opportunity across the country. I always advise mentees to remain open to possibilities that can take you to amazing places and experiences.”
Brenda’s answers are aligned with the way that she leads and influences. She sees the innovation in all the things we do, is inspired by the idea that nurses have the power to transform care and sees the possibilities in us all, if we are open to them.
References
Chief Executive Officer. (2016, March 16). Retrieved April 13, 2018, from https://www.ons.org/about/leadership/ceo
Pirschel, C. (2016, February 26). Brenda Nevidjon Attends Cancer Moonshot Roundtable With Vice President Biden. Retrieved April 13, 2018, from https://voice.ons.org/news-and-views/brenda-nevidjon-attends-cancer-moonshot-roundtable-with-vice-president-biden
The Western PA Healthcare News Team. (2014, July 14). Oncology Nursing Society Names Brenda Nevidjon as New CEO. Western Pennsylvania Healthcare News. Retrieved April 14, 2018, from https://www.wphealthcarenews.com/oncology-nursing-society-names-brenda-nevidjon-as-new-ceo/
Jessica Ann Emmons, MSN, CRNA
Clinical Editor,
Lippincott NursingCenter.com
Self-love, my liege, is not so vile a sin as self-neglect
William Shakespeare,
King Henry V, Act 2, Scene 4)
You hear the familiar chirping of your alarm and, though it might be pm or am, you roll out of bed, putting your feet on the floor to face another day. The familiar feel of the cool scrub fabric, the hug of your clogs, and the weight of your bag on your shoulder mean you’re ready to go. You jostle the weight of your bag and find your car keys, taking care not to spill the precious cup of coffee you will sip on your way to work. All of this occurring every workday as you leave behind your own family, their appointments, needs, obligations, parties - to go take care of people – veritable strangers – and put their needs ahead of your own. Parking, walking in, thoughts of the day or night ahead intrude, and you find yourself asking for guidance and strength to accomplish your tasks today. The journey to your unit finds you walking alongside a colleague taking the same path to start their day. Together you enter the office, unit, or wing in which you work, and hear the steady buzz of familiar voices, the tolling beep of the call bell system, the phones jangling in the background, the rhythmic thump of the wheels of a transport stretcher and soak in the familiar sounds of the shift starting. Your assignments, duties, case files, or patients for the day await you. Joining a colleague nearby, you get started, take report, and another day is underway.
If any of this sounds familiar, chances are that, like three million of us in this country in an amazing variety of settings, you are a nurse.
There are so many of you that I have witnessed over the years, quietly, anonymously bringing joy and comfort to patients, asking nothing in return, never seeking to be recognized for your work.
Your name may never have been on the Daisy™ banner in your unit.
You may never have received the extra mile award, or employee of the month award.
That lack of public recognition does not deter you from giving it your all every day, because your sense of pride in being a nurse isn’t based on outside awards or recognitions.
You measure your success in a different way - because you are a
nurse.
Your success can be experienced in the intimate space you create when respectfully caring for an incontinent patient in the hospital to maintain their dignity.
The quiet look of recognition and gratitude from a family member saying goodbye to a loved one for the last time, may be all the acknowledgement that you require.
Your sense of purpose may be reinforced by the conversations that you have with patients, where they may finally gain an understanding of their disease, or medicines.
Your ability to experience the full range of human experiences, from birth to death and everything in between, feeds your soul, and keeps you coming back to the bedside each day.
You are the therapeutic environment that you seek to create. You permit healing to occur through the micro-choices you make on behalf of your patients every day. You create safe space with your own words and deeds then use it to renew the human spirit.
To each nurse giving their heart and soul to this work every day, I implore you to apply the same rules of forgiveness, empathy, and care, to yourself.
Take excellent care of yourself. There is a cost to us, when we take care of patients who are barely invested in their own care. You are as worthy of care and respect as those in your charge. When you bring your WHOLE self to the bedside, you care for others, teach new nurses how to do it by example, and feed your joy, your love, your essence, into a system that needs you now more than ever.
As we shine a light on nurse wellness, and support our colleagues with mental illness, or secondary stress, we aim to keep our colleagues away from the cliff of depression, suicide, and professional paralysis.
Nurses need to celebrate their profession this week and every week, in my opinion. We need to continually renew our own inspiration and listen to the stories of colleagues. This week, or whenever you need to renew your passion for nursing, I urge you to ask a colleague to share a story about what inspires them or sparks their love of nursing.
Think back to an instructor or mentor that helped shape who you are as a nurse, and as a person. Imagine if they left the profession due to compassion fatigue, or worse, before they met you and had that impact. We rise and fall together in nursing, teaching and guiding one another as we go. The loss of that one person could have changed where you are right now. As mentors and teachers of patients and young professionals alike, remember that the small ripples we start can travel over great distances, over generations, and have a lasting impact.
Lynne Centrella Rudderow, MSN, RN, CRNP, WHNP-BC, CCE
Clinical Editor,
Lippincott NursingCenter.com
INSPIRE…is defined two ways, according to the
Oxford Dictionaries:
- To fill with the urge or ability to do or feel something
- Breathe in; inhale
When thinking of the word
inspire, we, as nurses, would likely think of the second definition first. The act of
breathing in is part of the vital signs. No matter how or where you practice, all nurses know the importance of inspiration. It keeps us alive.
Interestingly, when we think about the first definition, we can say the same thing. Being stimulated to do our best or to keep learning is an extremely important part of our lives.
Inspiration keeps us moving forward and that is living!
This Nurses Week, we think about
inspiration and reflect on what it means to be inspired both personally and professionally. I urge you to take a minute of introspection and think about what or who inspires you. Who do you think you inspire? I thought long and hard about what inspires me, particularly related to nursing. So many things came to mind; but, without a doubt, the most inspirational thing that has led and continues to lead me through my career is the female body
. I am in awe of its power, beauty and capabilities. Being a Women’s Health Nurse Practitioner, I am lucky enough to see firsthand what the female body can do. I am mesmerized by how it can create, grow and sustain another life. I am amazed by how it is equipped to nourish a child. I am astonished by how strong yet delicate its mind and soul can be. I am forever thankful that I get to witness, evaluate, support, assess, treat, and learn from the female body and all its glory. It is what inspires me to continue learning, continue helping, and continue living.
Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director of Continuing Education
Wolters Kluwer - Health Learning, Research & Practice
My colleague, Denise Felsenstein, tested an intervention during her Doctor of Nursing practice program that made a considerable difference in improving access to care for lesbian, gay, bi-sexual, and transgendered individuals in a community in Minneapolis, MN. What was this innovation? It wasn’t a new electronic medical records system. It wasn’t a mobile app, and it certainly didn’t involve virtual reality or artificial intelligence! It was a sign with an image of a rainbow that simply read, “All are welcome.” This sign was placed outside an ambulatory care center and in the lobby to make patients feel comfortable with seeking healthcare at that clinic.
Like Denise, many nurses solve problems, use observation, and research to test new interventions on a regular basis that can be considered innovations, but we may overlook the value of these interventions and never share them with the larger healthcare community. Consider how many tips you have given to new nurses during orientation that saved time or saved lives. Why is it that we rarely consider our contributions to be innovations? Perhaps it is because we typically consider technologies like robots, mobile apps, and medical devices to be innovations. Well that is just not the case; therefore, I challenge nurses to think differently about innovation.
Another way to think of innovation is to use an existing tool or device for a new purpose. An example of this is how older drugs are approved for new indications. Similarly, nurses may find a secondary benefit of an existing device that we can use to support nursing care like using a patient’s mobile phone to record patient teaching. There also may be great ideas that nurses can repurpose from another industry to solve a problem in healthcare. An example of this is how nursing professional development practitioners borrowed from the entertainment and gaming industry to foster learning in a more engaging format. Having received poor feedback about boring lectures in a nurse residency program, the organizers of the program implemented escape rooms to reinforce learning and to test problem-solving skills among nurse residents. (Adams, Burger, Crawford, et al., 2018).
The next time you improvise to solve a patient problem, document it in the form of a poster presentation or send it to a journal. You’ll have to do some research to explain the underlying science and to determine if your intervention is original. While you may not think your idea will have a significant impact, there’s a strong chance that your contribution may be just the solution that other nurses are seeking.
References
Adams, V., Burger, S.,Crawford, K., et al. (2018). Can You Escape? Creating an Escape Room to Facilitate Active Learning. Journal for Nurses in Professional Development, 34, E1-E5. doi:10.1097/NND.0000000000000433
Felsenstein, D. (2018). Enhancing Lesbian, Gay, Bisexual, and Transgender Cultural Competence in a Midwestern Primary Care Clinic Setting. Journal for Nurses in Professional Development, 34, 142-150. doi:10.1097/NND.0000000000000450
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse
Wolters Kluwer - Health, Learning, Research & Practice
This past week, we have been writing about the Nurses Week theme: Nurses Inspire, Innovate, Influence. What does influence mean and do we, as professional nurses, have the responsibility to influence those around us? The definition of influence according to the dictionary is "the capacity to have an effect on the character, development, or behavior of someone or something, or the effect itself." In essence, it means having the ability to be an instrument of change.
Change – not a favorite of those of us in clinical practice. It is much easier to accept things the way they have always been and not change our practice. However, we know that we are required to practice using the best available evidence and use best practice to provide quality patient care. As nurses, we are then required to influence our colleagues to practice using a higher standard to provide continuity of care; in essence, be a clinical leader at the bedside.
Practice is not the only place where nurses can be influential. Nurses need to be present where decisions are being made about healthcare and our own practice. That means we must be present where discussions are taking place about quality improvement, the physical practice environment, the equipment we will use in our practice, the monitors we use and even electronic healthcare record choices.
We must have a voice in the C-suite which means our chief nursing officer/executive and chief informatics officer must be at the same level as their medical counterparts. We must be part of healthcare boards and on boards that affect people. Who better to be advocates for people than nurses who care for them at some of the best and worst times of their lives.
Nurses must be present where decisions are being made related to our scope of practice and that means we must have a voice at the local, state, and federal level. We must understand the issues that are being discussed and voice our concerns and our support appropriately.
Never doubt the influence you have on the people around you, especially your family. I have three daughters and each of them have grown up to be influential women who are not afraid to use their voices and their actions to stand up for what they believe in.
Perhaps where we have the most influence is with our patients. We are advocates for our patients and can help our patient's make informed decisions regarding their healthcare and their life. We guide and teach our patients to understand diseases and conditions, how to take their medications, how to prevent sickness and most importantly, how to live their life as one of wellness.
Nurses are the most trusted profession for a reason and we have been for many years according to the gallop poll. It is because we have the courage and the ambition to inspire, innovate and influence others to be the best they can be.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the May 2018 inspired nurse story,
An Angel Got Her Wings.
An Angel Got Her Wings
Crystal Healy, Retired RN
I had just graduated nursing school in May that year and took my boards in June. My first ever patient encounter was on the Oncology floor with a young mother with two small boys. She had undergone a pulmonary surgery with lobe removal and had two dual chest tubes placed. I was her nurse on the day her chest tubes were to come out, so her surgeon asked if I would assist him, but something led me to refuse and tell him I'd rather watch and hold my patient’s hand as she endured the pain of this procedure.
A few nights later, she took a horrible turn. I called her husband to tell him to get there quickly as she wasn’t responding to me and was seeing lights and figures. When he arrived, we cried and prayed together, and held my patient’s hands all through the night. She managed to pull through with the grace of God and went on to tell everyone how much I had meant to her and how much of an angel I was for holding her hands all those times.
It's now ten years later and the woman who had once thought of me as her angel, just gained her wings a few days ago. Cancer didn’t win this battle,
she won this battle. I was her angel for ten years, but she will now be mine for the rest of my life!
We, as nurses, are aware of the profound impact that our profession has and continues to have on the advancement of patient care, policy and business. Nurses work at the bedside, teach at universities, conduct ground-breaking research, serve as hospital Chief Nursing Officers (CNOs) and hold high level executive positions within a variety of business organizations. While that might seem like common knowledge, I was disheartened to learn that nurses are not sought out by the media for their expertise. The research brief entitled
The Woodhull Study Revisited: Nurses’ Representation in Health News Media was released this month with some rather surprising results
.
In 1998, the original
Woodhull Study on Nursing and the Media: HealthCare’s Invisible Partner was published by Sigma Theta Tau International Nursing Honorary Society. The study, named after Nancy Woodhull, a founding editor of USA Today, aimed to determine to what extent nurses are used as sources for health-related news stories. The researchers analyzed health news stories in two leading national and five metro daily newspapers, three general interest weeklies, one business weekly and five health industry publications. They found that nurses were quoted in only 4% of newspapers and 1% in weeklies and industry publications. The study also found that nurses were never cited in health news stories on policy and were not identified in photos within the articles (Sigma Theta Tau International, 1997).
Led by Dr. Diana Mason, PhD, RN, FAAN, editor emerita of the
American Journal of Nursing, the Woodhull study was replicated by a team of researchers at the George Washington University School of Nursing to assess if progress had been made over the last twenty years. The research focused on three phases (Mason, et Al., 2018):
- Phase I: Are nurses represented as sources and identified in photos in health news stories in public and trade print publications with greater frequency than in 1997?
- Phase 2: What do health journalists perceive to be the barriers and facilitators to using nurses as sources in news stories?
- Phase 3: Are schools of nursing using social media to highlight the expertise of their faculty?
Results of the study were presented by the researchers on May 8
th at the National Press Club in Washington, D.C., followed by a panel of journalists who provided a response. A summary of the results is provided below.
Phase 1. Replication of Original Woodhull Study (Mason, et al., 2018)
Print news was analyzed in a similar fashion to the original study. A random sample of 537 articles (out of 2,234) were extracted and reviewed from seven newspapers, three weeklies, and three healthcare industry publications, excluding those that are no longer in print. The report found that nursing representation in the media had not changed over the last 20 years. Nurses were identified as sources in only 2% of quotes or other sourcing in health news stories and 1% in weeklies and industry publications. Nurses were mentioned in 13% of stories about healthcare and were more likely to be mentioned in stories about labor (57%), profession (44%), quality (32%), and education (25%). They were less likely to be mentioned in articles about research (9%), policy (4%) and business (3%). In several cases, nurses were not included even when their point of views were applicable to the topic discussed. Nurses were identified in 4% of images in the articles. Irrespective of profession, men were quoted twice as often as women and men were featured in 72% of images versus 48% for women.
Phase 2. Health Journalists’ Experiences with Using Nurses as Sources (Mason, et al., 2018)
In phase 2, the researchers interviewed ten health journalists regarding their experiences with nurses as sources in health news stories. This phase revealed a major barrier to utilizing nurses as sources in the media is bias about women, nurses, and positions of power in health care. Additional insights include:
- Although journalists believe that nurses can contribute important perspectives to health reporting, they do not fully understand nurses’ work, education and range of responsibilities.
- Journalists often don’t know how to find nurses to interview and have little time to track them down due to tight deadlines.
- Communications staff of hospitals and universities do not offer nurses as sources unless journalists request them.
- Editorial biases, policies and processes can prohibit the use of nurses as sources.
- Nurses and their colleagues lack a strategy for engaging journalists.
Phase 3. Use of Twitter by Schools of Nursing (Mason, et al., 2018)
This phase assessed how schools of nursing use Twitter to promote nursing faculty and researchers as experts. The most recent tweets from the public Twitter accounts of 47 of the top 50 nursing schools were examined. They found almost 80% of tweets were inward-facing or intended to engage nurses, members of the university/school community, or nursing conference attendees as opposed to outward-facing (intended to engage people outside the nursing and university/school community). In addition, only 1% of the 58,000 user accounts following nursing schools belonged to the media.
Mason et al. (2018) cite several factors that may contribute to the low representation of nurses within the media.
- Nursing is a female-dominated profession and women continue to be underrepresented as expert sources in the media.
- Journalists are not familiar with nursing responsibilities and how nurses might be able to contribute to stories.
- Journalists lack knowledge on how to locate nurses with expertise for a story. If they do use a nurse, they may need to justify this with their editor.
- Communications staff of universities and health care organizations may also be unfamiliar with nurses’ expertise and rarely recommend nurses as sources for journalists.
Yanic Rice Lamb, Associate Professor of Journalism at Howard University, who served on the journalist response panel stated:
"One of the things that journalists need to keep in mind is that nurses are everywhere. They are not only in the patient rooms but in the board rooms. And they can talk about policy, they can talk about management, they can talk about finances, they can talk about utilization review… they can talk about all the things we need to talk about as journalists working on our stories… In terms of being good journalists, and showing different points of view, it’s important to interview nurses…so that we are telling the complete story."
How can nurses and nursing leaders improve our profession’s representation in the media? During the study presentation, the researchers and journalists provided several recommendations.
- Nurses should be more responsive to journalists’ requests for interviews and better prepared for media opportunities.
- Nurses should develop relationships with journalists and offer unique stories ideas.
- Schools of nursing should promote their nurses’ expertise using more outward-facing social media methods, particularly on Twitter which is followed by many journalists to track issues.
- Nurses should be more proactive in recommending their expert colleagues to journalists.
- Nursing leaders, such as school of nursing deans and CNOs, should meet with their public relations staff on a regular basis and recommend their experts as sources for news stories.
- School of nursing deans and CNOs should integrate media competency training into the curriculum to improve clinical expert nurses’ comfort in communicating with the press.
Co-investigator Barbara Glickstein, MPH, MS, RN, stated “there is brilliant research being published by nurses in nursing journals.” She advised the nursing journals to work with the nurse researchers, to support them and teach them how to write press advisories and in a way that frames the research into newsworthy stories, so their research may reach the public.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Health Learning, Research & Practice for Wolters Kluwer, a sponsor of the Woodhull study, stated “The research that nurses are doing in the field of nursing and healthcare is vitally important to improve practice behavior and outcomes. It is incumbent for journal editors and publishers to work directly with authors to leverage their work in the media to improve discovery and dissemination of their research in order to integrate it into practice.” Lisa Bonsall, MSN, RN, CRNP, Senior Clinical Editor for Nursingcenter.com, part of Wolters Kluwer added, “Nurses have a perspective and an expertise that is unmatched, and I am so glad this issue is being revisited, with an even bigger view. Bringing attention to the role of nurse researchers and nursing journals, as well as the role of social media, specifically Twitter, will help fuel this movement. There is a lot to be learned from this research and I look forward to what the future holds!”
Do nurses remain invisible in the media? The study did not look at media that publishes exclusively on-line today; therefore, future studies will be needed to address this issue. Until then, the answer regretfully is “yes,” nurses do remain invisible in the media. Nurses have unique perspectives and have information to share. We need to be proactive, increase dialogue with journalists, and support one another so that the impact nurses continue to make in everyday patient care receives the recognition it deserves.
To view the study presentation, click here:
https://nursing.gwu.edu/woodhull-study-revisited
Resources:
Women’s Media Center:
https://www.womensmediacenter.com/
She Source Database:
http://www.womensmediacenter.com/shesource
Progressive Media Voices Media Training:
http://www.womensmediacenter.com/search?q=Progressive+Media+Voices+Media+Training
References:
Mason, D.J., Glickstein, B., Nixon, L., Westphaln, K., Han, S. and Acquaviva, K. (2018). The Woodhull study revisited: Nurses’ representation in health news media. Center for Health Policy & Media Engagement, The George Washington University. Retrieved from https://nursing.gwu.edu/woodhull-study-revisited
Sigma Theta Tau International (1997). The Woodhull study on nursing and the media: Health care’s invisible partner. Indianapolis, IN: Sigma Theta Tau International, Center Nursing Press. Retrieved from: http://www.nursinglibrary.org/vhl/handle/10755/624124
More Reading & Resources
The role of nurses, APNs, and healthcare reform in a changing political climate
Nurses and the Business of Caring: An interview with John Bluford [Podcast]
Sharing Your Knowledge: Getting Your Idea Published [CE]
Have you seen today's Google Doodle? Today, June 7
th, is the birthday of legendary physician, Virginia Apgar, the creator of the Apgar score. The Apgar score is used in delivery rooms around the world to assess newborn well-being. If you work in maternal-child health, you probably are very familiar with this screening test which looks at color, heart rate, reflexes, muscle tone, and respirations at 1-minute and 5-minutes after birth. It’s used to assess the transition of the newborn to extrauterine life.
Today would have been Dr. Virginia Apgar’s 109th birthday. Dr. Apgar was an obstetric anesthesiologist at the Sloan Hospital for Women, where, in 1952, she developed this scoring system for measuring the physical condition of newborn infants that bears her name. Here is a short lecture by Dr. Apgar which
Audio Digest recorded in 1966, where she describes how that scoring system came to be. We hope you enjoy this lecture.
Reviewed and updated by Megan Doble, DNP, CRNP, FNP-C, AGACNP-C: April 22, 2024
Since its inception in 2002, the Surviving Sepsis Campaign (SCC) has sought to improve the quality of sepsis care, improve survival for patients with sepsis and increase awareness of sepsis to both those in healthcare and the public. In the medical community, the most recognized products of the SCC initiative are guidelines for the management of sepsis and septic shock, and the sepsis “bundles,” which are tools that healthcare organizations can use to guide the implementation of evidence-based guidelines recognized to improve outcomes in the treatment of sepsis and septic shock. Directed by experts in the field from both the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine for the SCC, these guidelines inform clinical management and are updated regularly based on the latest literature, research and knowledge surrounding sepsis.
The major change we saw in the June 2018 release titled “The Surviving Sepsis Campaign Bundle: 2018 Update” was the elimination of the 3- and 6-hour bundles. Updates to clinical management guidelines typically precede the updates to the sepsis bundles. The first sepsis bundle was published in 2004 and included a “Sepsis Resuscitation Bundle” to be completed “as soon as possible” within the first 6 hours of presentation and a “Sepsis Management Bundle” to be completed “as soon as possible” within the first 24 hours. These initial bundles were revised in 2012 and changed to a “3-hour bundle” and “6-hour bundle,” with similar elements but with an effort to perform the interventions within a shorter time period. These 3- and 6-hour bundles were further revised in 2015 with the elimination of central venous pressure (CVP) and S
CVO
2 measurement. Driven by the release of the International Guidelines for Management of Sepsis and Septic Shock: 2016, the 2018 bundle update, titled the “Hour-One Bundle” emphasizes 5 steps recommended to begin immediately upon presentation in all patients with clinical elements suspicious for sepsis or septic shock. “Time zero” is the time of presentation to triage in the emergency department. If presentation occurs in a different setting (outpatient, nursing home, intensive care unit, hospital floor), “time zero” would be the first documentation in the chart with the elements of sepsis (Levy, Evans & Rhodes, 2018). It is understood that the interventions may not be completed within the hour.
The Hour-1 interventions are (Levy, Evans & Rhodes, 2018):
- Measure lactate level (repeat lactate if initial lactate is elevated [greater than 2 mmol/L]).
- Obtain blood cultures before administering antibiotics.
- Administer broad-spectrum antibiotics.
- Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L.
- Apply vasopressors if hypotensive during or after fluid resuscitation to maintain mean arterial pressure greater than or equal to 65 mm Hg.
While the central elements of the bundles remain consistent (lactate measurement, obtaining blood cultures, administration of IV antibiotics, IV fluid resuscitation and the application of vasopressors for those with refractory hypoperfusion), there have been significant changes over the years in the time frame during which these interventions should be initiated and completed.
The changes are based on the concept that sepsis is a medical emergency requiring immediate and timely intervention to improve survival not only at the time of presentation (“time zero”) but also during the subsequent hours of entry to the medical system (with ongoing evaluation and intervention). Furthermore, the measures provide points for data extraction to further improve the study of sepsis and sepsis outcomes. Since its inception in 2002, the implementation of the SCC bundles has led to more appropriate care in the treatment of sepsis and improved outcomes and survival (Prasad et al. 2017; Seymour et al. 2017). However, the guidelines and SCC bundles do not come without controversy. Some organizations feel that the guidelines are too restrictive and due to their adaptation by the Centers for Medicare and Medicaid Services (CMS) with linkage to reimbursement, there is a potential risk for conflict of interest between individual clinician judgment and satisfying the core measures required for reimbursement.
Understanding the controversies
The general sentiment of those that are in disagreement with the SCC guidelines and bundles are largely that they favor a protocolized approach to care for those fitting the diagnosis of sepsis with less emphasis on clinical judgment and individualized care. Patients with sepsis and septic shock may have significant differences in the acuity of their illness due to co-morbidities which could lead to variations in the delivery of care. Furthermore, the adaptation of sepsis core measure by CMS, linking the implementation of specific interventions to reimbursement leaves many healthcare providers conflicted. While it is understood that the intent of core measures is to ensure the provision of appropriate care across all those served by CMS thus preventing disparities in access to quality care, there is potential for exposure to improper care, including inappropriate fluid administration and broad-spectrum antibiotics which could lead to more harm than good. With the regulatory guidelines, there isn’t an option to indicate to CMS as to why the interventions did not take place. An example would be the decision not to administer a 30 mL/kg fluid bolus to a patient who flags for sepsis without evidence of hypoperfusion and a co-morbidity of end-stage renal disease or congestive heart failure for fear of progression to acute respiratory failure due to volume overload. Lastly, an argument can be made that there is no perfect “sepsis screen” or single diagnostic tool, as opposed to some of the more urgent time-based clinical emergencies, such as STEMI where elevated cardiac enzymes and specific ECG changes allow for a diagnosis to be made with more certainty.
What should we do at the bedside?
It is important to remember that the guidelines are developed to guide and should be considered as they have shown to improve patient outcomes and survival (Seymour et al. 2017), but they cannot and should not be applied to every patient in the absence of sound clinical judgment. As nurses, it is imperative that we understand and know the most current recommendations and stay abreast of literature updates. We should ensure that the care we provide is tailored to the individual patient. Those of us working in emergency rooms, intensive care units and on hospital floors spend more time on average at the bedside and play a key role in advocating for appropriate medical care.
As with the administration of any medication, it is essential to understand that there is potential for adverse outcomes from administration of IV fluids. It is important to remember that the goal of fluid resuscitation is to restore tissue hypoperfusion; if there is no response to fluids, there is no clear benefit for the continuation of fluids beyond the initial bolus and vasopressors need to be considered. There is no “one size fits all” for fluid resuscitation; treatment requires close and frequent hemodynamic monitoring and evaluation for response.
The latest international guidelines for the management of sepsis and septic shock were released in 2021. In these guidelines, we continue to see a trend towards less liberal fluid administration. For example, the strength and quality of the recommendation “for patients with sepsis-induced hypoperfusion or septic shock we suggest that at least 30 mL/kg of IV crystalloid fluid should be given within the first 3 hours of resuscitation” was downgraded from strong recommendation, low quality of evidence in the 2016 guideline to weak recommendation, low-quality evidence in the 2021 guideline (Rhodes et al., 2017; Evans et al., 2021). The implications of a weak recommendation, as stated in the guidelines is that alternate choices may be appropriate for different patients and that therapy should be tailored to the individual patient’s circumstances (Evans at al., 2021).
Even more significant is the addition of the statement “there is insufficient evidence to make a recommendation on the use of restrictive versus liberal fluid strategies in the first 24 hours of resuscitation in patients with sepsis and septic shock who still have signs of hypoperfusion and volume depletion after the initial resuscitation (Evans et al., 2021). This infers to the clinician that even if a patient shows signs of hypoperfusion, fluids may not be the answer; indiviualized treatment decisions are necessary.
Clinical Scenario
In a typical clinical situation, a call is placed to the medical provider when a patient develops a fever, hypotension, tachycardia, or if there is a “sepsis” alert via the medical record system. In these situations, we could expect an order for lactate measurement, blood cultures, broad spectrum antibiotics and possibly an order for 30 mL/kg of crystalloids (either normal saline or lactated ringers). As the bedside nurse, we are responsible to know the clinical histories of our patients, the reason they were hospitalized as well as their clinical trends over the past 12 to 24 hours. If, as the bedside nurse, you were aware of a recent echocardiogram which revealed an LVEF of 10%, the delivery of a large volume fluid bolus should be questioned. While ultimately, the ordering provider is responsible for knowing the clinical history of the patient they are treating, there is an opportunity here to prevent a harmful medical intervention. In this specific clinical situation, you may postulate: Is there a degree of cardiogenic shock (lactate can be elevated in any type of hypoperfusion)? Was there a vegetation on the ECHO (is this patient at risk for endocarditis?). Given the poor cardiac function, and presence of unfavorable vital sign trends, this particular patient may require earlier transfer to an intensive care unit, central line placement and initiation of a vasoactive medication.
The goal of the SCC is to improve outcomes, survival and awareness of sepsis. Despite some controversies, the organization has been successful in accomplishing this which has been supported by several studies (Prasad et al. 2017; Seymour et al. 2017). Over the years, the bundles have evolved from 6-hour and 24-hours and 8 steps, to 3- and 6-hour with 6-7 steps and most recently, a 1-hour time frame and 5 steps stressing the importance of timely intervention in managing this medical emergency. It will be interesting to see what comes of future guides concerning bundles.
What has been your experience with sepsis? Does your hospital routinely utilize the sepsis bundles and has there been any recent discussions in your organization about the recent updates?
References
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
Levy, M. M., Evans, L. E., & Rhodes, A. (2018). The Surviving Sepsis Campaign Bundle: 2018 update. Intensive care medicine, 44(6), 925–928. https://doi.org/10.1007/s00134-018-5085-0
Prasad, P. A., Shea, E. R., Shiboski, S., Sullivan, M. C., Gonzales, R., & Shimabukuro, D. (2017). Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data. Anesthesia and analgesia, 125(2), 507–513. https://doi.org/10.1213/ANE.0000000000002085
Rhodes, A., Evans, L. E., Alhazzani, W., Levy, M. M., Antonelli, M., Ferrer, R., Kumar, A., Sevransky, J. E., Sprung, C. L., Nunnally, M. E., Rochwerg, B., Rubenfeld, G. D., Angus, D. C., Annane, D., Beale, R. J., Bellinghan, G. J., Bernard, G. R., Chiche, J. D., Coopersmith, C., De Backer, D. P., … Dellinger, R. P. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine, 43(3), 304–377. https://doi.org/10.1007/s00134-017-4683-6
Seymour, C. W., Gesten, F., Prescott, H. C., Friedrich, M. E., Iwashyna, T. J., Phillips, G. S., Lemeshow, S., Osborn, T., Terry, K. M., & Levy, M. M. (2017). Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. The New England journal of medicine, 376(23), 2235–2244. https://doi.org/10.1056/NEJMoa1703058
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the June 2018 inspired nurse story,
Mind, body and spirit.
Mind, body and spirit
Aimee Brewer, Clinical Nurse
Tallahassee Memorial Hospital
Mind-body-spirit connection has always been essential to me in critical care nursing; not only for the patients and families, but for me as well, as their nurse. I once had a patient with multiple gunshot wounds which were critical but relatively stable. This patient had never been shot before and was obviously scared. The family had gone home, so he was all alone with his thoughts. The day shift was refusing him pain medications, so I told him I would take care of him and would be there when he needed me. I reassured him he was doing well, and added how lucky he was to be alive as he had arrived at this situation due to poor life decisions.
He then looked at me and said, “I’ve never been shot before, they tried to kill me.” I simply said, “yes they did.” At that point he asked me to pray with him and so I did. And when we finished, I noticed his heart rate had gone down, along with his blood pressure. His respiration had also evened out, with his oxygen saturation increasing. As a result, he had adequate pain relief for the rest of the night. I also sprinkled some lavender oil on his pillow for added comfort. When the day shift came in the next morning, they were amazed at how relaxed he was and how his vitals had normalized. While he still had a very long road ahead of him, for my shift, the post-op night 0 shift, it was a good night.
To share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit http://lippincottsolutions.lww.com/landing/inspired-nurses.html. Be sure to check our blog every month for a new inspired nurse’s story.
I could hear the tremble in the paramedic’s voice as he called in report to the ER medical command phone line. It was late February, we were in the middle of an ice storm, and he had a resuscitated code. As the emergency department charge nurse, I mobilized the troops, including ED and ICU physicians and we were ready when the medic arrived with our new patient. I can remember so many details from that night – I can see my hands untangling a mass of wires attached to the patient, I can feel the buttons beneath my fingers as I set her up on the vent, and I can still see the look on the face of her medical-phobic husband, Larry. He was alone here and would have preferred the distance of the waiting room, but I needed him near us in case anyone had questions. I posted him in a chair right outside of the room where we could keep an eye on him too. The memories are so vivid from that case – charting on the pale lavender T-sheet, pulling her IO before I put the hypothermia pads on her, and checking her pupils. In my mind’s eye I can see the moment when she started posturing, and the detour we took to CT, so we could scan her head on our way to the cardiac catheterization lab. Of all the details I remember from that night, there is one missing piece: I cannot recall her face.
Our trip to the cardiac catheterization lab was the typical trip – numerous pieces of equipment all hooked to one slight-framed human, barely recognizable under all of it, with staff surrounding the moving island of the stretcher, squeezing the ambu-bag, keeping the lines protected as we turned corners, and arriving to the waiting cath lab staff. All the while, Larry trailed behind us, and I let him know that it was safe to lean over and kiss her forehead, one of the few places where her skin was still exposed. Depositing him in the waiting area – so alone – felt like a betrayal, but I had to take his beloved wife into the lab and give report. Familiar faces greeted me in the cath lab, and I discussed with the receiving nurse Jill, how I was concerned for the patient’s neurological outcomes, and how we left the
cooling mechanisms in place.
Walking out of that cath lab, my stretcher topped only with equipment, we approached the Heart Center waiting room where I left Larry. I couldn’t just leave him there, all alone! I sat with him while we arranged for someone to join him, and the nursing supervisor came and stayed with him, so I could return to our busy emergency department. As I departed, I remember Larry hugging me quickly and whispering, “Thank you for staying.”
That shift progressed toward its end, like all shifts do, and I heard some updates about our patient. Life in the emergency department means that you move to the next thing when needed, and rarely do you find out how cases finish, how the story ends, and the final outcomes. I put this patient from my mind on my drive home, wishing her well, but knowing that I was unlikely to find out how the story ended.
Fast forward a few days, I picked up a shift in my other role, on the IV Team, and I did a PICC dressing check in ICU10. It was an unremarkable stop, where I spent time with a pleasant but confused lady who was perseverating about finding the book that she brought to the hospital. She was sure someone had stolen it and wanted help finding her book. I told her I would keep an eye out and I packed up my things and walked out of the ICU. There was something familiar about her, but I couldn’t put my finger on it – until I passed Larry – sitting in the glass-walled waiting room. He jumped up to hug me and I had my “A-HA” moment. I had just been in his wife’s room and she was alert, awake, and doing well. I asked Larry if I could inform the ED staff from that night how she was doing, and of course he agreed. Knowing that she was awake and expected to make a full recovery, was more closure than I usually get with my ED patients, but our story was not yet complete!
In March of that year I was invited to collaborate on a case presentation about Sue. It was an honor to present information about her care in our ED, the therapeutic hypothermia protocol, and the chain of survival. I only saw Sue briefly that night, as there were so many people eager to meet her and engage in conversation, and I knew it would be an overwhelming night for her in many ways. Instead, I made sure that Larry knew I was there, and that I would always remember them.
In May, my whole family attended the annual EMS awards banquet where my paramedic husband would be receiving county-wide recognition for clinical saves. We went every year and this year was no exception, with our daughters all dressed up and family in attendance. It was no different
until I saw Larry. He was being recognized for his citizen-save, for the CPR he performed on his own wife. While I was talking to Larry, and introducing him to my own family, Sue Davis walked over and introduced herself to me. We were very emotional as we told her the story of that night in the ED and trip to the cath lab, of me sitting with Larry, and of how much effort so many people had poured into the case to protect her and save her life. My six-year-old daughter was astonished to realize that it wasn’t just
Daddy who saved lives every day.
I heard the
pre-hospital story of Sue and Larry that night, and the amazing things that happened to them. How the ice storm had knocked out power, and Larry had used a cell phone to call 911. In the dark of the house, when Sue collapsed, how he had performed CPR on his beloved wife, then had to decide to stop and run outside when he heard the sirens get close enough. He used a flashlight – waved it in the air – to show them where to go, because they couldn’t read the house numbers with all the power knocked out. I got to hear how the paramedic (Matt E.) worked with a flashlight in his mouth to put in her IV, and intubate her, while running her code. I was so glad that I got to hear from the first-hand participants about this case and felt that a bond between our families had somehow started that night.
No surprise then when in June, watching the tracking board from my ED nurse charge desk, I saw her name pop up and I went immediately out to the waiting room to find her. She was pale, diaphoretic and hugged me as I directed her into a wheel chair. Back in a room, we seated Larry outside the curtain as he was still uneasy with all things medical. Inside the room, I worked quickly to get her situated on the monitor, started an IV, and grabbed a 12-lead EKG, as a colleague called my ED physician into the room. Dr. Clark opened the curtain, pulled Larry into the room and said, “Hey Jess, look at his shirt! He’s wearing Star Island gear!” Star Island is a tiny Unitarian retreat island off the coast of New Hampshire, near where Dr. Clark grew up. Generations of my family have vacationed there for over 50 years, and it is a very special place to us, as Dr. Clark knows. At this moment, we discovered even more connections between our two families, and that Sue and Larry have been going there since 1985 and knew my in-laws and my extended family. Sue and I lamented how we would not be visiting Star Island, our spirit’s home, that summer for different reasons. She could not go anywhere with her current recurrent SVT situation, and I was due in two weeks to have our third child, not time for either of us to take big road trips! As they were preparing to take her from the ED up to her monitored bed for admission, I could hear her saying that she would not leave until she saw me one more time. She wished me well, especially with the new baby, and said that she would see me soon.
To complete that year, I received a Christmas card from them, and the best gift anyone could give me. They donated to the hospital foundation on my behalf. The letter I get each year from the foundation is a prized reminder of the impact we have on our patients. The Christmas card from Sue and Larry is the one that stays up well into the warm months of the year.
I am still ashamed to say that I did not remember Sue’s face that first night I met her. But now, when out walking my dog, or at the hospital, or around town, all I have to do is catch a glimpse of her and I know her instantly. We shout greetings of joy and embrace whenever we are lucky enough to meet. I am glad that now, I remember her face, along my part of their story with warmth and gratitude.
In terms of the time that nurses give to their patients, she was one small part of one shift, that had a lasting impact on her and her family, along with everyone that she has touched and inspired since. She is an advocate for community CPR and teaches lay people CPR so that they too can be a critical link in preserving life.
I urge the nursing community to celebrate the successes we promote, both large and small. Share your stories, help renew your passion for our profession, and inspire others to recognize the impact we have on those we touch.
How do primary care concerns differ between an MD and an NP? Dr. Margaret Fitzgerald, Conference Chairperson for the National Conference for Nurse Practitioners (NCNP), explained it clearly during the opening session to the Spring 2018 NCNP:
“For example, when a patient presents with nausea, the MD wants to find out what caused it. The NP thinks ‘how can I make this patient feel better while we figure this out?’ We both have the same concerns, but our top priority differs.”
During last spring’s conference, my schedule allowed me to attend sessions from both the acute care and primary care tracks. I had the privilege to learn so much both in and out of my specialties of critical care and women’s health. Below are some highlights; some are pearls of information, as I’ve shared in the
past, but others are questions that generated discussion in the sessions. I think are good for us all to think about.
“The most important thing you can do for your health is sleep.”
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP
Gut Microbiome: Implications for Health and Chronic Disease
“Ask patients what their acceptable level of pain is. Use that number as a pain target.”
Mary Ann Barnes-Daly, MS, RN, DC
Liberating the ICU Patient: Understanding the ABCDEF Bundle
“What is the dynamic modulator of oxygen delivery?”
Honey M. Jones, DNP, ACNP-BC
Acute/Emergent Care: Hemodynamics – It’s More than Just BP
“X-rays lag about 24 hours behind clinical presentation.”
Acute/Emergent Care: RRTs: Improving Outcomes Through Best Practice
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
“Why is glucose monitoring in patients with acute ischemic stroke important?
Mindy Mason, MSN, RN, ACNP-BC
Acute/Emergent Care: Brain Attack? Management of Acute Ischemic Stroke
“The most common cause of painless jaundice is pancreatic heat tumor.
Bruce D. Askey, MS, ANP-BC
Evaluation of Abnormal Hepatic Enzymes
“Hirsutism is rare in Asian women. Think malignancy.”
Christine Kessler, MN, ANP-BC, CNS, BC-ADM, FAANP
Endocrine Zebras: Identifying Signs in Your Clinical Practice
Two of my favorite sessions – both new to me – were Using Essential Oils in Clinical Practice, a two-part workshop with Angela Golden, DNP, FNP-C, FAANP, and Making Healthcare TRANS-parent: Providing Culturally Sensitive Primary Care to the Transgender Patient, presented by Vanessa Pomarico-Denino, MSN, APRN, FNP-BC, FAANP. Learning about these hot topics from experts in their respective fields was a privilege.
This conference was truly one I’ll never forget! In addition to all I learned, it was at this conference that I actually got to meet
Dr. Loretta Ford!
Lippincott Professional Development (LPD) has received the American Nurses Credentialing Center’s (ANCC) Premier Accreditation Award for the second year in a row. As the Executive Director of Continuing Education at Wolters Kluwer, I accepted the award and was accompanied by Sherry Ratajczak, MSN, CPNP, Senior Clinical Editor and Janet Thomas, MSN, RN-BC, Manager of Continuing Education Accreditation & Compliance at Disney’s Coronado Spring Resort, in Lake Buena Vista, FL during the ANCC Continuing Nursing Education Symposium. We thanked ANCC for this prestigious award and expressed our appreciation of ANCC’s acknowledgement of the leadership and innovation that the team of nurses at LPD has brought to the field of nursing to improve nursing practice through key professional development activities and to share our best practices through presentations, publications, and mentorship.
The ANCC Primary Accreditation criteria have been a foundation for our processes in planning, implementing, and evaluating professional development activities. While ANCC upholds quality standards, its flexibility allows for more broadly defining professional development and continuing nursing education activities in a time when we find that similar accreditation boards or state boards in other health care professions, have set narrow standards for what qualifies for continuing competency or continuing education credit. In fact, some have only allowed online continuing education in the last 5 years. With the flexibility that ANCC allows, LPD can better meet the learning needs of nurses by testing and exploring new types of activities including: virtual journal club, point-of-care learning, and interactive cases. We are currently exploring innovative and creative ways of delivering and measuring learning which would not be possible without ANCC’s recognition of continuing nursing education credits from a variety of professional development formats. LPD is taking our activities a step further by measuring how our activities impact nursing practice and patient outcomes by working with partners in health systems to collect data that links to the learning objectives of the continuing nursing education activities and measuring outcomes using quality data reported to government agencies.
In addition to nurses with advanced degrees in the clinical editor and nurse planner roles, LPD has the internal resources including instructional designers, website designers, artists, and a videographer. This group continually examines our teaching methods and learning designs to make a difference in clinical learning. We also have an expanding pool of talented nurse experts who are in practice in dozens of specialties who spend the time delving into the latest research to keep our learning materials current.
We are extremely motivated by winning the ANCC Premier Accreditation Award to continue to test new technology to support learning. Also, our goal is to further improve our evaluation processes to have even better ways to demonstrate improvement in nursing practice and the quality of patient care. Most of all, we not only strive for excellence, we truly enjoy the work we do at Lippincott Professional Development and each have a personal and professional commitment to the quality of work we publish.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the July 2018 inspired nurse story,
Making a Difference.
Making a Difference
Randi A Schwarz, RN, CPC-P
Health Partners Plans
Clinical Investigator/Special Investigations Unit
My experience took place years ago, when I was working as a hospice case manager. I found hospice care to be the most rewarding part of my practice experience. People would often ask me how I could do hospice nursing as all my patients were going to soon pass away, to which I would reply, “My job is to ensure that these people have the best quality of life for whatever time they have left. I am doing God's work on earth.”
One patient I will never forget is Mary. She lived with her son in an old row home in Philadelphia. When I first began visiting Mary one hot summer, the vehicle I drove was old and without any air conditioning, so Mary's son made sure he always had a full pitcher of ice cold tea waiting for me every time. Seeing people in their home, makes you very close to the patient and their families.
As time went on, Mary's health deteriorated as expected (she had lung cancer.) One Friday I mentioned to her my birthday was that weekend, and when I arrived the following week, Mary had crocheted a beautiful afghan for me. To this day, that afghan is one of my most treasured possessions. But on that Friday, I saw Mary just hanging on, and I could tell she was going to pass imminently (a skill I hated to have developed). I was the on-call nurse that weekend so told her I would see her the next morning. She was so weak, so I did what I had to do that afternoon, and then left to go to my next appointment. Fifteen minutes later, I got a call from Mary’s son telling me she had passed away. I immediately went back to pronounce her death and fill out the death certificate. Mary's son asked if I would come to the wake/viewing a few days later, and when I arrived, he began introducing me around like I was a rock star. People told me how she would often speak about me and the way I provided her care. “I only did what I was trained to do,” I’d say. But I know I made a difference, which is why I went to nursing school in the first place.
To share an inspiring story of your own about being a nurse, or how you were inspired by another, and enter to win prizes, visit http://lippincottsolutions.lww.com/landing/inspired-nurses.html. Be sure to check our blog every month for a new inspired nurse’s story.
The gentle rise and fall of her breathing was peaceful and easy, as I gazed at her from the foot of her hospital bed in the post-anesthesia care unit. Report was given, but I just couldn’t bring myself to walk away from this fellow human in crisis. Her situation was troubling to me, and the solution seemed elusive. She was pleasant, articulate, successful, and otherwise healthy at present, except for her super morbid obesity.
According to her surgeon, she repeatedly refused to discuss her weight, eating habits, exercise, or any modifiable lifestyle factors with him. When he had attempted to broach the topic of bariatric surgical options with her, she adamantly refused to discuss it with him. So, there I remained, after giving anesthesia report to an amazing nurse in the PACU, still at the foot of her bed. Together, we were pondering what we could do to help support healthy changes for this one patient.
Then, it hit me. She is an inpatient now, we have her for at least a few days of care, and what she really needs is…. a
nurse.
You see, a nurse doesn’t simply name a diagnosis or give a medication. A nurse doesn’t just perform a procedure, apply a treatment, or arrange for home care.
A nurse will assess a family dynamic, identify a fear, and soothe a tired soul with his or her words. A nurse can build that intimate space for communication and human empathy, that comes with providing hands-on direct patient care.
Nurses are there, with the patient, every moment, every day, building the relationships that open doors. This healing space and ensuing trust allow nurses to initiate conversations with patients that no one else can manage.
That is why my patient in PACU needed
a nurse.
This is a
thank you, to all the nurses out there, who alongside of me, over so many years, invested so much of themselves in caring for their patients. To all the nurses who took the time to find out what was really going on with their patients and helped them on the path toward healing, I offer my gratitude.
To all of the nurses, quietly toiling away, making a difference every day in the lives of their patients and whomever they touch, I have a message:
There may not be a letter ‘K’ in certification, but there is certainly a ‘K’ in some of the certification acronyms. What does it mean?
The ‘K’ in some certifications, such as CCRN-K (Acute/Critical Care Knowledge Professional) and CHFN-K (Non-Clinical Certified Heart Failure Nurse), stands for ‘knowledge.’ Many of us – myself included – work in roles away from the bedside, but still stay informed and knowledgeable in our specialties. These certification programs allow us to demonstrate specialized knowledge that positively impacts other nurses, patients, and organizations. If you’ve transitioned away from a bedside role in nursing and want to learn more about the ‘-K’ certifications, visit your certifying association to see if this is offered. You can find a full list of nursing certifications in our
Certification Guide.
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the August 2018 inspired nurse story,
Candy and CPR.
Candy and CPR
Dawn Miller, RN
Lexington Healthcare
Being a nurse is more than just job and a paycheck -- it's a calling. The day I decided to become a nurse was when I was 13 and my younger cousin began choking on piece of candy he’d gotten from a waitress at restaurant. We were in the backseat of my grandmother's car when he started to cough and then begin to turn blue. My grandmother pulled over, took him out of the car, placed her arms around him and began performing the Heimlich maneuver. The piece of candy had been lodged causing my cousin to become unconscious. I was frozen and couldn't speak but prayed in that moment for a miracle.
My grandmother asked me to call 911 while she laid my cousin on the ground and began doing CPR. I didn’t know what CPR was at the time but did know that my cousin was dying. I watched as my grandmother began pumping on his chest and then saw the piece of candy shoot out of his mouth. She then began breathing life back into him and my cousin started to cough and tried to sit up. I looked at him and then at my grandmother who had started to cry. I asked her how she knew how to do that, and she said, "I learned it many years ago, when I was a caregiver in the hospital."
She then told me how she had always wanted to be a nurse, but money was tight. At that point my cousin stood up and began to tug on my grandmother's shirt asking for more candy. My grandmother and I just looked at each other and began to laugh, knowing that if she hadn’t had the skills needed to save his life, things might have gone terribly wrong. That was the longest ten minutes of my life, but I knew in that moment that I wanted to save people. I wanted to fulfill my grandmother's dream of becoming a nurse, and several years later I did. And although the journey was tough at times, I succeeded and have been a practicing nurse for ten years now, loving every minute of it.
More Reading & Resources
This week, Dr. Anne Dabrow Woods, Chief Nurse of Wolters Kluwer Health Learning, Research, and Practice, presented at the
Australian College of Nursing (ACN) 2018 National Nursing Forum, a signature leadership and educational event, which took place at the Gold Coast Convention and Exhibition Centre in Gold Coast, Queensland, Australia. This year’s theme was “Diversity and Difference,” with sessions related to health inequality and creating change, as well as tracks with sessions related to Information and Digital, Policy and Practice, and Trailblazers (Pushing the Boundaries).
In Dr. Woods’ Keynote Address,
Improving Healthcare Outcomes – The Business of Caring for People, she addressed today’s global healthcare challenges and the importance of using the best available evidence and technology to improve practice, patient outcomes, and global health.
A practicing nurse for over 34 years and a board-certified nurse practitioner since 1998, Dr. Woods’ expertise includes implementing evidence into practice to improve workflow, and acute and primary care nursing practice. Practicing every weekend as an acute care/critical care nurse practitioner for Penn Medicine, Chester County Hospital, she also serves as adjunct faculty in the graduate nursing program at Drexel University and she precepts nurse practitioner students.
There is no doubt that Dr. Woods’ expertise is welcomed and appreciated by all who have the privilege of learning from her.
And not surprisingly, the goals for the nursing profession in general throughout Australia are not very different from the goals here in the United States.
“And in this shift away from acute care, nurses, more than ever before, will be called upon to lead and deliver new models of care which fill emerging gaps in services.
Nurses will also have greater opportunities to work to full scope, undertake research, specialise, take on more complex workloads and be more heavily involved in decision-making.”
Steven Miles MP, Minister of Health & Ambulance Services
Sharing our goals and objectives, as well as the means to meet them, is key to learning and growing as individual nurses and as a professional group. Thank you to the ACN and Dr. Woods, for addressing challenges, sharing opportunities, and prioritizing issues, to move nursing forward.
Approximately six months have passed since the official launch of Nursing Now, a global collaborative campaign between the International Council of Nurses (ICN) and the World Health Organization (WHO). Nursing Now’s vision is to “improve health globally by raising the profile and status of nurses worldwide.”
1 In the short time since inception, Nursing Now has become a powerful influence around the world with programs and partnerships in countries such as Uganda, Kenya, Rwanda, South Africa, Israel, Turkey, Qatar, China, Taiwan, Singapore, India, Brazil, Jamaica, Mexico, Germany, France, the United Kingdom, Canada and the United States.
View notable highlights in this presentation
2:
Noncommunicable diseases (NCDs), such as heart disease, stroke, cancer, diabetes, and chronic lung disease, account for almost 70% of all deaths around the world. While management of NCDs is a current focus in many Nursing Now programs, infectious diseases such as HIV and AIDS continue to pose a serious public health challenge, particularly for countries with limited resources. According to the WHO, there were 36.9 million people living with HIV in 2017, of which 1.8 million had become newly infected and 940,000 died from HIV-related causes.
3 The African region accounts for the highest percentage of people living with HIV at 25.7 million, over two-thirds of the worldwide total.
3 Only 59% of all people living with HIV were receiving antiretroviral therapy (ART) in 2017.
3 Healthcare providers must be armed with the latest information in order to improve HIV prevention, treatment, and support services for all people living with HIV and/or AIDS.
In July 2018, the
Association of Nurses in AIDS Care, along with the National HIV Nurses Associations of the UK and the Netherlands, joined the Nursing Now campaign to “raise awareness about the roles of nurses in global health and supporting people living with HIV in sustained treatment.”
Wolters Kluwer Health will begin publishing The Journal of the Association of Nurses in AIDS Care (JANAC) in January of 2019. This cutting-edge, international journal is peer-reviewed and provides the most up to date information on HIV/AIDS prevention, evidence-based care management, interprofessional clinical care, research, advocacy, policy, education, epidemiology, and program development. Through this partnership, Wolters Kluwer will publish the journal in its Lippincott Portfolio, broadening the reach to a larger audience.
Through partnerships like this, the impact of nursing will grow strong. We as a profession, should continue to strive to implement change locally to influence healthcare globally.
For more information about Nursing Now, go to:
http://www.nursingnow.org/
References:
- Nursing Now (2018). Vision Statement. Retrieved from http://www.nursingnow.org/vision/
- Nursing Now. (2018) News. Retrieved from http://www.nursingnow.org/influencing-ncds-commission-guide/
- World Health Organization (2018). HIV/AIDS Statistics. Retrieved from http://www.who.int/news-room/facts-in-pictures/detail/hiv-aids
I recently had the pleasure of speaking with Dr. Mary Ann Fuchs, Vice President of Patient Care and System Chief Nurse Executive for Duke University Health System and the Associate Dean of Clinical Affairs for Duke University School of Nursing.
Dr. Fuchs began her career in oncology nursing, later becoming an oncology clinical nurse specialist, and continued on that path working with adult and pediatric stem cell transplant patients. However, like many of us, Dr. Fuchs did not imagine the turn her career would take. As opportunities were presented and mentors guided her, Dr. Fuchs is now a respected leader at a prestigious health system and nursing school.
During our conversation, Dr. Fuchs shared her passion in nursing, three pieces of advice for up-and-coming nurse leaders, and the important work being done by the Nurses on Boards Coalition. Dr. Fuchs emphasized the unique perspective and experiences of nurses – we understand what happens with patients, we understand how things work in clinical organizations, and we are the most trusted profession. Our service on boards is essential to share all that we know and advance the impact of our profession.
Please listen to our full conversation
here.
Thank you, Dr. Fuchs, for speaking with me and sharing your story.
About Dr. Mary Ann Fuchs
Mary Ann Fuchs, DNP, RN, NEA-BC, FAAN, is the Vice President of Patient Care and System Chief Nurse Executive for Duke University Health System and the Associate Dean of Clinical Affairs for Duke University School of Nursing. As vice president of patient care and system chief nurse executive, Fuchs is responsible for the practice of nursing by ensuring consistency in the standard of practice across clinical settings. As a member of the health system executive team, Fuchs supports and facilitates an interdisciplinary team approach to the delivery of care. This includes creating a nursing environment in which collaboration is valued and excellence in clinical care education and research is promoted and achieved. Read more…
More Reading & Resources
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the September 2018 inspired nurse story,
Laughter through the Pain.
Laughter through the Pain
Holly Tarta
McGuire VA Medical Center Nurse
There’s one special patient I will always remember. Time spent with her made me realize that nurses truly can make an impact on someone's life.
I was a new nurse on a telemetry floor. My patient was admitted for complications related to lung cancer. During my visits with her, we talked about her family and friends and she shared her feelings, fears, and the impact lung cancer had on her everyday life. I remember taking the time to be a good listener and shortly became the nurse she trusted most. Being new to nursing, I was not experienced in maneuvering her extra-long oxygen tubing, when she asked that I help her on a trip to the toilet. I was assisting her to a bedside commode, and during the transfer, both she and I became tangled in the tubing. We twisted left and right trying to get untangled, then laughed until we cried.
The following day, when I arrived to work I noticed she was not on my assignment list. I was shocked to learn it was because she had passed away peacefully, the night before, surrounded by family. To this day, I think about her and the time we spent talking and laughing too. And from those memories, I find peace in knowing that she and I shared her last laugh.
Reviewed and updated by Valerie Dziados, MSN, CRNP, ANP-BC, AGACNP-BC: March 8, 2024
A 54-year-old female with no past medical history presents to the emergency department with two hours of substernal chest pain, rated 8/10, and associated with diaphoresis and shortness of breath. She appears in mild distress and is pale. Her electrocardiogram reveals ST-segment elevation in the precordial leads. Initial cardiac high sensitivity troponin level was 225 ng/L; otherwise, her laboratory results were unremarkable. Her past medical history is significant for hypertension and she was recently diagnosed with breast cancer 3 weeks ago. She is emergently taken to the cardiac catheterization laboratory. The expectation was that obstructive coronary artery atherosclerosis would be identified as the culprit of her acute myocardial infarction and a lifesaving percutaneous coronary intervention with stent placement would be performed. However, her coronary arteries were angiographically normal without any evidence of obstructive disease. A transthoracic echocardiogram was performed and reported apical ballooning and akinesis, with estimated ejection fraction of 35%. Her troponin levels continued to rise and peaked at 1550 ng/L. This patient was diagnosed with myocardial infarction with no obstructive coronary artery disease, more specifically, takotsubo cardiomyopathy. A major life stressor, namely her recent cancer diagnosis, was identified as the provoking factor of this acute medical diagnosis. Takotsubo cardiomyopathy is a condition that falls under the category of myocardial infarction with no obstructive coronary artery disease (MINOCA).
Definition
MINOCA is a term used to describe an enigmatic clinical condition that has been documented for more than 75 years but has been gaining attention in more recent years (Pasupathy et al., 2017). A patient with MINOCA meets diagnostic criteria for a classic myocardial infarction (MI), including rise and fall of cardiac troponin associated with one of the following: symptoms of myocardial ischemia, electrocardiographic changes consistent with ischemia (new ST changes or new left bundle branch block), new pathologic Q waves, loss of viable myocardium, or new wall motion abnormality, and identification of intracoronary thrombus by angiogram or autopsy (Crea & Niccoli, 2017). MINOCA is differentiated from a typical MI by angiographically proving normal or near normal coronary arteries (Crea & Niccoli, 2017).
Prevalence and Prognosis
MINOCA represents 6-8% of all acute MIs, and may account for up to 50% of all MIs in women < 55 years of age (Parwani, et al). African-American and Hispanic patients are the most common ethnicity diagnosed with MINOCA (Crea and Niccoli, 2024). Risk factor profile was similar between those diagnosed with cardiovascular disease, including diabetes, smoking, hypertension, hyperlipidemia, and family history (Crea & Niccoli, 2017). Prognosis with MINOCA is more favorable than that of MI caused by obstructive coronary artery disease (CAD), however, it is far from benign. MINOCA is associated with 12-month mortality rate of 4.7% and up to 25% of MINOCA patients report persistent angina following the initial event (Claudio et al., 2018).
Causes
There are many potential pathophysiologic etiologies associated with the acute clinical presentation of MINOCA. The graphic below outlines both the coronary and non-coronary causes (Pasupathy et al., 2017)..
Diagnosis
The diagnosis of MINOCA cannot be made without a thorough history and coronary angiography (Pasupathy et al., 2017). Given that the classic clinical presentation of MINOCA mimics that of MI caused by obstructive coronary artery disease (CAD), these patients are often emergently triaged to the cardiac catheterization laboratory as standard of care. In the absence of obstructive CAD (<50% luminal obstruction), additional testing is then warranted to identify the underlying cause. While in the cardiac catheterization laboratory, intravascular ultrasound (IVUS) or optical coherence tomography (OCT) can be performed inside the epicardial arteries to identify plaque disruption, fissure, ulceration, or dissection. In addition, an ergonovine challenge is a provocative test also performed in the catherization suite and used to aid in the diagnosis of coronary vasospasm (Pasupathy et al., 2017; Crea & Niccoli, 2017).
One of the most useful non-invasive tests used to define the cause of MINOCA is transthoracic echocardiogram for assessment of the left ventricle. Regional wall motion abnormalities may indicate epicardial cause, such as vasospasm, thrombosis, or plaque rupture. Apical ballooning with apical akinesis is suggestive of Takotsubo cardiomyopathy (Pasupathy et al., 2017). Coronary artery embolism/microembolism should be considered in patients with prosthetic heart valves, atrial fibrillation, dilated cardiomyopathy with apical thrombus, infective endocarditis, and atrial myxoma. In these cases, a contrast enhanced transthoracic echocardiogram or transesophageal echocardiogram may be helpful in clarifying the etiology (Pasupathy et al., 2017).
Cardiac MRI is a useful test to identify myocardial edema, scarring or other myocardial anomalies (Pasupathy et al., 2017). Current data estimates cardiac MRI can identify the underlying cause in approximately 90% of MINOCA patients (Crea & Niccoli, 2017). Viral testing for parvovirus, human herpesvirus 6, and Coxsackie virus is indicated when suspicion for viral myocarditis is high. A hypercoagulable state can predispose a patient to coronary thrombus; Factor V Leiden, prothrombin gene mutation, Protein C and S, as well as Factor VII are most commonly tested when a hematological cause is high on the list of differential diagnoses (Pasupathy et al., 2017).
Management
Patients with MINOCA benefit from cause-directed treatment. Currently, there are no consensus recommendations from society guidelines (Parwani, et al., 2023). For example, in the setting of plaque disruption etiology treatment may include aspirin, statin, ace inhibitor or angiotensin receptor blocker, and cardiac rehab with consideration for beta blocker and P2Y12 inhibitor). Other therapies include lifestyle change, management of risk factors, weight loss/diet modification, smoking cessation, and regular physical activity (Claudio et al., 2018). There are two ongoing trials: MINOCA-BAT (Randomized Evaluation of Beta Blocker and ACEI/ARB Treatment in MINOCA Patients) and WARRIOR (Women’s Ischemia Trial to Reduce Events In Non-Obstructive CAD) with hope that these many identify optimal management strategies (Parwani, et al., 2023).
References:
Pacheco Claudio, C., Quesada, O., Pepine, C. J., & Noel Bairey Merz, C. (2018). Why names matter for women: MINOCA/INOCA (myocardial infarction/ischemia and no obstructive coronary artery disease). Clinical cardiology, 41(2), 185–193. https://doi.org/10.1002/clc.22894
Crea, F. & Niccoli, G. (2024, February 2). Myocardial infarction or ischemia with no obstructive coronary atherosclerosis. UpToDate. https://www.uptodate.com/contents/myocardial-infarction-with-no-obstructive-coronary-atherosclerosis
Parwani, P., Kang, N., Safaeipour, M., Mamas, M. A., Wei, J., Gulati, M., Naidu, S. S., & Merz, N. B. (2023). Contemporary Diagnosis and Management of Patients with MINOCA. Current cardiology reports, 25(6), 561–570. https://doi.org/10.1007/s11886-023-01874-x
Pasupathy, S., Tavella, R., & Beltrame, J. (2017, September 14). Unraveling the enigma of MI with nonobstructive coronary arteries. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2017/09/14/08/44/unravelling-the-enigma-of-mi-with-nonobstructive-coronary-arteries
We headed west last month for the National Conference for Nurse Practitioners (NCNP)! It was sunny and warm in Ahaheim, where nurse practitioners came together to learn, network, and have some fun! My experience at this NCNP really focused on pharmacology. With new drug approvals, expanded indications, and labeling changes occuring frequently, it is so important for us nurse practitioners to stay informed.
The Keynote Address, by Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAAN, FNAP, covered important drug updates of 2018, including a review of new insulins and oral antidiabetics, as well as other important changes. Here’s a good pearl to share:
Below are some more takeaways to give you a snapshot of what I learned and what inspired me:
“The QT interval is best measured in leads II and V5, using mean value from ≥ 3-4 cardiac cycles.”
QT Segment-Prolonging Medications: When to Worry
Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
“To succeed as an NP, you need passion and time, and to surround yourself with people better than you.”
Urticaria/Hives in All of Its Forms: Diagnosis and Treatment Paradigms for Cure and Control
Victor Czerkasij, MA, MS, FNP-BC
“Only 4% of patients with tension headaches present for care; 85% of migraine sufferers don’t experience aura.”
Pharmacotherapeutic Management of Headaches in Primary and Urgent Care
Wendy L. Wright, MS, RN, APRN, FNP, FAANP, FAAN, FNAP
“Always fluid resuscitate before starting vasopressors. Patients’ numbers may improve with vasopressors, but lactate will continue to rise.”
Diagnosis and Management of Acute Respiratory Distress Syndrome
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
“There is no such thing as a ‘peek-a-boo’ exam in dermatology; a full body skin check is a necessity.”
Dermatoses in Women’s Health
Jeremy Honaker, PhD, MSN, FNP-C, CWOCN
“For ongoing assessment of pain management, focus on the progress the patient is making, not the amount of pain they are having.”
Safe Opioid Prescribing: How, When, and When Not to Prescribe
Theresa (Tracey) Mallick-Searle, MS, RN-BC, ANP-BC
“Increased total bilirubin with normal direct bilirubin is usually the result of hemolytic anemia or transfusion reaction.”
Challenging Cases in Laboratory Diagnosis
Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
“When in doubt, immunize. You won’t hurt anyone by over immunizing.”
Drug Adverse Effects: A Focus on Some of the Most Significant Problems
Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP
I also learned about some new resources! Be sure to check out:
Want to attend an upcoming NCNP? Next year we’ll be in Chicago and Las Vegas!
We’ve all been nursing students – some more recently than others – but it shouldn’t be too hard to recall those first clinical experiences and the impact of our clinical preceptors. If you find yourself precepting a student this semester, remember this advice to make it the best experience for the student, and for yourself.
- Smile.
- Keep in mind that you were in the student’s shoes once.
- Introduce yourself and introduce the student to other colleagues on the unit. Make the student feel welcome, included, and part of the team.
- Treat the student the way you wish you were treated as a student.
- Be honest and communicate openly with the instructor in order to create an optimal experience for the student. Be sure to advise the instructor if having a student for that shift isn’t ideal.
- Establish responsibilities and pertinent details at the start of the shift, such as:
- The student’s hours for the day
- Documentation responsibilities
- In which stage is the student in terms of training (first semester, about to graduate?)
- What is the student allowed to do? What will the student be doing (a.m. care, emptying drains, giving meds [does this include PO, IM, SQ, IVPB], dressing changes)?
- Communicate! Give the student report and share how you usually prioritize your shift. Do you see all your patients first, then meds, and then a.m. care? Or do you see one patient at time and get them going for the day?
- Listen to the student’s concerns. For example, ask if the student is comfortable performing a task independently before assigning it. Pay attention to nonverbal cues as well.
- See if anything interesting is going on with your patients or if there are other experiences happening that would serve as a good learning opportunity such as bedside PICC insertion, bedside ECHO, etc. Is anyone going to the cath lab, radiology, IR, OR, HD?
- Share a story or memory from your days as a student or new nurse. Make sure to add that the path to a nursing career is a journey that many others have embarked on to become successful nurses and that the student is not alone.
Let’s help the next generation become the nurses we want taking care of our loved ones. What other advice do you have for clinical preceptors?
We all have interesting stories to share about our journey in nursing. I recently spoke with Dr. Angela Patterson, the Chief Nurse Practitioner Officer of CVS MinuteClinic and Vice President of CVS Health. Dr. Patterson knew from a young age that she wanted to be a nurse. Her career has evolved through the years, with transitions from medical/surgical nursing to later becoming a family practice nurse practitioner and co-owning a family medical practice, to her current role at CVS, as well as chairing the board for a charter high school for underprivileged high school students who wish to go into nursing. Wow!
Dr. Patterson has great advice for nurses to get involved with board membership. She describes resources such as the
Nurses on Boards Coalition,
Sigma Theta Tau International Honor Society of Nursing and the
Future of Nursing: Campaign for Action. She also reminds us that, as nurses, we have inherent skills, qualities, and traits for board membership:
- Nurses have firsthand knowledge of views and concerns of patients and families.
- Nurses know how to achieve high quality care.
- Nurses can offer innovative solutions to improve safety and quality.
- Nurses understand the need for collaboration across professions and settings.
- Nurses are great listeners and ask questions to better understand.
- Nurses respect a wide range of professional roles and skills, helping us work as effective team members.
By planning, being intentional, seeking ongoing education, remaining passionate, and networking, we can be better prepared for board membership. As the keepers of our patients’ stories, we need to take our seats at the table. Please listen to our full conversation
here.
I hope you all enjoyed this conversation – thank you, Dr. Patterson!
About Angela Patterson
Angela Patterson DNP, FNP-BC, NEA-BC is an advanced practice registered nurse, Vice President at CVS Health, and Chief Nurse Practitioner Officer of CVS MinuteClinic. In this role, she is responsible for providing clinical and professional practice governance for the more than 3,100 nurse practitioners and physician assistants who staff the organization’s more than 1,100 retail medical clinics located across 33 states and the District of Columbia. Read more…
Each year on October 30, orthopaedic nurses everywhere celebrate
International Orthopaedic Nurses Day. The tradition began in the United States’ Senate with a proclamation presented by Senator Carl Levin (D-MI) in 1990 to then-President George H. W. Bush.
The
National Association of Orthopaedic Nurses (NAON) is a nonprofit, volunteer-run organization that enhances the lives and careers of orthopaedic nurses. Formed in 1980, NAON was designed to promote the highest standards of nursing practice by educating its practitioners, promoting research and encouraging effective communication between orthopaedic nurses and other groups with similar interests.
As President-Elect of NAON, I am proud to report an organizational membership of approximately 6,000 RNs, LPNs, LVNs, student nurses and associate members from across the country and around the world who share an interest in musculoskeletal healthcare. Simply put, orthopaedic nurses – commonly referred to as ‘ortho nurses’ – are everywhere a patient receives care for a musculoskeletal condition.
Ortho nurses are:
- Practicing in the role of educators, managers, researchers, advanced practitioners and administrators
- Navigating care across the continuum in clinics, offices, hospitals, surgical centers, schools, rehabilitation facilities and in the home.
- Contributing to interdisciplinary collaborative teams with physicians, physical therapists, case managers and other professional colleagues
- Caring for patients and families 24 hours a day and 7 days a week
- Providing care in specialty areas like the operating room, post anesthesia care, intensive care, pain management, infection control, medical surgical and ambulatory care
- Managing care to patients of all ages, from newborns to pediatrics and adolescents to geriatrics
NAON is excited to celebrate its 1st Annual Orthopaedic Nurses Week, October 29th through November 2nd. Wishing you all a very happy International Orthopaedic Nurses Day and Week! Be sure to take advantage of these special offers from our journal,
Orthopaedic Nursing.
Enjoy complimentary access to these articles (10/26/18 through 11/30/2108):
PLUS! Save 50% on Orthopaedic Nursing (now through 12/31/2018)
A subscription includes 6 print issues plus full access to current and archived issues.
Enter Code WJK303ZZ at Checkout.
Reviewed and updated by Myrna Buiser Schnur, MSN, RN: March 20, 2024
When I first started my nursing career in the early 1990’s, I remember watching my preceptor in the critical care unit reflexively place her patient in the Trendelenburg position during episodes of acute hypotension and shock. She explained that lowering the patient’s head and elevating the legs above the chest helped to move blood from the lower extremities to the heart, brain, and other vital organs. It certainly made logical sense and seemed to work, at least transiently. I quickly integrated Trendelenburg into my everyday practice. However, researchers found that the use of Trendelenburg does not improve blood pressure and shock and instead, could have detrimental effects on specific patient populations.
The origins of Trendelenburg trace back to the late 1800s, when Dr. Friedrich Trendelenburg, a surgeon, pioneered this technique to gain better access to pelvic organs for operative purposes. During World War I, the position was utilized in the treatment of shock to increase circulation to the heart, increase cardiac output (CO), and improve blood flow to the vital organs (Shammas & Clark, 2007). Also known as autotransfusion, Trendelenburg became common practice in various healthcare settings such as emergency rooms, operating rooms, post-anesthesia care units, and critical care. In addition, Trendelenburg at a 10 to 15 degree head-down-tilt significantly increases the jugular vein diameter and is currently recommended as the optimal position for central line insertion, when clinically appropriate and feasible, to facilitate cannulation and reduce the risk of venous air embolism (Heffner & Androes, 2022). Health care providers also use the position briefly when obtaining IV access to start rapid fluid boluses. However, while the technique has been historically employed to treat hypotension, medical and nursing societies have not developed guidelines supporting the use of Trendelenburg to treat shock.
Physiologic Effects of Trendelenburg Positioning (Welch, 2024)
The controversy lies in whether blood moving from the extremities to the central part of the body contributes to hemodynamic stability and if there are harmful effects that outweigh the potential benefits. Trendelenburg position creates significant changes in the body such as:
- Increased central blood volume, venous return to the heart, and mean arterial pressure that may be tolerated in healthy individuals but could cause cardiovascular compromise in patients with cardiac disease
- Shifts in abdominal organs toward the diaphragm decreases functional residual capacity and pulmonary compliance of the lungs which may contribute to atelectasis
- Increased intracranial pressure
- Increased intraocular pressure
- Potential airway compromise from edema and swelling of the face, tongue, and laryngeal tissues
- Higher risk of passive regurgitation
Research
Shammas and Clark (2007) as well as Bridges and Jarquin-Valdivia (2005) reviewed several studies that evaluated the effects of Trendelenburg positioning. Research findings are summarized below.
- Sibbald, Paterson, Holliday, and Baskerville (1979) found that Trendelenburg did not consistently improve hemodynamic effects in critically ill hypotensive patients.
- Ostrow, Hupp and Topjian (1994) found no significant effect on CO, cardiac index (CI), partial pressure of oxygen (PO2), systemic vascular resistance (SVR) or MAP from either Trendelenburg or modified Trendelenburg (legs elevated 30 degrees).
- Terrai, Anada, Masushima, Shimizu, and Okada (1995) evaluated the effects of a 10-degree head-down-tilt Trendelenburg position on central hemodynamics and flow through the internal jugular vein. Results showed an increase in left ventricular end-diastolic volume (LVEDP), stroke volume (SV), and CO (increased 16%) with a reduced heart rate after 1 minute of 10-degree Trendelenburg position. After 10 minutes, the hemodynamic changes returned to pre-intervention levels.
- Fahy et al. (1996) studied the effect of Trendelenburg on lung mechanics. They concluded that Trendelenburg did not increase intrathoracic pressures but did affect lung and chest wall movement that resulted in reduced lung volumes. They surmised that the intervention may have a greater adverse effect on patients with increased body mass index and those with lung disease.
- Reuter et al. (2003) found that Trendelenburg positioning slightly increased preload volume and caused a small autotransfusion effect, but it did not significantly improve cardiac function.
While these studies consisted of small sample sizes and quasi-experimental designs without randomization or control groups, several conclusions can be made (Shammas & Clark, 2007).
- The research does not support the use of Trendelenburg as an intervention for hypotension.
- Trendelenburg should be avoided until larger studies are conducted as it may increase a patient’s risk for hemodynamic compromise and impaired lung mechanics.
- Specific patient populations should not be placed in Trendelenburg including those with:
- Decreased right ventricular ejection fraction (RVEF)
- Pulmonary disorders
- Unprotected airway and risk for aspiration (London, 2023)
- Increased intracranial pressure
- Head injuries
- Bleeding in areas that become dependent when head is positioned downward (London, 2023)
- Interventions that are successful in treating hypotension include inotropic agents, intravascular volume, and cardiac assist devices.
Trendelenburg versus Passive Leg Raise
It’s important to note that the Trendelenburg position is different from the passive leg raise or passive leg elevation (PLE) in which the legs are raised and held at 45 degrees for one minute, while the head and torso remain in a horizonal position (not lowered). Several studies have shown that a 10 percent rise in cardiac output during PLE is predictive of a patient’s fluid responsiveness (Mikkelsen, Gaieski & Johnson, 2023). PLE is therefore used briefly to help determine treatment options for hypotension.
Shedding Outdated Practices
Trendelenburg is no longer a part of my routine practice. It is important for clinicians to stay up to date on the latest research and be sure they are not perpetuating outdated patient management techniques that are potentially harmful. Further research is needed to evaluate the utilization and safety of Trendelenburg before it is incorporated into practice guidelines and as a standard of care. Are you still using Trendelenburg to treat your hypotensive patients?
References
Bridges, N. & Jarquin-Valdivia, A.A. (2005). Use of the Trendelenburg position as the resuscitation position: To T or not to T? American Journal of Critical Care, 14(5), 364-368.
Fahy, B.G., Barnas, G.M., Nagle, S.E., Flowers, J.L., Njoku, M.J. & Agarwal, M. (1996). Effects of Trendelenburg and reverse Trendelenburg postures on lung and chest wall mechanics. Journal of Clinical Anesthesia, 8(3), 236-244.
Heffner, A.C. & Androes, M.P. (2022, April 20). Placement of jugular venous catheters. UpToDate. https://www.uptodate.com/contents/placement-of-jugular-venous-catheters
London, M.J. (2023, July 13). Hemodynamic management during anesthesia in adults. UpToDate. https://www.uptodate.com/contents/hemodynamic-management-during-anesthesia-in-adults
Mikkelsen, M.E., Gaieski, D.F. & Johnson, N.J. (2023, December 8). Novel tools for hemodynamic monitoring in critically ill patients with shock. UpToDate. https://www.uptodate.com/contents/novel-tools-for-hemodynamic-monitoring-in-critically-ill-patients-with-shock
Ostrow, C.L., Hupp, E. & Topjian, D. (1994). The effect of Trendelenburg and modified Trendelenburg positions on cardiac output, blood pressure, and oxygenation: a preliminary study. American Journal of Critical Care, 3(5), 382-386.
Reuter, D.A., Felbinger, T.W., Schmidt, C., Moerstedt, K., Kliger, E., Lamm, P. & Goetz, A.E. (2003). Trendelenburg positioning after cardiac surgery: effects on intrathoracic blood volume index and cardiac performance. European Journal of Anaesthesiology, 20(1), 17-20.
Shammas, A. & Clark, A. (2007). Legal and Ethical: Trendelenburg positioning to treat acute hypotension: Helpful or harmful? Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 21(4), 181-187
Sibbald, W.J., Paterson, N.A., Holliday, R.L. & Baskerville, J. (1979). The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Critical Care Medicine, 7(5), 218-224.
Terrai, C., Anada, H., Masushima, S., Shimizu, S., & Okada, Y. (1995). Effects of Trendelenburg on central hemodynamics and internal jugular vein velocity, cross-sectional area, and flow. American Journal of American Medicine, 13, 255-258.
Welch, M.B. (2024, January 10). Patient positioning for surgery and anesthesia in adults. UpToDate. https://www.uptodate.com/contents/patient-positioning-for-surgery-and-anesthesia-in-adults#H551043064
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the October 2018 inspired nurse story,
You Saved My Life.
You Saved My Life
Grace Eisen
Nursing Faculty
Mid Michigan Community College
Woman’s health, particularly breast care, is of special interest to me having had two sisters-in-law who have survived. Working in the woman’s health area for several years and a member of the breast care team, I attended a program about breast cancer in my home community. The mother of one of my children’s classmates was sitting next to me. When the breast model was available to practice palpating breast masses, it was obvious that she didn’t know how to do a self-exam. I taught her the proper technique after she told me she thought going to the doctor once a year was enough. Of course, I didn’t realize at the time how this simple action would touch me or my role as a nurse so deeply.
“You saved my life” are powerful words considering I never worked in a critical care area, yet I heard those words less than two months later from that same woman when we met again in the grocery store. The evening of the presentation, she did a self-exam and found a breast mass, had a mastectomy and was starting chemotherapy. We have since celebrated several of children’s milestones including graduations, marriages, and each becoming grandmothers, while I also celebrate my role as a nurse each and every time I see this remarkable woman.
It’s always interesting to learn the different paths nurses take in their careers. In a recent conversation with Mary Beth Kingston, the Chief Nursing Officer at Advocate Aurora Health in Milwaukee, I learned about the turns her career has taken over her 41 years as a nurse, as well as her big jump from Philadelphia to Milwaukee just six years ago to accept her current leadership position.
I was impressed with Ms. Kingston’s typical day as a Chief Nursing Officer, although we know that in nursing there really is no such thing as a “typical day.” Most of her time is spent focusing on patient safety, quality of care, the patient experience, and workforce issues; making sure staff is highly educated and engaged; and working with shared governance teams. She has worked with the
Nurses on Boards Coalition (NOBC) both through her involvement in the
American Organization of Nurse Executives (AONE), a member organization of which she’s currently President-Elect, and through sponsorship of the NOBC by Aurora Health.
Her best advice when it comes to board membership? When someone taps you on the shoulder and says, “I think you’d be good at ____,” listen. Sometimes others recognize qualities and talents that you might not recognize in yourself.
Please listen to our full conversation
here.
Mary Beth Kingston is Chief Nursing Officer at Advocate Aurora Health in Milwaukee, the 10th largest not-for-profit, integrated health system in the United States and a leading employer in the Midwest with more than 70,000 employees, including more than 22,000 nurses. A national leader in clinical innovation, health outcomes, consumer experience, and value-based care, the system serves nearly 3 million patients annually in Illinois and Wisconsin across more than 500 sites of care. In her position, Kingston co-leads the strategy for integrated services, and provides strategic direction for nursing and clinical education. Read more…
Coronary heart disease (CHD) is the leading cause of death in adults in the United States, accounting for approximately one-third of deaths in patients over the age of 35 years (CDC, 2017). In 2018 the American Heart Association reported 28.1 million people in the United States have CHD, and it is estimated that approximately every 40 seconds an American will suffer a myocardial infarction (Benjamin et al., 2018). Acute coronary syndrome (ACS) refers to a spectrum of three critical diagnoses associated with CHD: unstable angina (UA), non-ST elevated myocardial infarction (NSTEMI), and ST elevated myocardial infarction (STEMI) (Amsterdam et al., 2014). ACS occurs when there is severe reduction of perfusion to the myocardium, resulting in ischemia and/or infarction. Given its high prevalence and strong association with morbidity and mortality, ACS is a diagnosis that must not be missed.
Symptoms of ACS (Amsterdam et al., 2014)
The most widely recognized symptom of ACS is chest pain. Chest pain, however, is a common symptom and can be linked to a multitude of etiologies listed in the table below.
Causes of Chest Pain |
Aortic dissection |
Pulmonary causes (pleuritic pain, pneumonia, pneumothorax) |
Expanding aortic aneurysm |
Musculoskeletal causes (costochondritis, cervical radiculopathy) |
Pericarditis/myocarditis |
Psychiatric disorders |
Pulmonary embolism |
Sickle cell crisis |
Gastrointestinal (GI) causes (gastroesophageal reflux disease [GERD], esophageal spasm, peptic ulcer disease) |
Herpes zoster |
In the setting of ACS, chest pain is frequently described as a pressure type sensation and can occur with rest or minimal exertion. Ischemic chest pain can radiate down the arms, to the neck, or jaw, and is commonly associated with diaphoresis, dyspnea, nausea, abdominal pain, or syncope. Importantly, new onset or increased exertional dyspnea is the most common anginal equivalent and is sometimes the only symptom.
There are several key patient characteristics or morbidities that increase suspicion that chest pain is caused by ACS:
- Older age
- Male sex
- Positive family history of coronary artery disease
- Presence of peripheral vascular disease, diabetes mellitus, renal insufficiency, prior myocardial infarction, or prior coronary revascularization
While chest pain is the most common symptom reported with ACS, nurses must also recognize the atypical symptoms of chest pain, which include epigastric pain, indigestion, stabbing or pleuritic pain, and increasing dyspnea in the absence of chest pain. An atypical presentation is most likely to occur in female patients, older patients (>75 years), and patients with diabetes mellitus, renal insufficiency, and/or dementia.
There are several features of chest pain that
are not characteristic of ischemia, including:
- Pleuritic pain (sharp or knifelike pain provoked by respiration or cough)
- Primary or sole location of discomfort in the middle or lower abdomen
- Pain reproduced with movement or palpation of the chest wall or arms
- Brief episodes of pain lasting a few seconds or less
- Pain that is of maximal intensity at onset
- Pain that radiates into the lower extremities
Physical Exam (Amsterdam et al., 2014)
Physical exam can provide many important clues to help differentiate ACS from other diagnoses and it is important to exam the patient quickly, yet accurately. Many patients with ACS can present with a normal exam. Patients may present with signs of heart failure, but it is important to remember that heart failure signs can exists without ACS, and thus heart failure symptoms are nonspecific. Additional signs of ACS can include the presence of an S4 heart sound, a paradoxical splitting of S2, or a new murmur of mitral regurgitation due to papillary muscle dysfunction. The following exam findings should raise concern for other diseases as mentioned below:
- Pain on palpation – think musculoskeletal disease or inflammation
- Pulsatile abdominal mass – think abdominal aortic aneurysm
- Back pain with unequal palpated pulse volume, a difference of ≥ 15 mmHg in systolic blood pressure between both arms, or a murmur of aortic regurgitation – think aortic dissection
- Pericardial friction rub – think acute pericarditis
- Pulsus paradoxus – think cardiac tamponade
- Pleural friction rub – think pneumonitis or pleuritis
Electrocardiogram (Amsterdam et al., 2014; Reeder, Awtry, & Mahler, 2018)
ACC/AHA guidelines suggest the 12-lead ECG (electrocardiogram) is pivotal in the decision pathway for the evaluation and management of patients presenting with symptoms suggestive of ACS and recommend an ECG should be performed and interpreted within 10 minutes of arrival to the emergency department/office. The initial ECG is often
NOT diagnostic in patients with ACS, thus a normal ECG does not exclude ACS. The ECG should be repeated at 15 to 30-minute intervals if the initial study is not diagnostic but the patient remains symptomatic and/or there is a high clinical suspicion for ACS persists. Keep in mind that left ventricular hypertrophy, bundle-branch blocks with repolarization abnormalities, and ventricular pacing may mask signs of ischemia/injury. ECG changes consistent with ischemia or injury with ACS may include ST depression (especially horizontal or down-sloping), transient ST-elevation, or new T-wave inversion. In the setting of a STEMI, nurses can expect to see new ST elevation at the J point in two anatomically contiguous leads; however, in the early hours of infarction, peaked, hyperacute T waves may be the only abnormality. In the setting of UA/NSTEMI, new horizontal or down-sloping ST depression in two anatomically contiguous leads and/or T wave inversion in two anatomically contiguous leads may be observed.
Cardiac Biomarkers (Amsterdam et al, 2014; Reeder, Awtry, & Mahler, 2018)
Serial serum biomarkers, namely troponin T and I are sensitive and specific of acute myocardial damage and are essential for confirming the diagnosis of infarction. They should be obtained in any patient at significant risk of ACS at presentation and repeated in three to six hours. Additional troponin levels beyond six hours may be considered when there is an intermediate to high suspicion of ACS or when dynamic EGC changes are noted. By definition, patients with UA will have
normal troponin levels and patients with STEMI or NSTEMI will have
elevated troponin levels. Troponins may be normal at the onset of an acute cardiac event and may not be elevated until 2 to 4 hours after symptom onset in STEMI/NSTEM. Elevated troponin can be used to evaluate infarct size, to diagnose reinfarction, and for prognosis.
ACS is a common, life threatening condition that nurses frequently encounter. Timely recognition of ACS is necessary for immediate management, which is crucial to reduce the risk of mortality and further cardiac events. Nurses have a crucial role in early recognition of ACS, as well as administering treatment, and helping patients to understand their condition and care.
References
Amsterdam, E.A., Wenger, N.K., Brindis, R. G., Casey, D.E., Ganatis, T. G., & Holmes, D.R. (2014). 2014 AHA/ACC Guideline for the Management of Patients with Non–ST-Elevation Acute Coronary Syndromes A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 130, e344-e426. doi: 10.1161/CIR.0000000000000134
Benjamin, E.J., Virani, S.S., Callaway, C.W., Chamberlain, A.M., Chang, A.R., Cheng, S.,...Munter, P. (2018). Heart Disease and Stroke Statistics—2018 Update: A Report From the American Heart Association. Circulation, 137, e67-e492. doi: 10.1161/CIR.0000000000000558
Centers for Disease Control and Prevention. (2017). Heart Disease Fact Sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm
Reeder, G. S., Awtry, E., & Mahler, S. A. (2018). Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department, UpToDate. Retrieved from https://www.uptodate.com/contents/initial-evaluation-and-management-of-suspected-acute-coronary-syndrome-myocardial-infarction-unstable-angina-in-the-emergency-department
Reviewed and updated by Myrna Buiser Schnur, MSN, RN: April 10, 2024
Diabetes mellitus remains a very complex disorder to medically manage requiring insulin for Type 1 diabetes mellitus (T1DM) and lifestyle modifications such as diet, exercise, and weight loss along with oral or injected antidiabetic medications for Type 2 diabetes mellitus (T2DM). Among the oral meds available, sodium-glucose co-transporters (SGLTs) are one class of drug used to manage T2DM. Several SGLT2 inhibitors have been on the market for years while one combination SGLT1/SGLT2 inhibitor was recently approved by the Food and Drug Administration (FDA). Let’s take a closer look at SGLT2 and SGLT1 inhibitors.
What do SGLT2 and SGLT1 do?
Glucose moves in and out of our cells by proteins divided into two classes: glucose transporters (GLUTs) that work by facilitated diffusion and SGLTs that actively transport glucose along with sodium into the cells using the sodium concentration gradient (Sano, Shinozaki & Ohta, 2020). Of the six different types of SGLT proteins in the body, two have been studied for their role in glucose absorption: SGLT1 acts mainly in the small intestine while SGLT2 works primarily in the kidney.
The glomerulus of the kidneys filter about 180 grams of glucose each day, most of which is reabsorbed in the proximal tubule. SGLT2 is a high-capacity, low affinity glucose co-transport protein which helps to reabsorb about 90-95% of glucose (160-180 g/d) in the S1 and S2 segments of the proximal tubule of the kidneys. SGLT1 is a low-capacity, high-affinity transporter that mediates approximately 5-10% of glucose reabsorption in the S3 (distal) segment of the proximal tubule and may help with additional renal glucose reabsorption. When blood glucose levels surpass the 180–200 g/d capacity of the glucose cotransporters, excess glucose appears in the urine which may indicate diabetes mellitus. SGLT1 is also found in the skeletal muscles and heart and is a primary mediator for glucose absorption in the small intestine.
Comparison of SGLT1 and SGLT2 (Novak & Kruger, 2017) |
|
SGLT1 |
SGLT2 |
Description |
Low-capacity, high affinity glucose co-transport protein |
High-capacity, low affinity glucose co-transport protein |
Location of action in proximal tubule |
Distal S3 segment |
S1 and S2 segments |
Renal glucose absorption capacity |
5–10% |
90–95%
160-180 grams per day |
Additional action in small intestine |
Yes |
No |
The following SGLTs have been approved by the FDA and are currently on the market (Facts and Comparisons, 2024b).
Selective
SGLT2 inhibitors |
Dual
SGLT2 & SGLT1 inhibitor |
Combination Drugs |
Bexagliflozin (Brenzavvy) |
Sotagliflozin (Inpefa) |
|
Canagliflozin (Invokana) |
|
Canagliflozin/metformin (Invokamet, Invokamet XR) |
Dapagliflozin (Farxiga) |
|
Dapagliflozin/metformin (Xigduo XR)
Dapagliflozin/saxagliptin (Qtern) |
Empagliflozin (Jardiance) |
|
Empagliflozin/linagliptin (Glyxambi)
Empagliflozin/metformin (Synjardy, Synjardy XR) |
Ertugliflozin (Steglaro) |
|
Ertugliflozin/metformin (Segluromet)
Ertugliflozin/sitagliptin (Steglujan) |
SGLT2 Inhibitors (DeSantis, 2024)
SGLT2 inhibitors promote the renal excretion of glucose, lowering elevated blood glucose levels in patients with T2DM. SGLT2 inhibitors are not typically used as initial therapy, however these medications have been helpful in patients with cardiovascular and kidney disease. They are beneficial in the following situations:
- In patients with atherosclerotic cardiovascular disease (CVD) or heart failure who can’t reach glycemic goals with metformin and lifestyle modifications
- To slow the decline in estimated glomerular filtration rate (eGFR) in patients with eGFR less than 90 mL/min/1.73 m2
- As a third-line agent in patients not meeting glycemic goals on two oral agents (i.e., metformin and sulfonylurea) if metformin and insulin are not therapeutic options
- As a third-line agent in patients with inadequate glycemic control on metformin and insulin therapy, where glucagon-like peptide 1 (GLP-1) receptor agonists are contraindicated and increasing insulin dosing would result in weight gain
- As a second agent in patients with inadequate glycemic control on metformin who aren’t willing or not able to consider injection therapy in whom weight gain or risk of hypoglycemia is an issue
Contraindications and precautions (DeSantis, 2024)
SGLT2 inhibitors should be avoided in the treatment of hyperglycemia in patients with:
- Type 1 diabetes
- Type 2 diabetes and eGFR less than 45 mL/min/1.73 m2 (ertugliflozin), or less than 30 mL/min/1.73 m2 (empagliflozin, canagliflozin, dapagliflozin, bexagliflozin)
- History of diabetic ketoacidosis (DKA)
SGLT2 inhibitors should be used with caution in patients with:
- Frequent bacterial urinary tract infections or genitourinary yeast infections
- Low bone density and high risk for falls, fractures, and foot ulcerations
- Factors predisposing to DKA (i.e., pancreatic insufficiency, drug or alcohol use disorder, ketogenic diets)
Dual SGLT1/s Inhibitors
Sotagliflozin (Inpefa) is a dual SGLT1/2 inhibitor approved by the FDA to reduce the risk of cardiovascular mortality and hospitalization for heart failure in adults with T2DM, chronic kidney disease, and other cardiovascular risk factors (Facts and Comparisons, 2024a). Sotagliflozin had been studied as an adjunctive therapy in T1DM. While phase III trials showed an improvement in A1C tests after 24 weeks, the rate of DKA was higher in the sotagliflozin group compared to placebo and therefore is not recommended as a treatment for T1DM (Weinstock, 2024).
Clinical considerations (Desantis, 2024; Padda, Mahtani & Parmar, 2023)
Prior to beginning treatment with SGLT inhibitors, assess the patient’s:
- Volume status and risk for hypovolemia and hypotension
- Correct hypovolemia prior to starting therapy
- Adjust diuretics and blood pressure medications as needed
- Renal function - efficacy will decline with decreasing estimated glomerular filtration rate (eGFR)
- Contraindicated in patients with end-stage renal disease or on dialysis
- Dapagliflozin and ertugliflozin are contraindicated for eGFR less than 60 mL/min
- Canagliflozin and empagliflozin are contraindicated for eGFR less than 45 mL/min
- Liver function before starting canagliflozin or dapagliflozin
- Bone density for patients at risk for falls and bone fracture
- Use of insulin or insulin secretagogues (sulfonylureas, glinides); reduce insulin dosage to decrease the risk of hypoglycemia
- History of recurring genital infections or urinary tract infections
- Neuropathy, foot deformity, vascular disease, and history of prior foot ulceration
For patients on SGLT2 therapy (American Diabetes Association, 2024; DeSantis, 2024):
- Monitor for signs of diabetic ketoacidosis (DKA); evaluate and treat promptly if suspected.
- Monitor volume status and kidney function (serum creatinine and eGFR).
- Monitor for signs and symptoms of genitourinary tract infections and foot ulcerations.
- Discontinue the SGLT2 about 3-4 days prior to scheduled surgery.
- Discontinue SGLT2 during critical illness or during prolonged fasting.
Be sure to stay current with the research as SGLT2 and SGLT1 inhibitors have the potential to positively impact clinical management and the outcomes of patients with T2DM and other chronic conditions. For complete information, please consult the drug’s specific package insert or the Nursing2024 Drug Handbook® + Drug Updates.
References
American Diabetes Association Professional Practice Committee (2024). 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024. Diabetes care, 47(Suppl 1), S158–S178. https://doi.org/10.2337/dc24-S009
DeSantis, A. (2024, March 19). Sodium-glucose co-transporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus. UpToDate. Retrieved from https://www.uptodate.com/contents/sodium-glucose-cotransporter-2-inhibitors-for-the-treatment-of-hyperglycemia-in-type-2-diabetes-mellitus
Facts and Comparisons (2024a, February 26). Sotagliflozin Oral. Facts and Comparisons. https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/7346202?cesid=7DJZjAhjRd9
Facts and Comparisons (2024b, January 31). Sodium-Glucose Co-Transporter 2 Inhibitors. Facts and Comparisons. https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/5545822?cesid=1tMly08RUaQ
Novak, L. M., & Kruger, D. F. (2017). Bolstering your armamentarium with SGLT2 inhibitors. The Nurse practitioner, 42(10), 28–34. https://doi.org/10.1097/01.NPR.0000524665.16846.63
Padda, I. S., Mahtani, A. U., & Parmar, M. (2023). Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitors. In StatPearls. StatPearls Publishing.
Sano, R., Shinozaki, Y., & Ohta, T. (2020). Sodium-glucose cotransporters: Functional properties and pharmaceutical potential. Journal of diabetes investigation, 11(4), 770–782. https://doi.org/10.1111/jdi.13255
Weinstock, R.S. (2024, January 2). Management of blood glucose in adults with type 1 diabetes mellitus. UpToDate. https://www.uptodate.com/contents/management-of-blood-glucose-in-adults-with-type-1-diabetes-mellitus
Zhao, M., Li, N., & Zhou, H. (2023). SGLT1: A Potential Drug Target for Cardiovascular Disease. Drug design, development, and therapy, 17, 2011–2023. https://doi.org/10.2147/DDDT.S418321
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the November 2018 inspired nurse story,
A Helping Hand.
A Helping Hand
Deb Velez
VA San Diego Healthcare System
Prevention of Amputation in Veteran's Everywhere (PAVE)
I have been a practicing nurse for more than 40 years and have had many inspirational encounters with many patients, but working at the VA and serving our returning Veterans has been the most inspirational.
One morning at the VA, a young prosthetics intern and former army staff sergeant got out of his car before being approached by a woman who had noticed the Purple Heart license plate on his car. “Are you driving your dad’s car?” she asked. “No, it’s mine,” he replied. “Well at least you came back with all your parts!” But what she hadn’t seen was his prosthetic arm, and it was then that I knew we would be seeing a whole new generation of combat Veterans. He was only 25 and had lost part of his right arm in an ambush in Iraq in attempts to ambush insurgents firing off mortars.
This particular story inspired me to write an article that was then published in
NURSING 2011 — “Provide a helping hand to patients with upper extremity prostheses” (Velez & Dellefield, 2011). While it had been a goal of mine to get something published before I left nursing, this story, one of the many I have encountered at the VA, touched me. I know that I will be retiring soon, but I also know that I will always have my nursing life experiences with me and have been inspired everyday by those who GAVE ALL.
Reference: (Velez, D.J., Dellefield, M.E. (2011). Provide a helping hand to patients with upper extremity prostheses. Nursing2011, 41(1). doi: 10.1097/01.NURSE.0000391403.05698.fa
The field of nursing is vast, ever expanding, and ever changing. With this in mind, the opportunities for us to advance our profession are clear. No matter what type of setting in which you work, there are opportunities to increase your knowledge and improve patient care.
A few years ago, I was asked by the head pharmacist of the hospital if I would be a member of the Pain Management Committee, as they were looking for floor nurses to participate. At first, I was a little intimidated – there were pharmacists, departmental managers, and attending physicians on this committee. But soon, I was giving my insight and suggestions on ways in which protocols and policies could be best implemented on the units for staff nurses. It gave me a sense of pride, knowing that I played a part in how we were improving care for our patients and how nurses were helping to raise the bar of medication safety for our patients too.
You might say to yourself, “I’m one nurse,” or “I’m a new graduate nurse. How can I make an impact?” Consider the quote from Florence Nightingale, “Let us never consider ourselves finished nurses…we must be learning all our lives.” As nursing professionals, we have the ability and opportunity to positively impact the patients we serve. We have a chance to leave our profession better than we found it. It just takes one idea and one vision to make improvements in the care that we provide to patients.
Start by joining a committee or council within your organization. Bring forth your knowledge and insight; let your voice be heard. Allow others to see the opportunities that are possible! We may think back to a time in our career when patient care did not go as planned or we experienced a near-miss. I recall once pulling medications out for a patient from the Pyxis machine. As I pulled my medications, I opened the drawer in the machine, but I later discovered that I had opened the wrong drawer and pulled out the incorrect medication. In reviewing my medications before I left the medication room, I noted my error, returned the medication to the machine, and pulled out the correct medication. This near-miss stopped me in my tracks and made me thankful that I double-checked my medication list before leaving the room. Instead of looking at experiences such as this as failures, we should see an opportunity to examine evidence-based practice and develop solutions.
How can you help develop new policies and lead the way for evidence-based practice to be implemented? To take action, research a topic of interest or concern. See what research has been published and what the recommendations are currently. With your newfound knowledge and evidence, work with your councils, committees, and leaders to increase awareness of evidence-based practice and advance the care you and your colleagues provide to patients.
Remember, that you don’t have to do this alone! Find coworkers that share your same interest and passion on the topic and work together. Collaborating with others will advance the team building in your department and help you and others develop their leadership and problem-solving skills as well.
As nurses, we can continue to be at the forefront of advancing and developing the patient care that we provide. What are you waiting for? Seek out the evidence that will advance the care you provide as a nurse. Seek evidence-based recommendations that will make you the best nurse you can be! As Florence Nightingale said, “For us who nurse, our nursing is a thing, which, unless in it we are making progress every year, every month, every week, take my word for it, we are going back. The more experience we gain, the more progress we can make.” So, go out there and advance your knowledge to advance the care that you provide to your patients. You can make a lasting difference!
Reference:
Nightingale, F. (1914). Florence Nightingale to Her Nurses: A Selection from Miss Nightingale's Addresses to Probationers and Nurses of the Nightingale School at St. Thomas's Hospital. London: MacMillan and Company.
What will you get for that special nurse in your life? Whether it’s a colleague, family member, friend, or a nurse who cares for you or your loved one, finding the perfect gift doesn’t have to be a challenge.
Fifteen great ideas are shared on the blog of Rasmussen College, from work-related tools to personal items. Here is another idea – how about a great book? All nurses benefit from the gift of knowledge.
Here are my top picks:
Lippincott Manual of Nursing Practice
This is a classic nursing reference. And, the new edition was just published in October! |
|
Lippincott Nursing Procedures
This new edition includes step-by-step instructions on over 400 nursing procedures – from basic to advanced! |
|
Nursing2019 Drug Handbook
I was a clinical editor on this book for years and know the rigor and research that goes into making sure the information is based on the evidence! It’s a must-have at every nurses’ station and medication cart. |
|
Reflections on Nursing
I’ve recommended this one before, but it’s worth keeping on the list! Full of inspirational stories from real nurses, it warms the heart and reminds us why we became nurses. |
|
Made Incredibly Easy!
Ok, this is more than one book – actually, there are over 50 titles! Perfect to help any nurse grasp a challenging concept and succeed on the job and in the classroom.
|
Nurses – what else is on your wish list this holiday season?
Our blog has seen a lot of growth this year with podcasts and interviews, our National Nurses Week series, and the addition of several new clinical editors who have contributed their time and expertise. Thank you for a great 2018 – we are looking forward to tackling the issues, developing more ideas, and continuing the conversation in 2019!
Here’s a peek at the top ten posts from this year! Catch up on what’s been popular among your peers and if you are inclined, please leave us a comment!
#10
#9
#8
#7
#6
#5
#4
#3
#2
#1
Lippincott NursingCenter.com is partnering with
Lippincott Solutions to bring you an inspired nurse’s story every month. Here is the December 2018 inspired nurse story,
Remembering Why I Am A Nurse.
Remembering Why I Am A Nurse
Ancitta Sebastin
Vijaya Hospital
I am a nurse from India, working in Dubai. I didn’t know what nursing was until my mom explained it to me. She told me that nurses provide care and are very kind-hearted.
When my elder brother was eight, he was diagnosed with late stage Typhoid fever. With his stomach distended making him look like pregnant lady, he was delirious and completely weak. The doctor said there was no hope, and that he would recover only with God's will. He was being treated at a government hospital – a place with little love as busy staff run here and there tending to many patients. But there was one nurse who was very kind and took care of my brother like he was her own son. She was not only kind to my brother, but also to all of the other children admitted to that unit.
This nurse administered medications and was always there to provide care to her patients during her rounds, even on night shifts. My brother eventually did recover, and my mother says it's because of that one nurse who was sent from God to care for him. She’s told that story to me since I was three, carving it into my heart and causing me to choose to want to become a nurse myself.
I know nursing is a profession that through love and care can make patients well. Back when I was still in school, I was proud to say that my ambition was to one day become a nurse. I entered the field in 2007 and I can still remember in one of my first classes hearing about Florence Nightingale. I too serve all my patients wholeheartedly and consider each one as a member of my own family. Thank you, Lippincott, for making me remember my beautiful past.
Mark your calendars! Here are the nursing recognition days, weeks, and months for 2019.
January
February
March
April
May
June
September
October
November
Let us know how you will celebrate or how you plan recognize your colleagues. Leave a comment or email us at
[email protected]. Have a great year!
Reviewed and updated by Valerie Dziados, MSN, CRNP, ANP-C, AGACNP-C: April 11, 2024
Approximately 200,000 pacemakers are implanted annually in the United States, and due to an aging population and increasing pacing indications, this number is expected to grow (Bhatia & El-Chami, 2018). While these devices are effective, approximately one in eight patients has an early complication, usually related to the transvenous lead or subcutaneous pocket. These complications include pneumothorax/hemothorax, cardiac perforation, lead dislodgement/integrity problems, pocket infections/hematomas, endocarditis, vascular obstructions, and tricuspid regurgitation (Bhatia & El-Chami, 2018). Pacemaker technology has rapidly advanced in the pursuit of decreasing complications and improving outcomes.
Leadless pacemakers were first proposed in the 1970s and finally gained FDA approval in 2016 (Bhatia & El-Chami, 2018). They are miniature leadless pacing systems that are small enough to be placed inside the heart and avoid the need for a subcutaneous pocket and transvenous leads, the weakest aspects of a traditional pacemaker (Vouliotis, 2023). The leadless pacemaker is dime-sized, free-standing, and inserted via femoral venous access, and in select patients it can be delivered through the transjugular approach (Link, 2024). The pacemaker is affixed to the right ventricular myocardium and released. The delivery system is then removed, and the pacemaker remains embedded in the right ventricle. Currently, there are two systems available: Micra (Medtronic) and Aveir (Abbott). Micra received FDA approval in 2016 and Aveir in 2022 (Link, 2024).
The leadless pacemakers have a battery longevity of five to ten years, which is comparable to traditional devices (Grippe, 2019). The initial models were capable of VVI or VVIR (ventricular demand pacing where only the ventricle is paced, sensed, and the pulse generator inhibits pacing output in response to a sensed ventricular event) pacing. A newer model, named Micra AV, offers the capacity to maintain AV synchrony by sensing atrial activity and pacing the ventricle using an accelerometer-based algorithm, thus providing VDD pacing. Additionally, there is the Aveir DR, which is an investigational device that includes implanting one device in the right atrium and one device in the right ventricle to provided AV synchrony (Link, 2024).
Preliminary reports of long-term performance and complications are promising, including low complications, few system revisions, and stable pacing parameters. These pacemakers maybe a good option for patients who have difficult vascular access, an expected low burden of need for pacing (i.e., severe recurrent vasovagal syncope), an expected high risk of infection, or those who have had prior implantable cardiac device infection (Link, 2024). Leadless pacemakers are also cosmetically appealing because there is no chest incision or visible pacemaker pocket and they are MRI compatible (Grippe, 2019).
Future avenues of development in this specialized area include transforming kinetic energy from cardiac motion to fuel the pacemaker to allow for a battery-free pacemaker, wireless left ventricular pacing system, potentially utilizing leadless pacemakers with subcutaneous defibrillators (Vouliotis, et al., 2023).
References:
Bhatia, N., & El-Chami, M. (2018). Leadless pacemakers: a contemporary review. Journal of geriatric cardiology : JGC, 15(4), 249–253. https://doi.org/10.11909/j.issn.1671-5411.2018.04.002
Grippe, G.A. (2019). The leadless pacemaker: an innovative design to enhance pacemaking capabilities. Journal of the American Academy of Physician Assistants, 32(6), 48-50. https://www.doi.org/10.1097/01.JAA.0000554750.85170.d4
Link, M. (2024, March). Permanent cardiac pacing: overview of devices and indications. UpToDate. https://www.uptodate.com/contents/permanent-cardiac-pacing-overview-of-devices-and-indications
Vouliotis, A., Roberts, P., Dilavernis, P., Gatzowlis, K., Yue, A., & Tsioufis, K. (2023). Leadless pacemakers: current achievements and future perspectives. European Cardiology, 18: e49. https://www.doi.org/10.15420/ecr.2022.32
The first time you probably heard the term sexually transmitted disease (STD) was in the awkward years of middle school in a mandatory health class that everyone dreaded. The classroom echoed with giggles and eyes roamed about! The teacher saying words like "chlamydia" and "discharge" made you want to put your head down and dream of escaping the torture. The teacher went on to review safe sex practices sandwiched between information on where babies come from and the lowdown on pubescent changes of both yours and the opposite sex. You thought your life was over.
Moving forward a
few years, now everyone is calling them sexually transmitted infections, or STIs! Your middle school self is confused and can't understand the change. What exactly is an STI and how does it differ from the well-known term STD?
The terms STD and STI are often used interchangeably, but they technically mean different things. Both terms still represent the same group of viruses and conditions – gonorrhea is still gonorrhea and herpes is still herpes! The one major difference is between the "D" and the "I". Think back to nursing school basics where we learned the difference between a disease and an infection. Simply, an
infection, often the first step, occurs when bacteria, viruses or other microbes that cause disease enter your body and begin to multiply. A
disease occurs when the cells in your body are damaged – as a result of the infection – and signs and symptoms of an illness appear.
The main take-away is that one has symptoms (STD), and the other one does not (STI). You can have infections without symptoms, as seen with chlamydia, and that is why the term STIs has become more mainstream. It is much broader and more encompassing and now able to incorporate certain infections—such as herpes virus or human papilloma virus (HPV)—where a large proportion of infected persons are asymptomatic. Typically, a woman with HPV does not have any symptoms, but she carries the virus. She has an STI; but if she develops cervical cancer from HPV, she now has an STD since cancer is a disease. The same holds true for women who have chlamydia or gonorrhea that develops into pelvic inflammatory disease.
Another benefit for the change is to hopefully remind people that STIs often have no symptoms and to remember how important it is to have routine testing. I encourage testing not only at problem visits but at all annual visits and remind my patients of the importance of routine testing and safer sex practices.
Did you know…?
American Journal of Nursing (AJN) offers an important collection of evidence-based resources to benefit nurses and other healthcare professionals who care for older adults.
This series of articles was published as a print supplement to
AJN and won the 2018 ASHPE Bronze Award in the Best Special Supplement category. Each article provides nurses with the evidence behind what and how to teach family caregivers; includes an informational tear sheet, Tips for Family Caregivers; and links to step-by-step instructional videos for the caregiver. Also, continuing education credits are available.
The
Supporting Family Caregivers: No Longer Home Alone covers topics such as ostomy care, falls prevention, wound care, medication administration and more. As nurses, we know how to meet the needs of our patients, but so much of their care falls to family members. Family caregivers are essential members of the health care team; we must work together to meet the needs of our patients and their loved ones. Use – and share – these
resources to help you and your colleagues educate family caregivers.
Produced in cooperation with the AARP Public Policy Institute and the Betty Irene Moore School of Nursing at University of California, Davis, we’re pleased to share this collection of articles and videos.
AJN is continuing to work with AARP and the Home Alone Alliance to develop another series of articles and videos which will focus on managing incontinence and nutritional needs of the older adult. These articles and videos will be added to the collection as they are produced, so be sure to check back often!
Reviewed and updated by Jennifer Collins, MSN, CRNP, ACACNP-BC: February 23, 2024
Adenovirus is a group of common viruses that can affect both animals and humans. These viruses typically cause mild cold- or flu-like illness in people of all ages with no specific seasonality (CDC, 2023). There are many different types of adenoviruses that can cause a range of illnesses ranging from mild to severe. With severe illnesses and even deaths reported secondary to adenovirus, it’s important to have a broad understanding of this virus so you can recognize symptoms, provide the best care to patients, and be able to answer questions.
There are more than 50 types of adenoviruses that can cause illness in people at any age; however, those who are immunocompromised, or who have chronic respiratory or cardiac disease are at greater risk of developing severe illness. Adenoviruses are highly contagious and spread through respiratory droplets and contact with contaminated surfaces or objects. It is important to note that those with weakened immune systems who have ongoing asymptomatic infections, but are asymptomatic, can continue to shed the virus. Also, epidemics can occur, without seasonality, including especially through communities or crowded settings.
Signs and symptoms
Patients with adenovirus typically present with cold symptoms. However, other wide range of illness and symptoms may occur, including:
- Sore throat
- Bronchitis
- Pneumonia
- Diarrhea
- Gastroenteritis
- Conjunctivitis
- Fever
- Cystitis
- Neurologic disease (CDC, 2024)
The CDC is currently working with health departments across the country and world to identify children diagnosed with acute hepatitis with an unknown cause to examine a possible relationship to adenovirus type 41 infection (CDC, 2022). In October 2021, in a hospital in Alabama five children were diagnosed with hepatitis with an unknown cause, including some with liver failure. All five children tested positive for adenovirus. In addition to looking for more cases in Alabama, the CDC issued a notice calling for state and local health departments nationwide to report potential cases (CDC, 2022).
Diagnosis
A variety of ways can be utilized to identify the adenovirus, including antigen detection, polymerase chain reaction (PCR), virus isolation, and serology (CDC, 2023). However, a diagnosis can prove challenging, as even if a person has adenovirus infection, it might not be causing their specific illness. Clusters of adenovirus infections should be reported to the state or local health department.
Transmission
Adenoviruses are usually spread from an infected person to others through personal contact, respiratory droplet particles, or transmission via contaminated surfaces. It is also possible for these viruses to be transmitted through water contamination, for example swimming pools and lakes.
Prevention
How can you help prevent transmission of adenovirus infections?
- Follow infection control protocol policies of your institution.
- Perform hand hygiene.
- Maintain contact and droplet precautions for infected patients.
- Keep staff informed of adenovirus-infected patients.
- Stay up to date on current outbreaks and recommendations from the CDC.
- The adenovirus vaccine is recommended for military personnel 17 to 50 years of age who are entering basic training or may be at high risk for adenovirus infection (CDC, 2020).
- Ensure environmental cleaning with appropriate disinfectants.
- Respond promptly and report clusters of cases.
Treatment
No specific treatment for adenovirus infection exists. Provide supportive management of symptoms and possible complications. For hospitalized patients with severe adenovirus infection, consultation with infectious disease experts is recommended.
A 42-year-old male with no significant past medical history presented to the emergency department (ED) with severe abdominal pain. Work-up revealed acute pancreatitis due to alcohol consumption. He disclosed being a binge drinker. Gallbladder disease, the most common cause of acute pancreatitis, was ruled out with imaging and laboratory studies. The patient was admitted to the hospital and treated according to the standard of care for management of acute pancreatitis which included aggressive fluid resuscitation and pain management. On hospital day 3, he developed mild shortness of breath. Although the etiology of his respiratory symptoms was initially unclear, upon further inquiry, he recalled several episodes of vomiting prior to arrival in the ED. Your suspicion for aspiration and possible aspiration pneumonia are raised. The patient is placed on supplemental oxygen via nasal cannula with no improvement. High flow nasal cannula (HFNC) is ordered and initiated with significant improvement in respiratory symptoms. He has a mild non-productive cough and low-grade fever. A chest x-ray revealed mild vascular congestion and a possible right middle lobe opacity. He is pan-cultured and started empirically on antibiotics to cover aspiration pneumonia, he is also given diuretics for suspected volume overload. Overnight, he became tachypneic with respiratory rate in the 40s and increased work of breathing. Peripheral oxygen saturation (SpO2) was 82% despite titration of fraction of inspired oxygen (FiO2) to 100% on HFNC. He was intubated, placed on mechanical ventilation and transferred to the ICU for management. A chest x-ray following intubation revealed diffuse bilateral infiltrates. He was initially placed on standard ventilatory settings with brief improvement but, over the next several hours, it became increasingly difficult to oxygenate him despite titration of FiO2 to 85% on the ventilator. He was given an additional dose of intravenous (IV) diuretic with no improvement. An arterial blood gas (ABG) revealed arterial oxygen of 70mmHg and a repeat CXR revealed progression of diffuse bilateral infiltrates. Acute respiratory distress syndrome (ARDS) was suspected and ARDS specific ventilatory strategies were initiated.
Does this scenario sound familiar? Scary? Both? Respiratory symptoms are something we see daily across healthcare settings. Depending on your role, you may be the first person to recognize a critical change in respiratory status. Understanding the potential continuum of respiratory decompensation is essential to ensure safe management of our patients. Respiratory failure is one of the most common conditions treated in intensive care units (ICUs). The etiology and presentation of respiratory failure can vary widely and may include acute respiratory infection (i.e. bacterial or viral pneumonia), acute exacerbations of chronic respiratory conditions (i.e. COPD, asthma), congestive heart failure (i.e. cardiogenic pulmonary edema), or upper/lower airway obstruction (i.e. angioedema, foreign body).
ARDS is a life-threatening complication of respiratory failure associated with high morbidity and mortality. It is characterized by an acute onset, diffuse, inflammatory lung injury leading to increased vascular permeability, increased lung weight and loss of aerated lung tissues (Ranieri et al., 2012) causing severe hypoxemia. Annually, ARDS affects close to 200,000 individuals and is responsible for 74,500 deaths in the United States (Rubenfeld et al., 2005).
Is this ARDS? Diagnosing and Classifying ARDS
Distinguishing ARDS from other forms of respiratory failure can be a challenge. There are several conditions placing one at risk for the development of ARDS. The most common risk factor, sepsis, from either a pulmonary or non-pulmonary source, accounts for 79% of ARDS cases (Rubenfeld et al., 2005). Other risk factors include aspiration, toxic inhalation, lung contusion/trauma, acute pancreatitis, blood product transfusion, near drowning, burn injury/smoke inhalation and cardiopulmonary bypass (Howell & Davis, 2018; Rubenfeld et al., 2005). The presence of any of these conditions in the setting of an acute change in respiratory status should raise your suspicion for ARDS.
Although it was obvious the above patient was in severe respiratory distress, ARDS was not always first in the differential diagnosis. In this particular patient, initial concern was for volume overload and aspiration pneumonia. In accordance with established definitions of ARDS, to diagnose ARDS, a patient must not only have an acute change in clinical condition, a high oxygen requirement, and diffuse bilateral infiltrates on radiographic studies, but the clinician must also rule out other conditions that could account for these respiratory findings.
There have been several definitions of ARDS since it was first described in the 1960s. The term acute lung injury, which had been used in past definitions, is no longer an accepted term in respect to the description or definitions of ARDS. The most current definition, developed by the ARDS definition task force in 2012 are termed the Berlin criteria (Ranieri et al., 2012). The Berlin criteria require the presence of the following 4 criteria to diagnose ARDS:
- The onset of respiratory symptoms beginning within one week of a known clinical insult, or patient must have new or worsening symptoms during the past week;
- the presence of bilateral opacities on either chest x-ray or chest CT scan consistent with pulmonary edema and are not explained by pleural effusions, lobar collapse, lung collapse, or pulmonary nodules;
- respiratory failure that cannot be fully explained by cardiac failure or fluid overload (consider echocardiogram or cardiac assessment if no other ARDS risk factors); and
- the presence of a moderate to severe impairment of oxygenation, as defined by the PaO2/ FiO2 ratio ≤ 300 (Raineri et al. 2012).
ARDS is classified according to the degree of hypoxemia as follows:
- Mild - PaO2/FiO2 ratio of 201-300
- Moderate - PaO2/FiO2 ratio of 101-200
- Severe - PaO2/FiO2 ratio £ 100 (Ranieri et al. 2012)
Looking back at our patient’s clinical history, he meets criteria for ARDS. His respiratory symptoms came on acutely, his clinical insult was pancreatitis and possible aspiration, he had the radiologic findings of diffuse bilateral opacities, and although he did receive aggressive fluid resuscitation, respiratory symptoms continued to deteriorate despite diuresis. Finally, he had a severe impairment in oxygenation. Based on his PaO2 of 75mmHg and FiO2 of 85%, his PaO2/FiO2 ratio was ≤ 100 classifying him as having severe ARDS.
What is actually happening in ARDS?
The pathophysiology involved in the development of ARDS is complex and may vary depending on the mechanism of injury. Furthermore, there are three phases in the progression of ARDS, the exudative phase, the proliferative phase and the fibrotic phase. These phases have distinct histopathologic and clinical features that go beyond the depth of this blog, but it is important to be aware of terminology surrounding ARDS. In general, the clinical sequelae of ARDS are related to increased vascular permeability and these distinct histopathologic changes in each phase of ARDS (Howell & Davis, 2018). The hallmark multifocal opacities are the results of tissue damage in the alveoli mediated by neutrophil, macrophage, and dendritic cell activation. Due to an overall inflammatory state with increased vascular permeability and release of inflammatory cytokines, a protein rich fluid accumulates in the alveoli resulting in impaired gas exchange (Han & Mallampalli, 2015) and subsequent hypoxia. This alveolar damage increases physiologic dead space (remember dead space? ventilation that does not participate in gas exchange; think of it as the fluid accumulating in alveoli, blocking the blood’s access to absorb oxygen) and decreased lung compliance (elasticity of lungs) leading to the “stiff” lung often described in ARDS (the fluid accumulation makes is difficult for alveoli to inflate).
Treatment of ARDS
Despite the high morbidity and mortality associated with ARDS, there are limited evidence-based therapies known to reduce mortality. Treatment remains largely supportive and primarily involves mechanical ventilatory support which, unfortunately, can further potentiate lung injury. In 2017, updated treatment strategies were published jointly by the American Thoracic Society, the European Society of Intensive Care Medicine and the Society of Critical Care Medicine. The following treatment recommendations were made (Fan et al., 2017):
- For all patients diagnosed with ARDS:
- Lower tidal volume mechanical ventilation (4-8 ml/kg predicted body weight) and lower plateau pressures < 30cm H2O
- Typical initial tidal volumes for those without ARDS is 6-8mL/kg predicted body weight
- It is recommended that tidal volume be adjusted to maintain goal plateau pressures
- Low volume ventilation and lower plateau pressures, sometime referred to as lung protective ventilation strategies are thought to prevent volutrauma (overdistension of alveolar units) and atelectrauma (cyclic changes in nonaerated lung).
- Prone positioning for > 12 hours/day in those with severe ARDS
- Involves placing patient in prone position while on ventilator, shifts weight of heart to ventral wall
- Potentially improves ventilation-perfusion, increasing end-expiratory lung volume, and decreasing VILI by more uniform distribution of tidal volume through lung recruitment and alterations in chest wall mechanics (Gattinoni L, Pesenti A, Carlesso E, 2013).
- For those with moderate to severe ARDS:
- Higher PEEP as opposed to lower PEEP
- In non-ARDS mechanical ventilation, typical initial PEEP is 5; however, PEEP can often be as high as 24 in the treatment of ARDS; increasing PEEP often allows for decreased FiO2
- higher PEEP may improve alveolar recruitment, reduce lung stress and strain, and prevent atelectrauma (Fan et al. 2017)
- Recruitment maneuvers (RMs)
- A transient, sustained increase in airway pressure with goal to open collapsed alveoli
- Involves applying high PEEP for a specified time and evaluating improvements in oxygenation
- Example: 30-40 PEEP for 30-40 seconds
- Both higher PEEP and RMs are thought to decrease atelectasis by improving alveolar recruitment (increasing the number of alveoli participating in tidal ventilation and improve end-expiratory lung volumes.
- It was noted that further research is necessary on the use of Extra-corporeal Membrane Oxygenation (ECMO) for treatment of refractory ARDS.
- Veno-venous ECMO works by pulling blood from the inferior vena-cava through a circuit (outside of the body) which removes carbon dioxide and oxygenated blood returning it to the venous system via internal jugular vein.
What was the outcome for our patient with ARDS? What treatment modalities were implemented?
Continue to
Part 2 where we review treatment modalities for ARDS in more detail, specifically the logistics of prone positioning in the treatment of ARDS and the outcome of our patient. Have you encountered a patient with ARDS? Do you have any experience with prone-positioning? Please share your experiences in the management of this challenging complication of respiratory failure.
References:
Fan, E., Del Sorbo, L., Goligher, E.C., Hodgson, C.L., Munshi, L., Walkey, A.J.,…Brochard, L.J. (2017). An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. American Journal of Respiratory and Critical Care Medicine, 195(9), 1253-1263. doi: 10.1164/rccm.201703-0548ST
Gattinoni L, Pesenti A, Carlesso E. (2013). Body position changes redistribute lung computed-tomographic density in patients with acute respiratory failure: impact and clinical fallout through the following 20 years. Intensive Care Medicine, 39(11), 1909–1915. doi: 10.1007/s00134-013-3066-x
Han, S.H. & Mallampalli, R.K. (2015). The Acute Respiratory Distress Syndrome: From Mechanism to Translation. The Journal of Immunology, 194(3), 855-860. doi: https://doi.org/10.4049/jimmunol.1402513
Howell, M.D. & Davis, A.M. (2018). Management of ARDs in Adults. JAMA, 319(7), 711-712. doi: 10.1001/jama.2018.0307
Ranieri, V.M., Rubenfeld, V.M., Thompson, B.T., Ferguson, N.D., Caldwell, E., Fan, E., Camporota, L. & Slutsky, A.S.; ARDS Definition Task Force. (2012). Acute respiratory distress syndrome: The Berlin Definition. JAMA, 307(23), 2526-2533. doi: 10.1001/jama.2012.5669
Rubenfeld, G.D., Caldwell, E., Peabody, E., Weaver, J., Martin, D.P., Neff, M., Stern, E.J., Hudson, L.D. (2005). Incidence and outcomes of acute lung injury. The New England Journal of Medicine, 353(16), 1685-1693. doi: 10.1056/NEJMoa050333
Four years ago, when an outbreak was occurring in California, we reviewed the
basics of the measles and what nurses need to know. We are seeing yet another resurgence of this preventable illness. New York is fighting its worst outbreak ever and Washington state has declared a public health emergency. Unfortunately, misinformation is spreading, and vaccination debates are making headlines.
How can we ensure that our patients and the public are basing vaccination decisions on the best evidence? Do we understand
herd immunity and are we educating others about it? And how can we recognize the presentation of measles? Stay informed yourself and share reliable, up-to-date resources:
As nursing students, one of the first things we learn is to treat our patients with dignity and respect. Part of treating patients with dignity and respect is addressing patients by the appropriate name and/or pronoun. This can prove challenging when caring for patients from the lesbian, gay, bisexual, transgender, queer or questioning, intersex, and asexual or allied (LGBTQIA) community. As our thinking evolves and we continue to educate ourselves on cultural and ethnic diversity, we can better care for our patients.
When in doubt, respectfully ask.
- What pronoun do you prefer, and what name do you go by?
- To eliminate discrepancies in billing, or errors in the medical record, what name is noted on your health insurance card, and driver’s license?
Gender and Sex – What is the difference?
Gender does not mean the same thing as sex. Sex refers to the biological traits one was born with; their chromosomes are expressed as “XX,” “XY,” or other variations. Gender refers to one’s
chosen identity, regardless of biological traits.
Know the Terminology
Learning the terminology, and appropriate pronouns, can assist you in starting an open-line of communication with a LGBTQIA patient.
L—Lesbian—women attracted to other women
G—Gay—one who has or desires to have a relationship with a person of the same sex; this term often refers to men who are attracted to other men
B—Bisexual—one who is attracted to both others of the same or different sex and/or gender
T—Transgender—people who identify or express their gender as the opposite of their biological birth sex.
- A trans woman is a biologic male that identifies as a female; MTF=male transitioning to female
- A trans man is a biologic female that identifies as a male; FTM=female transitioning to male
- One does not need to have undergone surgical intervention to be considered transgender. If a person says they are transgender, then they are transgender.
- Remember the importance of providing comprehensive care. For example, a transgender man (female transitioning to male) may still be at risk for ovarian or cervical cancer.
Q—Queer/Questioning
- Queer is an all-encompassing term that is not gender- or sex-specific.
- Questioning refers to people in the process of figuring out their identity and sexual orientation.
I—Intersex—a person who was born with both male and female sex organs, or ambiguous genitalia. This term is used instead of “hermaphrodite.”
A—Asexual/Ally
- An asexual person does not experience sexual attraction.
- An ally is any person that identifies as straight and is supportive of the LGBTQIA community
Cisgender—One whose identity and biological sex are the same.
Pronouns
Cismale: he/him/himself
Cisfemale: she/her/herself
Transgender male: he/him/himself
Transgender female: she/her/herself
Gender nonconforming (non-binary): they/them/themselves
Gender neutral: zhe/zhim/zher/zhimself/zherself
It’s important for all patients to feel respected, and safe in any healthcare environment. Communication is the beginning of a positive healthcare experience.
References:
Harker, M. (2018, November 3). LGBTQIA- Providing Care For Transgender Persons: Diversity and Inclusion in Care. INS National Academy, 2018.
Humphrey, C. (2018). Nursing Knowledge and Attitudes Toward Trans* and Gender-Nonconforming Patients. Magnet Conference, 2018.
Tollinche, L., Walters, C., Radix, A., Long, M., Galante, L., Goldstein, Z., Kapinos, Y., & Yeoh, C. (2018). The perioperative care of the transgender patient. Anesthesia & Analgesia, 127(2), 350-366. doi: 10.1213/ANE.0000000000003371
Have you seen the Netflix show,
Tidying Up with Marie Kondo? If you’re like me and need inspiration and guidance to get – and stay – organized, you may want to check it out. In the show, Ms. Kondo has a set strategy for encouraging her clients. Part of the process involves asking oneself if an item ‘sparks joy,’ and even if it doesn’t, to thank the item before passing it along, whether to the trash or donation pile.
What if we employed a similar tactic to our professional lives? Does nursing still spark joy for you? When I was in the clinical setting full time, there were many days that did not ‘spark joy.’ As I look back, I realize that over time, those days became more frequent and that burnout and compassion fatigue had real effects on my health and well-being.
Earlier this month, I did a presentation on Work/Life Balance for nurses at a local hospital. During my research, I discovered some eye-opening statistics:
- Registered nurses suffer from depression at almost twice the rate of those in other professions (Letvak et al., 2012).
- Female nurses are four times more likely to commit suicide than the average woman (American Society of Registered Nurses).
Wow – the numbers surprised me at first, but the more I think about it, it makes sense. We deal with life and death every day, make decisions and provide care that is life-changing for others, and then return to our own busy lives, often without debriefing or processing the events of our days.
One of the beauties of our profession is that there are so many opportunities. If your current specialty, setting, or role, doesn’t ‘spark joy,’ consider reevaluating your goals and make a change. You’re too important to ignore.
And if you do make a career change, be sure to say ‘thank you’ to whatever path you are moving on from. We learn from where we’ve been and for that we should be thankful.
References:
American Society of Registered Nurses. Nurses at Risk. Retrieved from https://www.asrn.org/journal-nursing-toay/291-nurses-at-risk.html
Letvak, S., Ruhm, C., & McCoy, T. (2012). Depression in hospital-employed nurses. Clinical Nurse Specialist, 26(3), 177-182. doi: 10.1097/NUR.0b013e3182503ef0
More Reading & Resources
What if you were excellent at inserting IVs and the nurse your colleagues came to when they had a patient with “impossible veins,” but you could not effectively communicate important details about your patient’s care at change of shift hand-off?
What if you knew your patient was exhibiting the classic signs and symptoms of congestive heart failure, but you did not have enough self-confidence to alert the nurse practitioner of the ominous change in your patient’s clinical condition, due to the fear of being incorrect in your clinical assessment?
Finally, what if you frequently left tasks undone for the next shift and arrived late for work, and then you applied for a charge nurse position on your unit and didn’t get the job? All of these situations could be remedied with soft skill enhancement.
What Are Soft Skills for Nurses?
Soft skills are personal attributes that are necessary to succeed in any work environment, including nursing. Hard skills of nursing are clinical competencies essential to performing tasks, such as IV insertion, medication administration, and wound care. But there is much more to nursing than clinical expertise, and in fact, soft skills can be just as important as strong clinical skills to achieve success.
The current healthcare setting is noted for having sicker patients, shorter lengths of stay, and multiple transfers among units, which speaks to the need for effective communication among all care providers (Ray and Overman, 2014). Undeveloped soft skills can lead to medical errors, unhealthy/unproductive work environments, job dissatisfaction, and unfavorable patient survey results, which can adversely affect hospital reimbursement.
Nursing curriculums and nurse leaders are called to teach, role model, and guide current and future nurses in the development of soft skills that will lead to development of emotional intelligence. Presented below is a list of the top ten soft skills nurses need.
Top 10 Soft Skills in Nursing
- Communication
- Attitude and confidence
- Teamwork
- Networking
- Critical thinking and creative problem solving
- Professionalism
- Empathy
- Conflict resolution
- Adaptability
- Initiative and strong work ethic
A successful nursing career is not just defined by educational degree, certifications, and hard clinical skills, but also in the ability to use soft skills to foster excellent patient outcomes and make a positive difference in the healthcare organization’s future.
Nursing Soft Skill References
Serious medication errors occur in healthcare as a result of both human and system factors. When a practitioner makes a mistake due to human error that results in a patient death, should that clinician be criminally indicted? Unfortunately, that can happen in many states, due to criminal laws and federal or state regulations. “Intent to harm” is no longer needed for an action to be considered a crime particularly in situations where public safety is a concern. This occurred to one nurse who was criminally indicted after accidentally administering intravenous (IV) vecuronium instead of Versed (midazolam) which resulted in the patient’s death. She was charged with reckless homicide and abuse of an impaired adult and could face two to 12 years in prison, incur a large fine, and lose her nursing license.
Humans make mistakes. During a time when clinicians are expected to carry heavy patient loads and assume more responsibilities, with fewer resources and limited time, some may feel pressured to take short-cuts to get their work done which can obviously lead to missteps. When fatal errors occur, the healthcare provider becomes a second victim. In other words, clinicians who are involved in serious adverse events may also suffer post-traumatic stress disorder (PTSD) from the event, including feelings of depression, shame, and guilt. Fatal errors may haunt second victims for their entire lives.
Criminal prosecution has widespread negative effects including:
- Discourages clinicians to report errors
- Supports a culture of blame
- Compels practitioner to leave clinical practice
- Decreases staff morale
- Prevents system improvements
In February 2019, in its report titled “Another round of the blame game: A paralyzing criminal indictment that recklessly “overrides” Just Culture”, the Institute of Safe Medication Practices (ISMP) covered this case and shared insights and strategies for prevention of such errors. Read the details
here.
Do you recall our 42-year-old patient admitted to the hospital with acute pancreatitis who subsequently developed severe ARDS?
(See ARDS: Part 1.) Several days into his illness, our patient developed respiratory distress that rapidly progressed to ventilator-dependent respiratory failure meeting the clinical criteria for diagnosis of severe acute respiratory distress syndrome (ARDS) (Ranieri et al., 2012):
- Acute onset
- Bilateral opacities
- Refractory hypoxemia
- FiO2/PaO2 ratio ≤ 100
Upon recognition of ARDS and continued decline in respiratory status, ventilator settings were adjusted; tidal volume was decreased to 6 mL/kg of his ideal body weight, PEEP was titrated up to 10 cm H
2O which allowed us to decrease his FiO2 to 60%. Several hours later, he had a precipitous drop in SpO
2 to 78% and no improvement with upwards titration of FiO
2. He began over breathing the ventilator (rate set at 18) and a dyssynchronous breathing pattern was observed. A decision was made to attempt a recruitment maneuver (RM) during which 30 cm H
2O of positive pressure was applied for 30 seconds. The response was not clear, a second RM was attempted, this time applying 40 cm H
2O for 40 seconds. The patient remained hemodynamically stable and SpO
2 improved, PEEP was increased 16 and SpO
2 was persistently at 92% which was considered acceptable within the goals of ARDS. Several hours later, his FiO2 was titrated down to 55%.
The cornerstone of treatment for ARDS is mechanical ventilation. The challenge of mechanical ventilation is the risk of lung injury and barotrauma. Treatment strategies for ARDS are aimed at minimizing ventilator-induced lung injury (VILI) while maximizing ventilation and oxygenation, all aimed at reducing morbidity and mortality associated with ARDS. The most recent clinical practice guidelines in the management of ARDS endorse the following strategies (Fan et al., 2017):
- Low tidal volume ventilation (all patients with ARDS)
- 4-8 mL/kg predicted body weight with lower inspiratory pressure to target lower plateau pressures < 30cm H2O
- Adjust tidal volume to maintain goal plateau pressures.
- Higher positive end-expiratory pressure (PEEP) as opposed to lower PEEP (in those with moderate to severe ARDS)
- Recruitment maneuvers (in those with moderate to severe ARDS)
- A transient, sustained increase in airway pressure with goal to open collapsed alveoli
- Involves applying high PEEP for a specified time and evaluating improvements in oxygenation (example: 30-40 cm H2O PEEP for 30-40 seconds)
- Prone positioning (severe ARDS) for > 12 hours/day (involves placing patient in prone position while on ventilator, shifts weight of heart to ventral wall)
Remember that the pathophysiology of ARDS involves diffuse alveolar damage due to accumulation of protein-rich inflammatory mediators in the alveoli causing non-cardiac pulmonary edema. The overall effect is stiffness and non-compliance in the alveoli, dead space, and impaired gas exchange leading to hypoxia and ineffective ventilation.
Recommendation: Low tidal volume ventilation
Let’s start with the primary recommendation for ARDS, low tidal volume ventilation. Although over-simplified in description, the changes in the lung as a result of ARDS lead to a significant decrease in the area of the lung (or alveoli) available for gas exchange. If one attempts to ventilate the ARDS lung at volumes and pressures required for a non-ARDS lung, this would lead to over-ventilation, barotrauma and ventilator-associated lung injury (VALI). Since a goal of ventilation in ARDS is to avoid VALI, providing tidal volumes to match the presumed available lung can provide the same amount of oxygen exchange with less risk for over ventilation and less risk of alveolar overdistention. Attempts to ventilate the stiff lung can lead to high airway pressures. Low tidal volume ventilation is considered “lung protective ventilation.”
Recommendation: PEEP
Other strategies for moderate to severe ARDS include higher PEEP and recruitment maneuvers which can decrease atelectasis and improve end-expiratory lung volumes. PEEP is intended to keep alveoli open. PEEP is pressure applied to alveoli by the ventilator at the end of expiration. When alveoli are open, air exchange can take place. Have you heard the balloon analogy to understand PEEP? Inflating a new balloon (collapsed alveoli) can be difficult, once some air (pressure) is applied, it becomes easier to inflate. The goal of PEEP is to keep the alveoli open (preventing collapse) during expiration so air exchange continues to take place during expiration and less pressure is necessary to inflate the alveoli with the next inhalation. The pressure to overcome the initial resistance in a collapsed alveolus (deflated balloon) will not be required if the alveoli remains open. In the ARDS lung, the alveoli are stiff and difficult to inflate, adequate PEEP can improve air exchange and is often titrated up to decrease FiO
2.
Recommendation: Recruitment maneuvers
Recruitment maneuvers (RM) involve applying increased airway pressure to transiently increase transpulmonary pressures (difference between airway and pleural pressure) with a goal of opening up collapsed lung and increasing the number of alveoli participating in air exchange.
There are several methods of applying RMs involving varying pressures and duration and may include prolonged high continuous positive airway pressures (30-40 cm H
2O) or incremental increases in PEEP until attaining the desired physiologic improvements. The technique used will typically be that which is preferred or most familiar to the ordering provider, or the technique accepted and utilized by the facility at which you practice.
The application of both PEEP and RM place a patient at risk of overdistention and barotrauma from the application of higher pressures and should not be used without experienced clinical judgement and understanding of hemodynamics and potential physiologic change associated with the maneuvers. Furthermore, the RM may require the use of increased sedation and/or paralytics for the patient to tolerate. The use of high level of sedation and paralytics may cause further hemodynamic compromise and do not come without risks.
Now back to our patient. When we last discussed him, he was on AC mode of ventilation with tidal volume at 6 mL/hr, RR 18, FiO
2 60% and PEEP of 16. Again, he began to decline from a respiratory standpoint. A decision was made to attempt prone positioning.
Recommendation: Prone Positioning
Prone positioning involves placing a ventilated patient on their abdomen. Theoretically, by placing the patient in the prone position, you can achieve expansion of dependent alveoli and reduce pressure on the lungs from cardiac structures and abdominal organs. The most recent guidelines for ventilation in the patients with ARDS recommend this strategy for 12 hours per day in those with refractory hypoxemia and ARDS. The use of this strategy requires a policy and procedure endorsed by your institution with strict protocols to reduce patient injury.
In order to utilize prone positioning, the practice must be supported by the hospital or facility that you work for as its success is dependent on the coordination of many staff members from multiple disciplines including nursing, medicine, respiratory, and wound care. It often requires 1:1 ICU nursing care as well. Each facility will have a specific list of contraindications but in general, the procedure is contraindicated in those with unstable fractures to the face, spine, cervical spine, pelvis, ribs or femur, or any spinal instability, and those with intracranial hypertension. Other common relative contraindications include pregnancy, life-threatening arrhythmias, burns or open wounds to the ventral surface, acute bleeding, shock, multiple trauma, increased ICP greater than 30 mm Hg, and cerebral perfusion pressure less than 60 mm Hg. Furthermore, each patient should be evaluated individually for potential contraindications to prone positioning. Each institution may have specialty beds or devices to assist in prone positioning and it always requires a highly coordinated effort from multiple disciplines. Successful prone positioning can decrease morbidity in severe ARDS.
Our patient did eventually recover from ARDS but required tracheostomy due to his long-term ventilator dependence and associated deconditioning due to a prolonged course of acute illness. He was discharged to a skilled nursing facility for rehabilitation. Following a patient with ARDS does not come without its challenges. It can be daunting to watch a patient deteriorating under your care while knowing the high mortality associated with ARDS and the limited treatment options. It can be equally rewarding to feel confident knowing that you and your team provide the most up-to-date, appropriate care available in the treatment of this condition.
Please share you experience with ARDS or placing a patient in prone positioning!
References:
Chadwick, J.R. (2010). Prone positioning in trauma patients: nursing roles and responsibilities. Journal of Trauma Nursing, 17(4). doi: 10.1097/JTN.0b013e3181ff2813.
Fan, E., Del Sorbo, L., Goligher, E.C., Hodgson, C.L., Munshi, L., Walkey, A.J.,…Brochard, L.J. (2017). An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. American Journal of Respiratory and Critical Care Medicine, 195(9), 1253-1263. doi: 10.1164/rccm.201703-0548ST
Han, S.H. & Mallampalli, R.K. (2015). The Acute Respiratory Distress Syndrome: From Mechanism to Translation. The Journal of Immunology, 194(3), 855-860. doi: https://doi.org/10.4049/jimmunol.1402513
Howell, M.D. & Davis, A.M. (2018). Management of ARDs in Adults. JAMA, 319(7), 711-712. doi: 10.1001/jama.2018.0307
Ranieri, V.M., Rubenfeld, V.M., Thompson, B.T., Ferguson, N.D., Caldwell, E., Fan, E., Camporota, L. & Slutsky, A.S.; ARDS Definition Task Force. (2012). Acute respiratory distress syndrome: The Berlin Definition. JAMA, 307(23), 2526-2533. doi: 10.1001/jama.2012.5669
Rubenfeld, G.D., Caldwell, E., Peabody, E., Weaver, J., Martin, D.P., Neff, M., Stern, E.J., & Hudson, L.D. (2005). Incidence and outcomes of acute lung injury. The New England Journal of Medicine, 353(16), 1685-1693. doi: 10.1056/NEJMoa050333
Patients must always be at the center of healthcare. Even though the practice of clinical care is constantly evolving, along with technology and information delivery, patient expectations are not. Patients always expect a high-quality experience, so a patient-centered healthcare culture isn’t a “nice to have,” it’s a “need to have.”
Healthcare institutions and professionals need to constantly strive to better understand the needs of their patients – and not just medically. We know that hospitals can be frightening places to people who don’t spend a lot of time there. And as a result, healthcare professionals must be aware of the anxiety or fear that patients sometimes experience when receiving healthcare and take responsibility for comforting and reassuring them at every step.
It’s important for the patient to always be considered “the captain of the ship” when it comes to decisions about their own care and treatment. Clinicians are there to inform, advise and support the patient, but it is ultimately up to the patient to determine what course of action will be taken. So, a patient needs to fully understand the procedures and treatments they will undergo, and clinicians must aim to make them as knowledgeable and comfortable as possible, especially when being treated for a complicated or painful illness or injury.
Evidence-based practice (EBP), a widely used problem-solving approach to clinical practice, integrates clinical expertise with the latest and best research evidence, along with known patient values for the best possible patient care. And possibly, the most important element of EBP is taking into account the needs and wants of the individual patient. We need to understand what’s most important to our patients; what are his/her preferences when it comes to treatment options and how does he/she define quality of life? All of these things come together to make up the definition of evidence-based healthcare.
And in the end, it’s important to never lose sight of the fact that all patients deserve to be respected and must to be at the center of focus during every healthcare encounter. Patients expect nurses and other healthcare professionals to be knowledgeable, competent and confident, but also kind and understanding too. Nurses are ambassadors for their institutions, the profession and for their patients too.
Today is World Autism Awareness Day. And while many people take this day to celebrate milestones, start discussions of awareness and advocate for inclusion...my feelings are different. I’ll be honest and say not every day is a celebration. Braden was diagnosed at 20 months old, was nonverbal until the age of 4, and was almost 5 years old before he told me he loved me.
He’s been invited to only one birthday party in his 4 years of schooling and the phone never rings for a play date. He still likes printing logos and watching Curious George. We can’t go on many family outings because the sights and sounds bother him...he’s deathly afraid of the ice cream truck so pool days in our neighborhood are out. At almost 9 years old, he still needs help showering and brushing his teeth; he can’t tie his own shoes. We’ve done feeding intensives, sleep studies, social skills, and countless IEP meetings...just to move towards some semblance of “normalcy.” I live in constant fear for his future...and of my own mortality. What does his future hold? What if I’m not there to protect him, care for him? It’s frustrating, exhausting, and heartbreaking.
But....in the midst of this, are those big brown eyes who look at me with unequivocal trust and love. Who has no boundaries for “personal space,” but has begun to hug without prompting and will tell me “I love you, Mom” at moments when I swear he knows I need to hear it most. Autism Awareness is every day in this house...it’s our normal - good, bad or indifferent.
He’s our light. And even on our worst days, he’s the best part of me.
Unless someone is a nurse, is related to a nurse, or has depended on care from nurses, it’s clear that there is a knowledge gap about our work. We learned this a few years ago, when
Joy Behar referred to one of our most important tools as a “doctor’s stethoscope” on The View, and we are reminded again by the comments recently made by Washington State Senator Maureen Walsh:
“I understand… making sure that we have ‘rest breaks’ and things like that. But I also understand that we need to care for patients first and foremost… I would submit to you that those [critical access hospital] nurses probably do get breaks! They probably play cards for a considerable amount of the day!”
– Sen. Maureen Walsh 4/16/19 comments on SHB 1155, a bill eliminating loopholes in mandatory overtime
Details of the story, presented by the Washington State Nurses Association, can be found
here along with the video of Walsh’s remarks. Her comments are demeaning, yes, but demonstrate that despite the recognition of nurses as the
most trusted profession, many do not understand the important work that we do.
Let’s educate them, shall we?
Nurses Do
Nurses
do care for individuals, being present during some of their happiest and saddest times. We are there when people are their most vulnerable and bring comfort and understanding. We are proud to be able to thoroughly assess the whole person – physically, emotionally, and spiritually. We are critical thinkers and are quick to recognize subtle signs of illness. We have a unique skillset to know how to prioritize, how to advocate, and when to simply listen.
Nurses
do care for families. We support loved ones and caregivers. We are skilled communicators and educators.
Nurses
do care for communities. We know that for individuals to be their healthiest, they must have access to a healthy environment.
Nurses Don’t
Nurses
don’t “play cards for a considerable amount of the day.”
When a public figure demeans our work, it is disheartening but rallies us together to correct the error. Through education and sharing our important work, we can help elected officials understand the need for legislation to keep patients and staff safe, which is the bigger issue at hand here. Please consider
reaching out to the elected officials in your state and educating them and the public. And always, always be proud to be a nurse!
#nursesdontplaycards #notplayingcards #savinglives
I recently had the privilege of speaking with Mike Singer, CEO of Strategic Partners, Inc (SPI). Mr. Singer’s extensive and successful business career has been – and continues to be – deeply engaged with nurses. In our conversation, Mr. Singer shares his personal and business experiences with nurses, really focusing on the value of nurses in decision-making. As natural leaders and collaborators, nurses bring unique skills and experiences to improve the health of communities across America.
Mr. Singer also shares the philanthropic efforts of his company as well as valuable advice for nurses to get involved with boards. As you listen to our conversation, Mr. Singer references the important work of SPI with
The Daisy Foundation,
A Nurse I Am, Scrubs Magazine and
ScrubsMag.com. Also, SPI is a Founding Strategic Partner of the
Nurses on Boards Coalition and is involved in sharing the Coalition’s important work, “To improve the health of communities and the nation through the service of nurses on boards and other bodies.”
I encourage you to explore these resources and you can listen to our full conversation
here.
This truly was a great conversation – it is inspiring to hear others speak so passionately about the important work that nurses do. Thank you, Mr. Singer!
Mike Singer is the CEO of Strategic Partners, Inc. (SPI). Established in 1995, SPI is the industry leader in medical uniforms, medical footwear and accessories. The company designs, manufactures and distributes medical apparel under the Cherokee, Dickies, HeartSoul, Infinity ELLE, Disney Scrubs, Code Happy and ScrubStar brands, medical footwear under the Cherokee, Infinity, Anywear, Asics and K-Swiss brands, and distributes medical instruments and medical accessories under 3M Littmann, MDF Medical Devices and other brands. The company supports nurses and other healthcare professionals through Scrubsmag.com, the world’s top online lifestyle destination for nurses, with 12 million visits annually. Learn more.
National Nurses Week is almost here! Our numbers are vast, our knowledge and skills are top-notch, and our compassion is unparalleled. We have much to celebrate! We asked Wolters Kluwer nurses what they celebrate, and the answers are inspiring – take a look…
Stay tuned for our upcoming National Nurses Week blog series, with a deeper look at the themes of
professional progress,
unique talents and passions,
the next generation of nurses,
leadership in nursing,
daily wins,
evidence-based practice, and
elevating our profession.
From Wolters Kluwer nurses to all of you – Happy Nurses Week! We are proud to celebrate with you!
In celebration of National Nurses Week 2019, the
American Nurses Association created the tagline,
4 Million Reasons to Celebrate as an affirmation of the number of individuals that make up the nursing profession. The sheer number of us made me think about the many unique individuals that make up our profession. We may not realize it but every one of us brings to the profession our special talents and passions. Consider the things you love to do, the skills that come naturally to you. Perhaps you’re a gifted listener, speaker, artist, musician, or writer. Have you used one of your special gifts to create change in a patient’s life or your profession?
Varied Settings and Specialties
Nursing – with its varied settings and specialties – provides us with the opportunity to use our unique talents and passions in numerous ways. According to
The 2017 National Nursing Workforce Survey, hospitals rank as the primary employment setting, ambulatory care the second most selected setting, followed by extended care, and home health (NCSBN, 2019). Specialties range from critical care to behavioral health, from pediatrics to geriatrics, from maternal-child health to palliative care and hospice, from nursing education to clinical documentation, just to mention a few. Each of these settings and specialties benefits from nurses with unique talents and passions. For instance, behavioral health care benefits from nurses gifted with good listening skills, nursing education benefits from those gifted with speaking, and school nursing benefits from those with a passion for children.
Discovering unique talents and passions
As a new graduate nurse, I practiced on a surgical floor. At the time, the critical care unit became short staffed. Recognizing my observation skills and attention to detail, a nursing supervisor asked if I might be interested in transferring to the critical care unit. Before she had approached me, I never thought that I possessed unique talents that could benefit critically ill patients. In the weeks to come, I transferred my talents to the critical care unit where I discovered a passion caring for critically ill adults. Years later these talents translated to publishing, where my observation skills and attention to detail help develop evidence-based content that nurses use to guide care in various care settings, including critical care. I feel blessed to be part of a profession that offers endless opportunities to use our unique talents and passions.
As one of the
4 Million Reasons to Celebrate this week, what unique talents and passions make you shine in our profession? How did you discover them? We’d love to hear your story!
#ThankaNurse #4MillionReasonsToCelebrate
Reference:
National Council of State Boards of Nursing. (2018, updated 2019). The 2017 National Nursing Workforce Survey. Journal of Nursing Regulation, 9(3 Supplement), S1-S88. Accessed April 28, 2019 at https://www.journalofnursingregulation.com/article/S2155-8256(18)30131-5/pdf
As we celebrate Nurses Week, it is a good time to consider those nurses whose leadership inspires the ability to survive and
thrive amidst the current challenges inherent in our profession. No doubt many nurses might relate that it is not a “nurse leader” who has the most impact on their professional tenure, but instead a trusted nurse friend, role model, or colleague who keeps them coming back time and time again. Whoever they are, these are the nurses who promote true engagement in the profession and perhaps even spark the motivation to pursue advancement and overcome adversity. They are the advocates for positive change in workplaces, professional organizations, and in political arenas. That begs the question, then, who are the leaders in nursing and why is it so important to develop healthy leadership competencies in today’s healthcare environment? Hint: effective and inspirational leadership in nursing does not require a formal title or portfolio.
First and foremost, nurses are leaders when they motivate and influence others.
Motivating and
influencing are the key ingredients of leadership’s secret sauce. Yes, a nurse leader may be in a role with a managerial title, but do not forget the nurses who act as mentors as well as those whose opinions can sway the views and attitudes of staff, other leaders, patients, or members of the public. Whether or not these “nurse influencers and motivators” are in formal management roles is immaterial; their “yay or nay” may be enough to make an initiative wildly successful or to hasten its demise. They have the power to promote a healthy workplace culture or destroy it. Most of us can readily identify the nurses who wield these powers, some for better and others for worse. There are nurses who thrive on new ideas, positive change, and promoting harmony; others with a penchant for the negative derive satisfaction by demeaning others, instilling unnecessary stress and worry, or generally behaving as an adversary when confronted with a clear choice to do the right thing.
True, the ability of any leader to motivate and influence can be wielded for good, or for less than honorable reasons. World history is replete with examples. We can probably all come up with our own personal stories as well. In some cases, the individual’s intent may be good, but the methods employed are immature, misguided or just plain wrong, potentially leading to unintended consequences. Rather than creating engagement and motivation, the opposite effect can occur; nurses on the receiving end may be left feeling angry, demoralized, or even persecuted. Work culture may take on a distinctly negative atmosphere. Long-term outcomes of this type of unchecked leadership behavior, whether by managers or influential clinical nurses, can result in apathy, burnout, and staff turnover. Nurses transfer to other units, leave the employer altogether, and may even leave the profession itself. Ultimately, nurses need to feel prepared to do their jobs, valued, respected, and offered a safe work environment that is resourced adequately and with barriers that threaten effective and efficient care delivery addressed.
High quality leadership fosters positive relationships through connecting with people, actively listening to diverse perspectives in a non-judgmental way, mentoring, and maintaining a focus on clinical excellence. Strengthening leadership abilities of clinical nursing staff as well as those in formal leadership roles can lead to more productive, collaborative planning discussions and problem solving.
Given that healthcare workers constitute the very fabric of our health systems, ECRI listed “burnout and its impact on patient safety” as the third-most important issue on their list of the top 10 healthcare safety concerns for 2019 (ECRI Institute, 2019). Accordingly, there is an urgent and compelling need to develop healthy leadership abilities in all levels of nurses, across healthcare organizations and in the community-at-large to recognize and fix issues in healthcare delivery systems that lead to burnout. Where nurses prosper, patients reap the benefits. Healthy leadership competencies from the frontline to the C-suite are key to successfully accomplishing this mission. Effective leadership does not equate to actions that impose rules or more complexity as many believe; it is more about having the courage and competency to change dysfunctional systems that negatively impact job performance and enjoyment.
By now it should be clear that leadership is not solely the domain of a nurse manager; that mindset deflects impact and accountability from other important sources of nursing influence. Although there are nurses with inherent leadership skills who have no formal leadership education, their skills can be further enhanced through mentoring and continuing education. Leadership skills and strategies can be taught. Leadership and management are concepts that are often felt to be the same; both are necessary but different. Managers can also be great leaders, but so can nurses without a management title. Leaders learn how to harness and use their own personal power to think critically and effectively in addressing workplace factors that create barriers to a workplace that fosters excellence for both nurses and patients. Success is contingent on having leaders exhibit intelligent, mature, and constructive behaviors and problem-solving skills. That means recognizing operational problems with the system itself rather than having a propensity to blame people.
This Nurses Week, remember the nurses who you looked to for healthy inspiration and motivation. Whether it is promoting the safe passage of new graduates to become experienced nurses, creating strategies to retain good employees, solving clinical, operational or health system issues, or leading change, developing nursing leadership knowledge and skills are foundational for all nurses to assure our ongoing success as a profession.
Happy Nurses Week!
When we Baby Boomers think about the new nursing graduates coming into our workplaces, we tend to envision a group of young, fresh-faced women who are eagerly awaiting the chance to work hard to provide the best in patient care. While that may have been true in years past, today’s new graduates often present a different profile – what does that mean to you?
Certainly many new nurses are young women, but we are fortunate to also have other faces in the crowd. Those faces may be older, have mustaches and beards, speak with a foreign-sounding voice, or have different work expectations than we might have anticipated. Looking at what current literature tells us, the Millennial generation (Gen Y – born 1980-1995) typically is interested in the “why” of what to do, expect instant feedback, are technologically savvy, and want mentoring with constant feedback. The next generation of nurses (Gen Z – born 1996-2015) is also characterized by being technologically savvy and even technologically dependent, learn by demonstration and practice, are visual communicators and learners, and are teamwork- and outcomes-oriented (Christensen et al., 2018).
What does all this mean to us, the more experienced nurses in the workplace who need to work with and support the next generation of nurses? Here are some ideas and approaches to consider:
- Listen – This is probably one of the most important actions to take to support our newer nurses. Let them know they are heard.
- Inclusion – Actively take steps to incorporate new nurses into your teams.
- Introductions – As a preceptor, take opportunities to introduce your orientee to physicians, APNs, allied health practitioners and management. Your orientee will be quickly recognized as a new employee by others, but these are all new and unknown people and roles to new employees in the organization.
- Feedback – This is an overall need and want that newer nurses require in order to thrive. Be sure to give invaluable feedback on performance to newer team members; praise loudly when praise is due. When feedback is needed for performance improvement, give it soon and clearly. Too much sugar-coating may dilute the importance of the message, but stick to the facts of the situation so as to not demoralize the recipient. Even when things go badly and a corrective message must be delivered, do it in private and be sure to end with a message of support.
- Offer help – Check in with new staff members and offer help. It may be difficult for new nurses to ask for help thinking they “ought” to be able to do it all by themselves. You can be instrumental in retaining a new hire by extending an offer of help.
- Debriefing – After a difficult event, take the time to debrief your orientee by examining the cause, actions, process and result of the event. Doing so helps to bring perspective to the situation for greater understanding. It can help the nurse better cope with the event and possibly avoid a similar event in the future.
- Resist stereotyping – Every new hire is an individual with unique interests, talents, needs and wants. Grouping nurses by their generation may provide a starting point, but as individuals we all have our own needs, wants, learning styles, strengths and areas of concern. Take the time to get to know the new nurses you work with so you can help support them appropriately.
- Calling physicians/providers – Remember your first call to a doctor? How stressful was that? Make sure all the data needed is at hand and provide phrasing to help the call go succinctly and successfully. Helping script what to say and standing by during the call will assist your new nurse to provide a clear message with more confidence than he/she may actually feel.
- Socialization – Include new nurses in unit activities and plans. Not every new nurse will be interested in socializing outside the workplace, but extend the invitations so they know they are welcome if desired.
The way we, as experienced and successful nurses, interact with new nurses of any generation will have a big impact on new hires into our organizations. Nurses who feel they are being listened to, supported in their clinical work, included in workplace social activities, and frequently provided with appropriate feedback will benefit from all of the above. Most importantly, nurses treated with respect for what they know and assisted when challenged with new experiences are more likely to be happy and remain with your organization for a long time.
Reference:
Christensen, S., Wilson, B., & Edelman, L. (2018). Can I relate? A review & guide for nurse managers in leading generations. Journal of Nursing Management, 26(6). doi: 10.1111/jonm.12601
Is your employer planning anything special for Nurses Week? Do you typically get a small gift or token – perhaps a pen or water bottle? While we all can agree that adequate staffing and safe work environments would be much more valuable gifts, anytime someone notices and recognizes the hard work that nurses do is a win in my book. If we’d like to see those bigger “gifts” become a reality, we just might have to shoulder some of that responsibility ourselves.
What if we celebrated daily ‘wins’ – both our own and that of our colleagues? Wouldn’t that make our work environments a more pleasurable place to be? Small acts of kindness can have great impact, so this Nurses Week as we focus on the theme of “4 Million Reasons to Celebrate,” let’s do exactly that – celebrate each individual nurse and the day-to-day ‘wins’ that we achieve. Here are some daily wins from my own nursing life that I have celebrated and have celebrated for others:
- A genuine smile from a patient with chronic pain and depression who rarely feels or shows happiness
- A thank you from a colleague in another discipline
- Recognizing a subtle sign of a patient becoming fluid overloaded and collaborating with the prescriber to change treatment
- Noticing ST-elevation on telemetry, thereby getting MI workup and treatment started early
- Precepting a nursing student who then returns to your unit as an RN colleague
- Feeling valued as a member of the healthcare team
- A hug and thank you from a patient’s family member
- Holding the baby of a patient who has struggled with fertility issues
- The look on the face of a new nurse when he interprets an ABG and is correct in his thinking of what ventilator changes are likely to improve the results
- Transporting a critically ill patient to and from MRI
- The first words of an ARDS patient after being weaned from the ventilator
- Getting ALL charting done before giving report to the next shift
- That shift when you completed all tasks and got a jump on things for the oncoming nurse
- Sitting with a dying patient when loved ones couldn’t be there
- Successfully troubleshooting the IV pump that just won’t stop beeping
So, when similar daily wins occur during your day, don’t be afraid to celebrate them! Tell your colleagues about the patient with no veins who you got labs from with just one stick or the staffing issue that you just solved. Keep your tone humble but share it just the same. And when you see or hear about these simple successes from your colleagues, be sure to give them the kudos they deserve.
Nurses are under so much stress – physically and emotionally and sometimes it may feel as if the negative outweighs the positive – let’s turn that around. We do hard work and if we don’t support one another, how can we expect support and respect from others? Let’s make it a priority to lift each other up and celebrate the work that we do. A simple smile and word of encouragement can go a long way.
Please leave a comment and share some daily wins that you’ve experienced or seen!
As nurses, we have many accomplishments to celebrate. Just consider the progress that has occurred since Florence Nightingale set the foundations for nursing as an art and science in the 19
th century. Following Florence’s example, nurses have built upon data collection, documenting evidence, and dissemination of knowledge to advance nursing as a profession. During the late 19
th century, nursing textbooks were published in America to educate nurses in hospital-based schools of nursing. The procedures and nursing interventions in those texts were primarily based on the observations and experiences of a few nurses rather than rigorous research methods that developed in the 20
th century. If you have some free time, you may want to peruse the early nursing textbooks that are in the digital archives at the National Library of Medicine to appreciate the progress we have made.
The Future of Nursing Report published by the Institute of Medicine in 2010 helped to accelerate the progress nurses have made by addressing areas of concern. Notable advancements include: the growth of nurses with doctoral degrees; a higher percentage of nurses with bachelor’s degrees; increasing ethnic diversity; and increased participation of nurses on community, healthcare, and other boards. These advancements don’t only benefit nurses as a profession, but also result in improvements in the quality of health care delivery because nurses are better educated and can take leadership roles and influence health care policy and decision-making.
One organization that is responsible for routinely promoting nursing excellence and celebrating the achievements of nurses is the
American Nurses Credentialing Center (ANCC). ANCC, the largest nursing certifying organization, supports professional progress of individual nurses’ who earn board certification. On a larger scale, ANCC encourages the advancement of nursing practice, nursing science, and nursing care quality by granting the Magnet, Pathway to Excellence, and the Premier CNE Provider Awards. These highly sought-after recognition programs create a culture of continuous improvement that result in progress in nursing that we see at conferences and published in peer-reviewed journals.
This National Nurses Week, we celebrate nursing progress, but also reflect on how you can contribute to the ongoing progress of the nursing profession. Happy Nurses Week!
As we think about reasons to celebrate nurses’ work during Nurses Week, we shouldn’t overlook significant changes that have changed how we approach our work and that have, I think, done much to improve our credibility as a profession based on science.
When evidence-based-practice (EBP) gained momentum several years ago, many nurses I spoke with rolled their eyes and shrugged. They essentially looked at it as another “fad” that administrators and educators were propagating and that would just add to the already heavy workload of staff nurses. But EBP was and is different, and is vitally important for nursing – more importantly, it’s vital to our patients.
Nursing processes in hospitals were static over many decades. Just think of the many “sacred cows” of nursing that have been refuted by research – vital signs every four hours; pre-op skin shaving; daily dressing changes; instilling saline into endotracheal tubes; keeping new moms on bedrest after delivery; putting newborns to sleep on their stomachs, just to name a few. Some of these practices impeded healing or put patients at higher risk for complications. EBP has eliminated or replaced them with care processes grounded in science. Not only have patients benefited, but consider the amount of nursing time, effort and resources wasted on interventions that offered no benefit!
Hospitals accredited by The Joint Commission are required “…to select evidence based or peer reviewed literature” to support clinical practice guidelines, and most electronic health records now have evidence-based protocols with references to the literature on which they are based. And now nurses are becoming major contributors to this literature, as they disseminate information about successful quality improvement efforts based on implementing EBP.
AJN is happy to support and disseminate these worthy projects (We grouped them under “Quality Improvement” under the Collections tab on our Web site,
www.ajnonline.com ). We’ve enlisted Lynn Gallagher-Ford, PhD, RN, NE-BC, DPFNAP, FAAN, and Sharon Tucker, PhD, RN, FAAN, both at the Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare at the Ohio State University College of Nursing in Columbus, to lead a series to help nurses implement EBP. (Here’s a blog
post explaining the series.) These experts found that while nurses know about EBP, they often get stuck in making the change “stick” over the long term. The first article, “
EBP 2.0: From Strategy to Implementation,” appeared in our April issue and will run every other month through the year. (Our original series,
Evidence-Based Practice, Step by Step is available AND you can earn CE credit.) And there’s a wealth of information, too, on NursingCenter’s
Evidence Based Practice Network.
As I pondered what I would write for this blog, I kept going back to a chapter I wrote for the commemorative edition of Florence Nightingale’s
Notes on Nursing: What It Is and What It Is Not, that has just been published to celebrate Nurses Week. To elevate the nursing profession, we must understand where it has been, how has healthcare changed, the importance of being a leader at the bedside to the boardroom, and the responsibility of being an ambassador and advocate for our profession and our patients. I would like to share with you my entry in the book called,
Notes on Nursing – Not Unlike the Lady With the Lamp.*
While attending nursing school, I was required to read the book, Notes on Nursing, by Florence Nightingale. And while I could certainly understand how addressing such issues as exposure to clean air and water, sanitation, hygiene, and exposure to sunlight daily, were important to the healing process, I did not fully appreciate the impact Nightingale’s work would have on methods of healthcare in the years to come.
During Nightingale’s time, nursing care was administered only by women, and in fact, Notes on Nursing was written directly to women with instruction on how to conduct themselves while caring for the sick as well as the healthy. Times have certainly changed since 1859 when the first edition was published. Men are now part of a fast-growing profession that has moved from one of mere servitude to that of equal partnership with all healthcare professionals. What is most remarkable about Nightingale’s work, is that she was one of the first clinicians to use the concepts of epidemiology and care quality to improve healthcare delivery and patient outcomes. Today, the use of evidence to inform practice and improve outcomes is the bedrock of quality care on a worldwide basis. And for those who doubt the power of the nursing profession to influence and make change, all one must do is consult the history books.
One topic that Nightingale writes about is the importance of listening and communicating with her patients. For me, the skill of active listening truly joins the art and science of what we do as nurses. However, this is perhaps one of the most difficult skills to employ. In today’s fast-paced environment where technology is ever present, and various medical apparatus such as intravenous pumps, mechanical ventilators, and other machines sit between us and our patient, stopping in for a moment to just be present with a patient to hold his or her hand, wipe a fevered brow and/or actively listen to what he or she is saying in acknowledgement to what they’re feeling is sometimes more of a challenge than it should be.
Not too long ago I went into a patient’s room in the critical care unit and had to find my way through the jungle of tubing and machines to speak with my patient, Helen, as I will refer to her. Helen was lying in her bed with her eyes closed and her face dwarfed by a breathing mask. She had a diagnosis of stage four chronic obstructive pulmonary disease and had been admitted for an exacerbation due to pneumonia. Her eyes fluttered open when I touched her hand. as I introduced myself, and asked her how she was feeling, she smiled and said “fine.” I could tell she was far from it, I sat down in a chair next to her bed and held her hand, and she said she had lived a good life, and just wanted to die peacefully. She then told me about her husband who had passed three years prior, and how she wanted to be with him again. She said me she was ready to stop everything and just die peacefully.
I explained to her about hospice, and then conveyed her wish to the attending physician who said he didn’t know she was ready to go on to hospice. I asked him if he had asked her what she wanted, and he told me, “No. I was busy with other patients and was told by the emergency room physician that she wanted to be a full code.” The physician spoke with her and her family, and ordered a hospice consult, and as luck would have it, she was transferred later that evening to an inpatient hospice unit.
As the ambulance attendants wheeled her out, she reached out to me and said, “thank you for taking the time to sit with me and listen.” Helen died the next day in hospice, on her own terms, and surrounded by her loving family.
That’s who we are. We are our patient’s advocate when they need a voice. We listen to their stories, help them come to terms with their diseases and conditions, make sure their basic needs are met and provide a hand to hold when that’s needed too. We look beyond the tubes and machines to see the life in the bed as one that is worthy of our time and respect, and so give them the choice to heal or to die on their own terms.
A lot has changed since Nightingale wrote Notes on Nursing in 1859. The access to medications, devices and medical breakthroughs has significantly extended our lifespans. But, one must remember that the concept of quality of time, versus quantity of time has remained constant. As nurses, we use the best available evidence to assist patients to make informed decisions about their healthcare. And yet, we can still have crucial conversations or employ the power of just being present and listening when that’s all that’s needed. We are caregivers who are privileged each day to practice our profession of nursing, so not so unlike the original lady with the lamp.
Thank you for your innovation, dedication, and courage to be a member of the nursing profession and give the gift of yourself every day to the patients you serve. You are the true heroes of healthcare!
*Reprinted with permission.
Reference:
Dabrow Woods, A. (2020). Notes on Nursing – Not unlike the lady with the lamp. In Notes on Nursing: What it is and What it is Not. 160th edition. (54-56). Philadelphia, PA: Wolters Kluwer.
Fractional excretion of sodium (FENa) utilizes urine chemistry to distinguish between different causes of acute kidney injury (AKI). Is it a prerenal cause (decreased perfusion), acute tubular necrosis (ATN), or a post-renal cause (obstruction)? Since AKI is often multifactorial, we must remember that prerenal injury may progress to or coexist with intrinsic renal disease. If taken in clinical context, FENa is a useful additional data point in patients whose volume status is difficult to assess.
Procedure
Collect urine and plasma electrolytes simultaneously. Use the calculation below to calculate the FENa. (U
Na = urine sodium
, P
Cr = plasma creatinine, P
Na = plasma sodium, U
Cr = urine creatinine).
Interpretation
|
Pre-renal |
Intrinsic |
Post-renal |
FENa |
<1% |
>1% |
>4% |
Causes |
Hypovolemia
Heart failure
Renal artery stenosis
Sepsis |
Acute tubular necrosis
Interstitial nephritis |
Obstruction
- Prostate enlargement
- Bladder stone
- Ureteral obstruction
|
Clinical Considerations
- Do not use in patients receiving diuretics or patients with chronic kidney disease.
- FENa percentage should not be considered in isolation. Always consider the patient’s history, physical exam, clinical context, and current medications.
- Non-volume depleted states which may cause low or borderline FENa include: acute glomerulonephritis, contrast-induced nephropathy, cardiorenal syndrome, and hepatorenal syndrome.
References:
Espinel, C.H. (1976). The FeNa Test: Use in the Differential Diagnosis of Acute Renal Failure. JAMA, 236(6), 579-581.
Miller, T.R., Anderson, R.J., Linas, S.L., Henrich, W.L., Berns, A.S., Gabow, P.A., Schrier, R.W. (1978). Urinary Diagnostic Indices in Acute Renal Failure: A Prospective Study. Annals of Internal Medicine, 89(1), 47-50.
Pahwa, A.K., Sperati, C.J. (2016). Urinary Excretion Indices in AKI. Journal of Hospital Medicine, 11(1), 77-80. doi: 10.1002/jhm.2501
My amazing niece graduated high school this past weekend and like thousands of other eager 18-year-olds, she will be heading off to college in the fall. The special thing about this situation though is that she will be starting her nursing career!!! To say I am excited would be an understatement! There is so much to teach her, so much to prepare her for and more thrilling SO MUCH TO GET HER!!! All of this has led me to think “what is the perfect nursing student gift?” I have been searching the internet for hours on end to come up with fun, meaningful and useful gifts!!
I had the very best time searching through pages and pages of nursing tools. I read review after review, blogs, diaries, nursing department school supply lists, but what really helped me is just remembering! I sat and thought long and hard about my own nursing student days (I like to pretend it wasn’t that long ago), and just tried to remember what tools I used or liked the most! I laughed at how unsure I was; I cried as I remembered certain patients; I cringed at the way things “used to be done.”
I compiled a big list and went “shopping” on the internet! I found all of what I wanted (and more that I didn’t even know I wanted). I got practical things, useful things, unnecessary things and even fun novelty things!*
My niece absolutely LOVED everything! She was eager to learn about each item! You could see just how excited and ready she is to begin her nursing classes!
But, I will say I am the one that got the greatest gift! Shopping for her gifts gave me the opportunity to sit and reflect on my very own nursing student days! I saw (the young version) of myself in this beautiful young woman who is eager to learn and beyond excited to dive head first into becoming a nurse!
The best gift was not the shiny new stethoscope or blood pressure cuff that I gave her. The best gift was what she has given me – an opportunity to reflect on my student days, a spark that lit my own eagerness to learn and most important, someone special to share my love of nursing!
Congratulations to all the new student nurses…and everyone they will inspire!
Have a product or gift idea that you’ve received or would like to suggest? Please leave a comment!
*Reference or photograph of any specific product is for general informational purposes and does not constitute an endorsement or recommendation.
As baby boomers age and eventually leave the nursing workforce, we can expect to experience a significant shortage of nurses. Researchers project that one million registered nurses will retire by 2030 (Buerhaus et al, 2017). Think about the years of experience and knowledge that will no longer be available to us, our colleagues, and our patients.
Staggering numbers
Currently, there are four million practicing nurses in the US and 29 million nurses globally, and we are already short 7.2 million nurses. By 2035, that number is expected to increase to a shortage of 12.9 million nurses (Global Health Workforce Alliance and World Health Organization, 2013).
Today, the average nurse turnover rate is 17.2%, with over 20% leaving their positions within the first year. To replace a bedside nurse, it costs an average of $52,100 (range $40,300 to $64,000 per nurse) (NSI Nursing Solutions, Inc., 2019). View the infographic below to learn about contributing factors and strategies to address the current and projected shortage.
Want to learn more?
Watch this video.
References:
Buerhaus, P., Skinner, L., Auerbach, D., & Staiger, D. (2017). Four Challenges Facing the Nursing Workforce in the United States. Journal of Nursing Regulation, 8(2). doi: https://doi.org/10.1016/S2155-8256(17)30097-2
Global Health Workforce Alliance and World Health Organization (2013). A Universal Truth: No Health Without a Workforce. Retrieved from https://www.who.int/workforcealliance/knowledge/resources/hrhreport2013/en/.
NSI Nursing Solutions, Inc. (2019). 2019 National Health Care Retention & RN Staffing Report. Retrieved from http://www.nsinursingsolutions.com/Files/assets/library/retention-institute/2019%20National%20Health%20Care%20Retention%20Report.pdf.
I recently had the opportunity to speak with Dr. Connie Delaney, Professor & Dean of the School of Nursing at the University of Minnesota. We spoke about her nursing career, her current work and the importance of nurses getting involved as board members. Dr. Delaney shares her wealth of experience with board membership, including her insights on the Nurses on Boards Coalition and their important work.
Listen to our full conversation to learn how Dr. Delaney also pursued a degree in math while studying nursing, her thoughts on planetary health, and the
cutting-edge facilities at her institution. What advice does she have related to nurses and board membership? Here are two key pieces she shared:
- Be authentic – know yourself and know nursing.
- Recognize the importance of team – respect strengths and boundaries.
Listen to our full conversation
here.
Connie White Delaney is Professor & Dean, School of Nursing, University of Minnesota. She also served as Associate Director of the Clinical Translational Science Institute –Biomedical Informatics, and Acting Director of the Institute for Health Informatics (IHI) in the Academic Health Center from 2010-2015. Delaney is the first Fellow in the College of Medical Informatics to serve as a Dean of Nursing. Delaney was an inaugural appointee to the USA Health Information Technology Policy Committee, Office of the National Coordinator, Office of the Secretary for the U.S. Department of Health and Human Services (HHS). She is an active researcher and writer in the areas of national data and information technology standards development for essential nursing and health care, outcomes/safety, data science, and translational science. She serves on numerous health, business/industry and policy boards/advisory committees. She holds a BSN with majors in nursing and mathematics, MA in Nursing, Ph.D. Educational Administration and Computer Applications, and completed postdoctoral study in nursing & medical informatics. Read more…
“We face as nurses huge challenges and how do we take advantage of the technology we have without losing the art of nursing.”
STUART FISK, CRNP, Director, Center for Inclusion Health - Allegheny Health Network, Pittsburgh, PA
As nurses, we are key members of the healthcare team and organizations know that to ensure evidence-based care, a high-quality nursing workforce is imperative. Our skillsets are in-demand as high-acuity patients benefit from our critical thinking, as well as our art of caring, to have the best outcomes.
For some of us, our role is changing. As the healthcare environment shifts to one of prevention and wellness, many – including those in advanced practice roles – are providing medical and nursing care for people in settings outside of the hospital. The bottom line is that we
all need to practice to the full extent of our education and training to best meet the needs of the changing healthcare system, whether we are at the bedside within healthcare organizations or caring for people in their homes and communities. In either case, we need to look beyond the patient as an individual with a specific medical need. There is so much more that contributes to an individual’s health and well-being.
The
World Health Organization defines social determinants of health as “the conditions in which people are born, grow, live, work and age.” These social determinants of health – socioeconomic status, environment, food insecurity and food safety, education, employment, social networks, homelessness, and racism – impact health. As nurses, our attention to these factors is not new. We focus on holistic care for every patient and therefore we are positioned to be leaders as this new paradigm in healthcare unfolds. Like anything else, we can’t do it alone. Collaboration with other members of the multidisciplinary team is critical.
Caring, leadership, and teamwork – three characteristics that nurses exemplify. We’re celebrating nurses at Wolters Kluwer in recognition of all that they do every day.
Learn more and watch “Care without Judgement: The HeART of Nursing.”
STUART FISK, CRNP, Director, Center for Inclusion Health - Allegheny Health Network, Pittsburgh, PA
Stuart Fisk has been involved in HIV research, nursing, and prevention since 1988. Involved in the development and legalization of Prevention Point Pittsburgh, a syringe exchange program for injection drug users in the region, Fisk currently serves on its Board while, while providing primary care for persons with HIV infection at the Positive Health Clinic in Pittsburgh, PA. Fisk has provided hospice, nursing and medical care for persons living with HIV disease since 1992, with a focus on providing care for persons with substance use and mental health disorders. By helping to develop innovative care programs for these populations, he was instrumental in the development of the Positive Health Clinic, and the Center for Inclusion Health at Allegheny Health Network, where he serves as Director.
Watch our Facebook LIVE with Stuart from October 22, 2019.
I’ve written before about a
special nurse that came into our lives many years ago – over 18 years ago, in fact. I’m sad to say that Nurse L died earlier this month after battling brain cancer. While we did keep in touch through the years, both by mail and seeing each other out in the community, I learned several things about her over the past few months.
Nurse L worked as a neonatal intensive care unit (NICU) nurse until symptoms started that prompted her to see her own health care provider for a thorough workup. During treatment, with the help of her family, she continued to be in touch with former patients and families. Her NICU nursing career spanned 38 years and she was in her late 70’s when she died.
For 18 years, Nurse L would send birthday cards and holiday greetings to our family. She even sent graduation wishes to my sons last spring. We will miss her kind words and remembrances and are consoled by the fact that she did what she loved for so long and impacted so many of us.
At her funeral, her selflessness and compassion were evident through words from her family, her NICU colleagues, and other families of babies she had cared for. Those of us who spent time with Nurse L and the other NICU staff know – and will always remember – the help, support, and love given to our babies . As a nurse myself, it was difficult to relinquish both my “new mom” and nurse role to a stranger for those months many years ago. We are so lucky to have had Nurse L to care for our boys. For her knowledge, skills, and compassion, my family and I will forever be grateful.
This article is sponsored by King University Online and was first published on March 12, 2019.
One of the most important topics being discussed within the field of nursing is rising nurse-to-patient ratios. In general, nurses across the country are being asked to care for more patients at a time, and individual states or healthcare centers are left to deal with this growing problem.
In most states, individual healthcare facilities have the ability to set their own safe staffing standards. Currently, 14 U.S. states have passed some form of safe staffing laws (American Nurses Association, n.d.) However, in 13 of those states, the laws only require there to be a general plan in place to manage the ratio as opposed to regulate it. The outlier, California, became the first state to pass a law mandating an average nurse-to-patient ratio in 2004 (Mark et al., 2013). Their standard is one nurse for every five patients on average in medical-surgical units.
Despite California being the only state to have a law on the books, more states are recognizing how important safe nurse staffing levels are to both patient care and the success of the nursing field. In recent years, there has been a new wave of support behind state- and federally-mandated nurse staffing minimums. Studies have shown benefits to both nurses and patients in California in the years after the state law was enacted, and lawmakers in Pennsylvania and Massachusetts recently considered codifying minimum nurse staffing standards, as well.
Why is Nurse-to-Patient Ratio Important?
A balanced nurse-to-patient ratio can lead to many positive outcomes. Nurses, patients, and even healthcare facilities have experienced success when using a safe nurse staffing method.
Nurses
When nurses have fewer patients to care for at one time, they’ve shown higher levels of job satisfaction. A study published by labor union AFL-CIO showed that, in contrast to nurses studied in New Jersey and Pennsylvania, California nurses felt their workload was reasonable and led to providing better care (AFL-CIO: Department of Professional Employees, 2011). They also reported receiving adequate support services, such as nursing assistants. They even had time to take quick breaks during their shift.
When nurses are without this support and feel unreasonable expectations placed upon them, they could experience a phenomenon known as
nurse burnout. In 2018, as many as 62 percent of nurses felt symptoms of burnout in their jobs, according to the RN Network (Cornwall, 2018). Nurses suffering from burnout have a harder time providing quality patient care and often report strained relationships at work.
Patients
The quality of patient care decreases as the number of patients in a nurse’s care increases. A study published in the
New England Journal of Medicine found that unsafe staffing levels were “associated with increased mortality” for patients (Needleman et al., 2011).
Aside from risk to the patient, satisfaction is a concern as well. Where nurse-to-patient ratios weren’t effectively balanced, patients reported viewing nursing staff and the facilities where they worked poorly. Research published in the
BMJ noted that patients’ thoughts on their care in a hospital were associated with nurse staffing and quality of care (Aiken et al., 2018).
Hospitals
It may not seem like it, but employing more nurses can actually be cost effective for healthcare facilities. A study published in
Medical Care found that hiring more nurses and having a lower nurse-to-patient ratio shortened hospital stays for patients and helped save in medical costs (Dall et al., 2009).
As mentioned above, quality nursing care also improves the overall perception of a hospital facility, as well as outcomes for the patients. The better nursing care provided, the better the perception of the facility.
What You Can Do About Safe Staffing
Even in an adequately staffed hospital, there could still be days with an imbalanced nurse-to-patient ratio. A nurse could call out sick or more patients than normal could be admitted. In either case, a higher nurse-to-patient ratio means that nurses have to step up to the challenge of caring for more patients. We talked with a pediatric nurse with years of experience, and she explained how drastic the situation is between a manageable nurse-to-patient ratio and a high ratio.
“When you have a light patient load, you likely have time to do a full set of vitals and systems assessments, administer all medications, and inquire about any requests or needs before leaving each patient’s room,” Dawn D., RN said. “When you have a larger patient load, you need to decide what takes the greatest priority; which patient needs your attention first?”
You likely won’t have a say in the nurse-to-patient ratio at your facility. That’s why, according to Dawn, it’s important to be a team player.
“It’s uncommon for every nurse on your shift to have a difficult patient load,” she said. “When you see a coworker struggling to keep up, offer to help. In turn, your coworkers will likely do the same for you when you are having a busy day.”
There are also other ways for you to make an impact outside of the hospital. Nurses are playing a larger role in politics as more states take notice of the impact of nurse-to-patient ratios. In Tennessee, the
Tennessee Nurses Association created a Political Action Committee (PAC) called the Tennessee Nurses Political Action Committee (TNPAC) to help lobby the state legislature for nursing improvements. They also provide legislative updates to members as bills pertaining to the healthcare industry and nursing move through the Tennessee General Assembly. Individually, you can educate elected officials and raise awareness of nursing issues in your community, as well as take a leadership role in your state’s nurse’s association.
Being active in finding a solution to rising nurse-to-patient ratios could make the difference at your hospital and in your community. If you’re looking to step into a leadership role and make a positive impact, enroll today in King University’s
online RN to BSN program. Grounded in Christian faith, our program will teach you strategies to become a better nurse, enabling you to provide better care to patients. With transfer credits, you can complete this program in as little as 16 months, and thanks to our online format, you can accomplish your education goals while balancing your busy life.
References:
AFL-CIO: Department of Professional Employees. (2011). Impact of Nurse-to-Patient Ratios: Implications of the California Nurse Staffing Mandate for Other States. Retrieved from https://dpeaflcio.org/programs-publications/issue-fact-sheets/impact-of-nurse-to-patient-ratios-implications-of-the-california-nurse-staffing-mandate-for-other-states/
Aiken, L., Sloane, D., Ball, J., Luk, B., Rafferty, A., & Griffiths, P. (2018). Patient satisfaction with hospital care and nurses in England: an observational study. BMJ 8(1). doi: 10.1136/bmjopen-2017-019189
American Nurses Association. (n.d.) Nurse Staffing. Retrieved from https://www.nursingworld.org/practice-policy/nurse-staffing/
Cornwall, L. (2018). RNnetwork 2018 Portrait of a Modern Nurse Survey. Retrieved from https://rnnetwork.com/blog/rnnetwork-2018-portrait-of-a-modern-nurse-survey/
Dall, T., Chen, Y., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic Value of Professional Nursing.Medical Care, 47(1). doi:10.1097/MLR.0b013e3181844da8
Mark, B., Harless, D., Spetz, J., Reiter, K., & Pink, G. (2013) California's Minimum Nurse Staffing Legislation: Results from a Natural Experiment. Health Services Research, 48(2). doi: 10.1111/j.1475-6773.2012.01465.x
Needleman, J., Buerhaus, P., Pankraz, V., Leibson, C., Stevens, S., & Harris, M. (2011). Nurse Staffing and Inpatient Hospital Mortality. New England Journal of Medicine, 364(11). doi: 10.1056/NEJMsa1001025
The World Health Organization (WHO) has made a historic move by designating 2020 as the “Year of the Nurse and Midwife,” which has been supported by leading nurse organizations around the world. With the changes in healthcare we are seeing from a national and global perspective, and not to mention the honoring of the 200th birth anniversary of Florence Nightingale and the Nursing Now initiative, the timing could not be more perfect. One of the most spirited discussions across the globe is whether all people have a right to healthcare. When we look at this from a humanitarian perspective, we all have a right to health care, and in order to achieve optimal health and maintain it, education, support, and care are often involved.
Nurses are at the center of care. It is our relationship with the people and their communities that facilitates optimized health outcomes. Throughout history, nursing, as a profession, has developed many theories and models of care that reflect a better understanding of the definition of health such as the social and behavioral determinants of health and the needs of individuals within the community.
Wolters Kluwer recognizes the importance of nurses and midwives and their impact on people and health in general. We support the important work nurses and midwives do every day, and the impact they have on the people they serve. Throughout the year, we look forward to bringing you information and resources reflected in our practice, research, and educational products that support your work and professional development.
I have been a nurse since 1984, and a nurse practitioner since 1998, and am forever honored to be a member of this remarkable profession, humbled daily by the many stories I hear from nurses around the world, regarding the impact they are making on people’s lives.
I celebrate each and every one of you and the contributions you are making in providing quality care to those in need. Let’s make 2020, not only the Year of the Nurse and Midwife, but the year that every person on the planet can truly say, I am lucky to have had my life touched by a nurse.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Chief Nurse; Health Learning, Research & Practice, Wolters Kluwer
Nurse Practitioner, Penn Medicine Chester County Hospital
Adjunct Faculty, Drexel University
Thank you for a great 2019! Here’s a peek at the top ten posts from this year. See what your colleagues have been reading and catch up on any you may have missed. More to come in 2020!
#10
#9
#8
#7
#6
#5
#4
#3
#2
#1
The dreaded holiday work schedule… we know the requirement and we remember which “winter holidays” we worked last year, yet there always remains this small glimmer of impossible hope that we will somehow be sprinkled by holiday magic and be able to spend the holidays at home with our families!
It just sometimes doesn’t seem fair working the holidays when most people have off. But nurses are not “most people.” Nurses are a special group of caring people that give up their time and energy – every day, not just on holidays – to care for their patients. Nurses realize that as much as we do not want to work during the holidays, it is our patients that suffer the most. So, we make the best of it and we face the music and accept the fact that the hospital does not close even though the calendar may say it’s a holiday. Perhaps we plan a celebration with our “work family” or try and help each other with small shift changes so a young mom can make it home in time to tuck in her kids. One thing that doesn’t change is that we give extra special care to not only the patient, but their family at the bedside.
Working in labor and delivery I was in the special, sacred part of the hospital where patients were usually happy to be in the hospital! Though working the holiday shifts were still not favorable, there was always extra energy on the floor waiting for a holiday baby to be born! There is one special patient I remember well while working a 12-hour night shift on Christmas Eve. It was my 3
rd shift in a row and the unit wasn’t particularly busy, but steady. I was caring for a young mom who came in to the hospital in early labor in the middle of the night. I thought it was going to be an easy night of early labor and I would be home with by family by 0800. I got this mom settled into her room and couldn’t help but notice that she didn’t have anyone with her. I asked her a plethora of admission questions and nonchalantly asked who her support person would be. She stoically responded that she was going to labor by herself and didn’t need anyone to “support” her; but the tear in her eye and the shaking of her hands caught my eye…and my heart.
I got to talking to this brave yet broken young mom only to find out she was not only newly married but new to the country. She and her husband had traveled across the world, leaving family behind, to start a better life for themselves. However, only days after finding out they were expecting, the husband suddenly passed away. This young mom was all alone, on Christmas Eve, having a baby.
Earlier I had been complaining that I was missing my family dinner, but knowing I would make the family breakfast and knowing I had a house full of friends and family waiting to see me. This young mom did not complain, instead told me of all the things for which she was happy, especially the healthy baby she was about to welcome to the world, all by herself. I remember this moment as if it were yesterday, her maturity, her grace, her gratefulness…all still remain with me. It is this patient that changed me. This young woman made me a better person, a better nurse. I stayed the night by her side and helped her ride the highs and lows of labor. My shift came to an end, but my time with her did not. She gracefully welcomed a beautiful baby girl, named Noelle, in the late morning of Christmas day. I chose to stay after my shift not because she needed me, but because I needed her.
Working holiday shifts can be challenging and not ideal; however in the season of giving, nurses have a special and unique opportunity to give of themselves to their patients. And when you least expect it, you may just be given the greatest gift in return.
This article is sponsored by Emmanuel College and was first published on September 11, 2019.
Once you’ve completed your nursing program of choice and passed the state licensing exam, there’s one last hurdle to jump before entering the world of professional nursing: the interview.
Every step in your nursing education and development has been a test, and the interview is no different. Whether you’re going out for a job at your top hospital, a volunteer position or to work in nursing education, the interview will be designed to test your knowledge and wherewithal.
Nursing interview questions are designed to suss out how you think and whether you’d be a good fit for the organization where you’ve applied to work. All questions are important to the interview, even if there’s no right or wrong answer to them. Interviewers want to see who you are, how you’ll fit in with their team and if you’ll be an asset to their team. All of that is reflected in their questions.
While that may seem like a lot of pressure, don’t panic! If you prepare ahead of time, your interview will be a chance for you to highlight your successes and areas of competence. We’ll go through some sample interview questions here so that you can get a feel for what to expect from your interview and start preparing the best responses.
Sample Nursing Interview Questions and Answers
The following are some of the more common questions you’ll see in nursing interviews. We go over each question and give advice for how to answer. After reading through, take the time to think about and write out your answer to each one. Before your interview, look back at what you’ve written, tighten it up and practice your polished responses until you’ve got them down perfectly.
1. What drew you to the nursing profession?
This is a question you’ll almost certainly hear in a nursing interview. It’s easy to take the easy route when confronted with this question and offer up an answer like, “I love to help people.” That probably is why you got into nursing, but you can convey that sentiment a little more impactfully by relating a personal story here. “When my little brother fell off his bike, I cleaned up his skinned knee and bandaged it myself. That’s when I knew I wanted to do this,” would be an answer that gives more insight into who you are as a person than something more cookie-cutter.
2. Tell me about a time you caused a conflict without meaning to.
This is a bit like the “What’s your greatest weakness” question. Take it as an opportunity to be honest with the interviewer; they know you aren’t perfect, and they don’t expect you to be. They do, however, expect you to be able to own up to and learn from your mistakes. Use this question to share a time when you did.
3. Talk about a time when you stepped into a leadership role.
This is an excellent opportunity to show what you’re capable of. Relate a time when you stepped up, took the initiative and took charge of a situation. What happened? What did you do that resolved the situation? Make sure when giving your answer that you give proper credit to anyone else involved. Just like your interviewer knows no one is perfect, they also know no one is an island, and they’ll be looking for someone who can work well with a team.
4. How do you communicate with people who don’t know medical jargon? What’s an example of a time you explained medical terminology to someone?
Questions like these look at how you interact with people outside the medical system, whom you’ll regularly come in contact with. Your patients, their families and an assortment of others will need medical conditions explained to them in plain English. Do you take the time to make sure they understand what’s going on? Explain a time where you had to do this and what steps you took to make sure you were understood.
5. What can you bring to our team?
This question gives you the chance to highlight your strengths you might not have gotten the chance to discuss earlier in the interview. Again, concrete examples of how you’ve contributed to a team in the past will do a lot to help you here. Make sure they’re relevant, to the point and give the interviewer some insight into why you’re a good choice for their team now.
6. Tell me about a time when a patient or their family was dissatisfied with your care. How did you handle that?
Make sure you break down the situation in detail when explaining it, including what happened on both sides. Do not disparage the patient or their family; simply lay out the facts, how you handled the situation and what the outcome was. If it was a misunderstanding, state that and own the blame if the mistake was yours.
7. Describe a time where you were effective at educating a patient and their family.
A good way to break this down would be to relate a time you know the patient retained what you told them. What does that look like? How did you explain the patient’s situation to them so that it stuck?
8. Tell me about a time when you were able to anticipate potential problems with a patient and prevent a problem.
Explain step-by-step what you did in this situation. How did you realize the potential problem? What steps did you take to solve it, and what was the outcome?
9. Give an example of when a time when you helped a patient with decision-making. How did you educate and support the patient?
Use a story from your experience to describe when you were faced with a patient seeking your help to make a difficult decision. What was the situation, and what steps did you take to present the facts and support the patient? What was the outcome?
10. How would you handle an awkward situation with a work colleague, like working closely with someone you found difficult?
You can draw on any past professional experience here, but if you can draw from past nursing experience, that would be ideal. Lay out what the situation was, what may have made you uncomfortable and what you did to solve the problem. Again, avoid bad-mouthing anyone and stick to the facts.
STAR Method for Nursing Interview Questions
You may have noticed a pattern in the advice we’ve given you for each of these questions. The key to acing a nursing interview – or any interview, really – is to connect with the interviewer. Telling personal stories both reinforces your point and makes your responses more memorable. When formulating your anecdotes, there’s a certain format that usually works best. It’s called the STAR method, where STAR stands for:
Situation: Describe the specific instance where you used the skill in question.
Tasks: What did you have to do? What were you responsible for in this situation?
Action steps: What steps did you take to carry out that responsibility?
Results: What happened afterward, and how did you handle that?
Hanging your stories on that outline will relay all the relevant information while leaving you room to tell what makes you unique.
“Do You Have Any Questions for Me?”
Knowing what to say during the interview is half the battle, but an interviewer also wants to see if you’re curious about the place where you’re applying to work. Always have at least a couple of your own pertinent questions to ask at the end and keep an ear out for anything you might be curious about during the interview itself. A few good sample questions could be:
- How would you describe the culture here?
- What would a successful first year in this position look like to you?
- How will my performance be evaluated?
- How will a new person in this role be trained?
- Are there any reservations you still have about whether I’m fit for this role that I could sort out now?
Arm yourself with these questions and you’ll be going into your interview much better prepared to advance your career. You can open a world of new career options by continuing your education and earning an advanced degree. If you’ve been meaning to finish your BSN or want to improve your skills while maintaining your current position, consider earning an
RN to BSN online. When you graduate, you’ll have the skills to deliver high-quality patient care, making you an asset to any medical facility.
January 11 is
National Human Trafficking Day. Use this infographic to learn the facts and questions to help you identify potential victims. As nurses, we are on the front lines of health care and we have a responsibility to stay informed on this global issue so that we can recognize victims, collaborate with law enforcement and other professionals, and ensure safe and effective care.
Reference:
Blue Campaign. U.S. Department of Homeland Security. Retrieved from https://www.dhs.gov/blue-campaign
In this interview with Angelleen Peters Lewis, PhD, RN, FAAN, Vice President of Patient Care Services and Chief Nursing Officer at Barnes-Jewish Hospital in St. Louis, Missouri, we learn three key pieces of advice to help nurses prepare for board membership:
- Be confident.
- Take risks.
- Engage with colleagues and find mentors.
While there are many words of wisdom shared by Dr. Peters Lewis, my favorite has to be her statement that “The work of nursing happens in the moment but can have a lifetime impact.” Her dreams of giving nonjudgemental care stemmed from her own experiences as a young pregnant woman. The nurses she encountered cared not only for her physical needs, but also thought about her future and ensured coordination of care so her education would not be interrupted.
Listen to our full conversation
here and also learn Dr. Peters Lewis insights on 2020 as the Year of the Nurse & Midwife!
Dr. Peters Lewis received her doctorate in nursing from Boston College, where she graduated with distinction and received the Dorothy A. Jones Award for Scholarship, Service and Development. She earned a master’s degree in nursing from Northeastern University and earned her bachelor’s in nursing from Simmons College in Boston. Dr. Peters Lewis’s postdoctoral work included an executive nurse fellowship with the Robert Wood Johnson Foundation and the executive leadership development program at Harvard Business School.
The shelves are already empty, and those who need personal preventive equipment (PPE) the most will be feeling the effects. Fear and panic are causing members of the public to purchase and stockpile masks and other PPE supplies, and people are paying top dollar for them.
Late last week the World Health Organization (WHO) released Interim
Guidance for the Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19).
Based on the available evidence, the COVID-19 virus is transmitted between people through close contact and droplets, not by airborne transmission. The people most at risk of infection are those who are in close contact with a COVID-19 patient or who care for COVID-19 patients (WHO, February 27, 2020).
Even the U.S. Surgeon General is urging the public to
stop buying face masks. As clinicians, we know what lies ahead if there is a shortage of appropriate PPE, but let’s break down the facts so we can educate those around us. Here’s what we know:
- Coronavirus is spread through contact and droplets, not airborne transmission.
- Particulate respirators, including N95 masks, are indicated to protect against airborne transmission of infection.
- Proper use of N95 masks requires fit testing.
- The Centers for Disease Control and Prevention (CDC) recommends the use of N95 masks by health care workers at the “highest risk of contracting or experiencing complications of infection.”
- In addition to health care workers, the use of proper face masks is essential for those directly caring for someone in close settings, including homes, and immunocompromised persons.
- By depleting supplies, those directly caring for patients with infectious disease – including COVID-19 – will be at risk for infection themselves and can contribute to its spread.
- Wearing masks unnecessarily can contribute to a false sense of security, causing lapses in other measures, such as hand washing, which has shown time and time again to be the most effective method of decreasing infectious disease risk and spread.
You may also want to listen to the following podcast...
COVID-19: What Nurses Need to Know about Personal Protective Equipment (PPE)
Remember – and remind others – about the most important measures to prevent the spread of any infectious disease:
Yesterday (March 11, 2020), the
World Health Organization declared the coronavirus disease, also known as COVID-19, a pandemic. Let’s break down the terms for our own understanding and help keep our patients and the public informed.
Pandemic
Pandemic refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people (CDC, 2012). Most often, a pandemic results from a novel strain of influenza, and in general, evolves over time as influenza strains mutate. However, the 2009 H1N1 pandemic illustrated that a pandemic could occur suddenly, without warning (Rebman, 2020).
Epidemic (CDC, 2012)
Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. Epidemics may result from recent increases in amount or virulence of an agent, recent introduction into a setting where it has not been before, an enhanced mode of transmission, change in the susceptibility of the host response, and/or factors that increase host exposure or involve introduction through new portals of entry.
- An outbreak refers to an epidemic in a more limited geographic area.
- A cluster refers to an aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even if the expected number may not be known.
You may also want to listen to the following podcast...
COVID-19: Terminology and Preparedness
Social distancing (CDC, 2020a)
Social distancing refers to remaining out of congregate settings, avoiding mass gatherings, and maintaining a distance of about 6 feet or 2 meters from others.
Quarantine (Rebman, 2020)
Quarantine is the separation of people who are not yet symptomatic but have been exposed to a contagious person and are believed to be at risk of developing an infection. Exposed people are separated from others to rapidly identify onset of illness if it occurs and keep them away from susceptible people. Once a person in quarantine develops signs or symptoms of disease, it should be assumed that they are infected, and they would need to be
isolated. Quarantine also means excluding healthy people from areas that are known or suspected of being contaminated or housing infected patients. Quarantines can be voluntary or enforced. In general, the length of quarantine equals the length of the
incubation period for the disease to which the person was exposed.
Isolation (CDC, 2020a)
Isolation means the separation of a person or group of people known or reasonably believed to be infected with a communicable disease and potentially infectious from those who are not infected. Isolation may be voluntary or enforced by federal, state, or local public health order.
Transmission/spread (CDC, 2020b)
Transmission refers to the mechanism(s) by which an infectious agent spreads. At the time of this writing, we are still learning how COVID-19 spreads and to what extent we can expect. The current thought is that person to person transmission of COVID-19 is the main mode of transmission. People are thought to be most contagious when they are most symptomatic. Some spread might be possible before people show symptoms and it may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the main way the virus spreads.
Incubation period (CDC, 2020b)
The incubation period is the time from exposure to the virus until the first symptoms develop.
What about specific terminology you may be hearing related to the virus itself?
Viruses, and the diseases they cause, are named differently. Think: human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency virus (AIDS).
Here are the basics related to COVID-19 (WHO, 2020):
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
SARS-CoV-2 is the virus causing COVID-19. This virus name was determined by the International Committee on Taxonomy of Viruses (ICTV) on February 11, 2020 due to its genetic relation to the coronavirus responsible for the SARS outbreak of 2003.
Coronavirus disease (COVID-19)
On February 11, 2020, the World Health Organization named this disease coronavirus disease, or COVID-19, in the International Classification of Diseases (ICD).
Please stay up to date on this rapidly evolving situation using reputable sources, keep your patients and the public informed, be cautious and stay safe.
References:
Centers for Disease Control and Prevention (CDC). (2012). Principles of Epidemiology in Public Health Practice, Third Edition. Lesson 1: Introduction to Epidemiology. Retrieved from https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html
Centers for Disease Control and Prevention (CDC). (2020a). Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposures: Geographic Risk and Contacts of Laboratory-confirmed Cases. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html
Centers for Disease Control and Prevention (CDC). (2020b). How COVID-19 Spreads. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/about/transmission.html
Rebman, A. (2020). Infectious Disease Disasters: Bioterrorism, Emerging Infections, and Pandemics. Association for Professionals in Infection Control & Epidemiology (APIC) Text Online.
World Health Organization (2020). Naming the coronavirus disease (COVID-19) and the virus that causes it. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it
In December 2019, a novel acute respiratory virus called COVID-19 (SARS-CoV-2) created an epidemic in Wuhan, China and in a few short months grew to an unprecedented incidence of infection and mortality across the globe leading to a pandemic. Eighty percent of COVID-19 patients only experience mild symptoms and will recover within 2 weeks. The other 20% of those effected are not as lucky; they become critically ill with acute respiratory failure, acute respiratory distress syndrome and shock.
The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) and other health organizations around the world have developed recommendations for screening, infection control and diagnosis in the noncritically ill population; recommendations for critically ill patients has been missing.
In response to this need, the Surviving Sepsis Campaign partnered with leading experts from 12 countries across the globe (many who have had direct experience caring for these patients), to develop a practice guideline on managing critically ill patients with COVID-19. The culmination of their work is called: “Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019.”
Their work addresses five areas including: infection control, laboratory diagnosis, hemodynamic support, ventilatory support and COVID-19 therapy. The guidelines have been accepted and will be published in
Critical Care Medicine, the journal of the Society of Critical Care Medicine and
Intensive Care Medicine, the journal of the European Society of Intensive Care Medicine.
For those of us who practice in critical care, these guidelines are instrumental as we face an unprecedented onslaught of patients requiring our services and expertise. The guidelines offer recommendations on wearing the correct type of mask, acute resuscitation using balanced/buffered crystalloids, oxygenation and ventilation, and optimizing hemodynamics.
While there is no cure for COVID-19 at this time, these guidelines offer us a start at having evidence-based, best practice recommendations to inform our clinical decision making. Throughout history, healthcare professionals have been faced with situations where they need to combine their expertise with a spirit of inquiry to determine which interventions have the best efficacy and outcomes. We will learn together as a united, global healthcare team, how best to care for these patients.
Full guideline:
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)
I have been a nurse since the mid 1980’s and during that time I have witnessed a variety of staffing and onboarding models. In the days of nursing shortages, we were using a team nursing approach where one RN directed the team of LPNs and certified nursing assistants to care for 10 – and sometimes more – patients. As the nursing shortage eased, we went to a primary care model where one RN cared for 5-6 patients on a medical/surgical unit and if the nurse was lucky, there would be a CNA to help with activities of daily living, vital signs, intake and output, and blood glucose monitoring. Often the CNA was shared with other RNs. In long-term care, the team model still exists but in this case the RN is responsible for many more patients.
Today we are in a crisis due to the coronavirus, or COVID-19. We are seeing a surge of patients that are overwhelming our healthcare system, and in many of the hardest hit areas, hospitals have been granted permission to increase their bed capacity. While that sounds wonderful to the public, it is a nightmare for hospital administrators and those of us on the frontline of care.
We need to ask ourselves the question, who is going to care for those patients?
The nursing shortage –we have talked about it coming back for the past 10 years – is now front and center. Not only are there not enough nurses to care for patients due to the surge beds we’ve added and the increased number of patients, but also nurses are getting sick from COVID-19. And let’s be clear, this shortage not only effects nursing; it is also affecting physicians, nurse practitioners, physician assistants and other healthcare providers and support staff in the hospital.
You may also want to listen to the following podcast...
COVID-19: Alternative Staffing and Onboarding Models
The healthcare system needs to find a different way to care for these patients and staff these beds. So, what can our healthcare systems do to increase staff quickly?
1. Utilize existing staff.
First, look at the specialties within your hospital and utilize the staff you have. Many hospitals have cancelled elective surgeries so there will be nurses and CRNAs available to care for the increased number of patients. CRNAs and many PACU nurses have extensive critical care training; these individuals can work in critical care units after they’ve had a quick orientation or onboarding to those units. If you have nurse practitioners or physician assistants that work in specialties that are not admitting a lot of patients, such as cardiothoracic (CT) surgery, utilize those individuals to supplement your in-house hospitalist and intensivist teams.
2. Reach out to retired nurses and nurses in other specialties.
Bring in nurses who are retired or who are working in specialty practices that are not seeing a lot of patients. These nurses can be quickly onboarded to supplement your medical/surgical nurses. Let’s not forget LPNs and CNAs who can also deliver basic care to the patients.
3. Use seasoned med/surg nurses to work in stepdown units.
There is no reason a med/surg nurse can’t work alongside a stepdown nurse in a team model; the med/surg nurse can take care of the basic nursing needs while the stepdown nurse can focus on managing the patient’s more critical needs. Some hospitals may be forced to use experienced med/surg nurses in critical care to supplement the critical care nurses. It is crucial to remember the importance of competency in these situations. Focus on the skills the med/surg nurses can do and reserve the critical care skills for the critical care nurses.
4. Implement an “onboarding essentials” program.
We are in a crisis situation and don’t have time for a long, in-depth orientation program. Give the new team members the information they need to care for these patients alongside the more experienced nurses. Focus on the ‘need to know’ and leave the ‘nice to know’ for later. Have the professional development team work with vendors to create bundles of procedures and quick learning activities for each area that highlight the most common diagnoses and the core procedures the nurse will need to know, such as working the IV pumps, performing an ECG, inserting a urinary catheter or nasogastric tube in a med/surg unit. In critical care, focus on basic skills such as recognizing lethal arrhythmias such as asystole, ventricular tachycardia and ventricular fibrillation; putting on the cardiac monitoring electrodes correctly; and knowing the basics of ventilator management. The professional development team or staff educators are more important than ever in this situation because they are responsible for the rapid onboarding of nurses to new and different units and they can insure the nurses have the skills to deliver safe and effective care.
5. Implement the team model approach to care.
Have supplemental staff report directly to an experienced med/surg or critical care nurse. This will allow the experienced nurses in each area oversight of more patients and they will have sufficient nurse support to take care of the basic nursing needs of the patient. Each unit will have to determine how many patients the experienced nurse/team leader can handle based on the acuity and number of patients. This approach can also work with the medical service as well.
We all recognize this is a crisis and it will greatly tax our already stressed healthcare system. However, if we work together to find innovative ways to manage the care of patients and work as a team, we have a chance to make this situation healthcare’s finest hour.
You are called to a rapid response or a code blue and the patient is in isolation for COVID-19. It takes you several minutes to don your personal protective equipment, delaying life-saving interventions by several minutes.
You go in and out of one isolation room after another donning and doffing the PPE and by the end of the shift you are exhausted and wonder if you can keep going.
A patient with COVID-19 is dying due to acute respiratory distress syndrome because there are no ventilators available. Another patient is on a ventilator and declining despite proning the patient and he is not eligible for ECMO. You know this patient will die.
Patients are dying alone because visitors are not allowed, and you are simply too busy with other patients to come and hold their hand and tell them you are there.
During this crisis, we are faced with ethical and moral dilemmas many of us have never encountered before. Perhaps being a nurse in war time is similar; but for those of us who have not served in that capacity, all of this is new and is shaking us to the core. We are a caring profession and our instinct is to run towards adversity not away from it. That’s what we are doing now. But, we have always said we would be there to care for the sick, hold their hand, just be present when they needed us, and above all, never let a patient die alone. It presents a dilemma for us when we can’t be the type of nurse we were just a few short months ago.
The reality is this, we have to protect ourselves first so we can help others. So, just like the announcement says before every flight, put your own mask on before helping others, we have to take the time to put on PPE before we enter a patient’s room if they are in isolation. Taking those few minutes to do the right thing is imperative if we are going to be healthy enough to care for the many patients who need our care. We cannot allow ourselves to be a casualty because of not taking the time to protect ourselves first.
You may also want to listen to the following podcast...
Facing Moral & Ethical Dilemmas During COVID-19
Caring for so many patients is overwhelming. We need to think about each patient as an individual and give what we can of ourselves for that one patient when we are with them. It is not about what we can’t do, it is about what we can do with the resources we have available. Doing our best for each individual patient is all we can do.
For front line caregivers, be vigilant in recognizing when your patient is heading for trouble. You have a sixth sense; use it. It is always better to address a situation before it becomes a rapid response or a code blue situation. Performing procedures and interventions in a nonemergency situation is always preferable.
As healthcare professionals, we haven’t seen a test of our healthcare system of this magnitude since the Spanish Flu pandemic of 1918. This is a learning experience for all of us and one that will test us to our very core. We are facing ethical and moral dilemmas, but we carry on because we know we can’t save everyone, but we will save as many as we can. We need to do the best we can for our patients, one patient at a time.
The COVID-19 pandemic is an opportunity for nursing to show what were made of – we are a caring profession that rises above challenges to provide care to those in need. We recognize the need to protect ourselves first so we can provide care to the masses. When we are with our patients, we will focus on one patient at a time and think about what we can do for them – not what we can’t.
Acute respiratory distress syndrome (ARDS) is a life-threatening disease, characterized by acute onset of hypoxia and pulmonary infiltrates, and incited by conditions such as sepsis, pneumonia, trauma, burns, pancreatitis and blood transfusion. ARDS causes diffuse lung inflammation which leads to increased pulmonary vascular permeability, pulmonary edema, and alveolar epithelial injury.
The diagnosis of ARDS is made based on the following criteria:
- acute onset,
- bilateral lung infiltrates of a non-cardiac origin on chest x-ray or tomographic (CT) scan, and
- moderate to severe impairment of oxygenation.
In the absence of drug therapy to treat or prevent ARDS, the treatment strategy consists of positive pressure ventilation and supportive care. Severe ARDS carries a mortality rate of 45% (Ranieri et al., 2012).
The severity of the ARDS is defined by the degree of hypoxemia, which is calculated as the ratio of arterial oxygen tension to fraction of inspired oxygen (PaO
2/FiO
2). ARDS can be mild, moderate or severe as clarified by the Berlin definition of ARDS, outlined in the table below (Ranieri et al., 2012).
Berlin Definition of ARDS (Ranieri et al., 2012) |
ARDS Severity |
PaO2/FiO2 |
Mild |
200 - 300 |
Moderate |
100 - 199 |
Severe |
< 100 |
*on positive end expiratory pressure (PEEP) ≥ 5 cm H2O |
Determining the PaO
2/FiO
2 requires arterial blood gas (ABG) analysis. To calculate the PaO
2/FiO
2 ratio, the PaO
2 is measured in mmHg and the FiO
2 is expressed as a decimal between 0.21 and 1. As an example, if a patient has a PaO
2 of 100 mmHg while receiving 80 percent oxygen, then the PaO
2/FiO
2 ratio is 125 mmHg (ie, 100 mmHg/0.8).
The PaO
2/FiO
2 ratio is a valuable clinical measure of the patient's respiratory status while receiving supplemental oxygen. It enables bedside clinicians to monitor the degree of hypoxemia, quickly detect early progression of respiratory failure, and intensify treatment. For example, proning the patient may improve oxygenation when the ARDS patient progresses to from mild to moderate ARDS. Treatment of severe ARDS might include neuromuscular blockade to reduce oxygen consumption, extracorporeal membrane oxygenation (ECMO), or inhaled nitric oxide (Ramanathan et al., 2020).
References:
ARDS Definition Task Force, Ranieri V., Rubenfeld G., Thompson B., Ferguson N., Caldwell E., Fan, E., Camporota, L., & Slutsky A. (2012). Acute respiratory distress syndrome: the Berlin Definition. JAMA,.307(23). doi: 10.1001/jama.2012.5669.
Matthay, M., Ware, L., & Zimmerman G. (2012). The acute respiratory distress syndrome. The Journal of Clinical Investigation, 22. doi: 10.1172/JCI60331
Ramanathan, K., Antognini, D., Combes, A., Paden, M., Zakhary, B., Ogino, M., MacLaren, G., Brodie, D., & Shekar, K. (2020). Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. The Lancet Respiratory Medicine. doi: https://doi.org/10.1016/S2213-2600(20)30121-1
Researchers, retirees, and others who’ve been away from clinical practice now back in scrubs and caring for patients…
Dermatologists, gynecologists, orthopedists and others specialty clinicians relocating to COVID-19 testing sites, emergency departments, and intensive care units…
Educators and students now teaching & learning nursing – including clinical skills – virtually…
Have you heard or seen these occurrences in your setting? Maybe you are now taking on roles and responsibilities that are outside your primary area of practice.
First and foremost, thank you.
Secondly, here are resources that you may find helpful for yourself or to share with those you know.
Returning to Clinical Practice
- Rapid Onboarding from Lippincott Procedures
60-day free institutional access to 1,700+ Lippincott Procedures, including a new Rapid Onboarding discipline designed to help healthcare organizations quickly onboard staff to safely care for patients with COVID-19
Brushing Up on Critical Care Skills
For Educators and Students
*We will update this list as more resources come to our attention. Please leave a comment if you know of others to add to these lists. Thank you!
These are scary and uncertain times that COVID-19 is creating. We all have a story to tell – who we know, how we are being impacted, and how our lives are changing. Certain patient populations are facing unique experiences and challenges. The evidence on prenatal, intrapartum, and postpartum risk and transmission is limited, however, there is some data available and there are some recommendations being provided by the
Centers for Disease Control and Prevention (CDC) and professional organizations, such as
The American College of Obstetricians & Gynecologists (ACOG) and the
Society for Maternal-Fetal Medicine (SMFM).
Special considerations for care of pregnant women
The situation is rapidly changing. We do know that in pregnancy, immunologic and physiologic changes do occur which could make pregnant women more susceptible to viral respiratory infections, including COVID-19 (CDC, 2020). However, based on limited evidence, pregnant women don’t appear to be at increased risk for severe disease (ACOG, 2020).
Alternate care delivery during pregnancy, labor, and postpartum may be necessary in some settings.
“ACOG encourages local facilities and systems, with input from their obstetric care professionals, to develop innovative protocols that meet the health care needs of their patients while considering CDC guidance, guidance from local and state health departments, community spread, health care personnel availability, geography, access to readily available local resources, and coordination with other centers.”
Prenatal care
Changes to prenatal care delivery may be necessary to limit the risk of exposure to the virus for the mother and the fetus or infant. ACOG (2020) recognizes the possible need for these temporary modifications:
- Spacing out appointments
- Alternate or reduced prenatal care schedules
- Grouping components of care together to reduce the number of in-person visits
- Phone and telehealth screenings before in-person visits to assess COVID-19 exposure or symptoms
- Prudent use of ultrasonography and avoidance of elective ultrasound examinations
- Postponement or cancellation of some testing or examinations if the risk of exposure and infection within the community outweighs the benefit of testing
If a pregnant woman is infected with COVID-19, consider the following recommendations (SMFM, 2020):
- Detailed mid-trimester anatomy ultrasound following first-trimester maternal infection
- Ultrasound for fetal growth in the third trimester for women who have experienced COVID-19 later in pregnancy
Regarding steroid use, the recommendation is to avoid corticosteroids in patients with COVID-19 due to prolonged viral replication period observed in MERS-CoV patients. However, in pregnant patients with suspected or confirmed COVID-19, the recommendations for antenatal corticosteroid use for fetal maturation are as follows (ACOG, 2020):
- Between 24 0/7 weeks and 33 6/7 weeks of gestation and at risk of preterm birth within 7 days : antenatal corticosteroids should continue to be offered as recommended.
- Between 34 0/7 weeks and 36 6/7 weeks of gestation and at risk of preterm birth within 7 days: antenatal corticosteroids should not be offered.
Modifications may be individualized, weighing the neonatal benefits with the risks of potential harm to the pregnant patient.
Group B streptococcus (GBS) screening should occur as indicated during the usual recommended time period, 36 0/7–37 6/7 weeks of gestation, however consideration may be given to grouping other components of care at that time to reduce the number of in-person prenatal visits needed. Or, if self-testing is available, patients can self-collect after proper patient education is provided (ACOG, 2020).
Additional considerations during the prenatal period include offering mental health or social work services or referrals, and anticipatory counseling related to communication with team, changes to labor and postpartum plans, visitation, and postpartum contraception.
You may also want to listen to the following podcast...
Intrapartum Care
Hospitals and birth centers that are both licensed and accredited remain safe places to give birth in the United States (ACOG, 2020). When a pregnant patient with suspected or confirmed COVID-19 is admitted and birth is anticipated, the obstetric, pediatric or family medicine, and anesthesia teams should be notified. Highlights from the ACOG recommendations include:
- It is reasonable to attempt to postpone delivery (if no other medical indications arise) for a woman with suspected or confirmed COVID-19 in the third trimester until a negative testing result is obtained or quarantine status is lifted.
- Cesarean delivery should therefore be based on obstetric indications and not COVID-19 status alone.
- Decisions related to labor inductions and cesarean deliveries should be made at the local and systems level based on health care personnel availability, geography, access to readily available local resources, and coordination with other centers.
- Delayed cord clamping is appropriate in the setting of appropriate clinician personal protective equipment.
Postpartum Care
Recommendations for the postpartum period include (ACOG, 2020):
- When mother and infant are healthy, it may be appropriate to expedite discharge. Decisions regarding early discharge will require input from the pediatric team and home telehealth visits for the mother and infant should be considered.
Similar to during the prenatal period, additional considerations include offering mental health or social work services or referrals, and anticipatory counseling related to communication with team, changes to postpartum plans, visitation, and postpartum contraception.
Pregnant healthcare workers
At the present time, there are no additional restrictions on pregnant health care workers because of COVID-19 alone. As for all health care providers, strict adherence to the
CDC’s Interim Infection Prevention and Control Recommendations for Patients with Confirmed 2019 Novel Coronavirus (2019-nCoV) or Persons Under Investigation(PUI) for 2019-nCoV in Healthcare Settings should be maintained.
If staffing permits, facilities may want to consider limiting exposure of pregnant health care personnel to patients with confirmed or suspected COVID-19 infection, especially during aerosol-generating procedures (CDC, 2020). If exposure to patients with suspected or confirmed COVID-19 occurs, CDC risk assessment and infection control guidelines should be followed.
Vertical transmission
Vertical transmission is transmission of a pathogen from a mother to her fetus or newborn before, during, or immediately after delivery (CDC, 2020). Some pregnant women with COVID-19 have had preterm births, but it is not clear whether the preterm births were because of COVID-19; it’s also not clear if COVID-19 can pass to a fetus during labor and delivery (ACOG, 2020).
Recent studies have shown that there were no findings suggestive of COVID-19 in neonates born to affected mothers, and amniotic fluid, cord blood, and breast milk, were negative for SARS-CoV-2 (Chen et al., 2020). However, in one cohort, three of 33 infants (9%) presented with early-onset SARS-CoV-2 infection which resolved by days 6-7 (Zeng et al., 2020). In these cases, the likely sources of SARS-CoV-2 in the neonates’ upper respiratory tracts or anuses were maternal in origin, however the vertical maternal-fetal transmission cannot be ruled out (Zeng et al., 2020). Therefore, screening of mothers and close monitoring of neonates at risk are essential.
ACOG (2020) also provides the following recommendations for infants born to mothers with confirmed COVID-19, based on limited data and considerations for other respiratory viruses, such as influenza, SARS-CoV, and MERS-CoV:
Breastfeeding
In limited case series reported to date, no evidence of virus has been found in the breast milk of women with COVID-19 and no information is available on the transmission of SARS-CoV-2 through breast milk. Antibodies against SARS-CoV were detected in at least one sample (CDC, 2020).
There are rare exceptions when breastfeeding or feeding expressed breast milk is not recommended and the decisions on breastfeeding should be made by the mother in coordination with her family and health care practitioners. At present, the primary concern is whether an infected mother can transmit the virus through respiratory droplets during the period of breastfeeding, not whether the virus can be transmitted through breastmilk (ACOG, 2020).
References:
The American College of Obstetricians and Gynecologists. (2020). Novel Coronavirus 2019 (COVID-19) Practice Advisory. Retrieved from https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/03/novel-coronavirus-2019
Centers for Disease Control and Prevention (CDC). (2020). Information for Healthcare Providers: COVID-19 and Pregnant Women. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/pregnant-women-faq.html
Chen, H., Guo, J., Wang, C., Luo, F., Yu, X., Zhang, W., Li, J.,…Zhang, Y. (2020). Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet, 395 (10226). doi: https://doi.org/10.1016/S0140-6736(20)30360-3
Society for Maternal-Fetal Medicine. (2020). Coronavirus (COVID-19). Retrieved from https://www.smfm.org/covid19
Zeng, L., Xia, S., Yuan, W., Yan, K., Xiao, F., Shao, J., & Zhou, W. (2020). Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatrics. doi: 10.1001/jamapediatrics.2020.0878
More Resources
Why did I become a nurse?
The short answer
I wanted to help people and I like to take care of people.
The long answer
The biggest influence was my grandmother who was a Cadet Nurse in World War II. I always admired her knowledge and the way she cared for me when I was sick, as well as my aunt (her daughter) who had Down Syndrome and multiple medical issues. She was always close with the women she went to school with, always maintained her license (for decades after she stopped working), and always bought the newest edition of the Merck Manual (that I would look through for hours when I was little). She was the first example, for me, that being a nurse means becoming a nurse; it is who you are. The biggest honor I received was being able to take care of her when she was on hospice, and also being the one that held her hand at the end. Her nursing pin and nursing school class ring sit in my jewelry box and her books from nursing school sit on display in my dining room hutch. I am always reminded of her and her influence she had on my career.
About 18 months into my first nursing job, when the fear of making a mistake was replaced by confidence and critical thinking, I began to appreciate how creativity in nursing can enhance the patient experience as well as job satisfaction.
In this COVID-19 pandemic, examples of creativity abound, borne of both limited resources and severe restrictions on elective patient services and inpatient family visitation. Personal protective equipment (PPE) shortages are forcing clinical leaders to look beyond usual supply chains, reaching out to the community for donations, and accepting 3D-printed face shields and hand-sewn masks. Nurses are finding novel ways of helping patients connect with their families through video call services, printing emailed photos to hang at the bedside, and playing favorite music through streaming platforms. Existing technology is being utilized creatively to facilitate staff meetings and telemedicine visits. The cancellation of elective surgery is leading to hundreds of idle operating room employees. Instead of staff furloughs, administrators are creating impromptu training and mentorship opportunities to facilitate use of perioperative nurses in busy hospital units.
To be creative is to combine skills, experiences, and ideas to improve existing routines or technologies. It can lead to innovation in the tools of the trade, e.g. monitoring devices, specialty beds, lifts and wound dressings. Or it can lead to improved efficiency in the delivery of care or greater effectiveness in patient education. Creativity is needed when there are limited resources, requiring clinical staff to make-do or improvise. In a global society, nurses encounter patients from different races, cultures, socioeconomic backgrounds, levels of education, and religions. Experienced nurses account for these differences almost subconsciously, adjusting their approach to nursing tasks according to individual needs.
Nurses are busier than ever, caring for sicker patients and tethered to impersonal electronic medical record systems which demand screen after screen of documentation. Creativity can offset some of the stress of these responsibilities by improving our disposition and humanizing our interactions with patients, families, and colleagues. It does not require expensive resources. It is authentic and enables us to share our personalities. Pediatric nurses are more likely to employ playful strategies to promote patient compliance and well-being, but adults appreciate this too.
I remember taking care of 2 female patients in the same semi-private room who were exhausted from having to urinate every 2 hours. One was receiving diuretics and the other was being treated for nephrogenic diabetes insipidus. They were both apologetic about having to call me for assistance to the commode so frequently. At the end of my shift, I fashioned a blue ribbon award out of a chux pad, taped it to a (clean) urinal, and presented it to the patient with the most urine output for the shift. We all had a good laugh and they stopped feeling bad for a clinical situation over which they had no control.
Nursing involves more than medications, data, hygiene and protocols. It requires a thoughtful approach to each patient’s needs and a willingness to think outside the box to accomplish good outcomes. I find that my job satisfaction is tied with opportunities to apply creativity into my clinical practice. Although it’s never been directly measured, I’d bet that patient satisfaction also improves when nurses use creativity in delivering care.
Growing up, I wasn’t certain that nursing was my calling. My mother was a nurse, an excellent, well-respected surgical intensive care nurse. I remember her leaving before 6 am for work and coming home at 8 pm, exhausted after a long 12-hour shift. I listened with wide eyes as she told stories of running codes on fresh post-operative patients, conflicts with physicians as she advocated for specific treatments and even resuscitating a patient’s family member in the hospital lobby. While she loved her work, it was physically and emotionally demanding so she often advised me not to follow in her footsteps. And frankly, I didn’t want to be another cliché as Filipinos are practically synonymous with the profession of nursing - it’s in our blood.
When I think about my own journey in nursing, I cannot ignore the history of my culture. It is strongly rooted in the colonization of the Philippines by the United States dating back to 1898. With the Treaty of Paris ending the Spanish-American War, Spain sold the Philippines to the U.S. for $20 million. The U.S. Army then started to enlist Filipinos to work as Volunteer Auxiliary and Contract Nurses. At the turn of the century, through the Pensionado Act of 1903, Filipino student scholars were allowed to come to the U.S. for higher education, many of whom were nurses. When these nurses returned to the Philippines, they set up 17 nursing schools, taught in English, utilizing American text books and curriculums (Jurado & Saria, 2018). American-based training gave Filipino nurses an advantage and they were actively recruited due to a nursing shortage following World War II (Brice, 2019). The Exchange Visitor Program of 1948 and the 1965 amendments to the U.S. immigration laws opened the doors again to Filipino nurses and other professionals. These programs and policies provided an attractive opportunity for Filipinos, as the earning potential in the U.S. was and still is 20 times greater than salaries they could earn in the Philippines. The Filipino people are well-known for their work ethic, loyalty, compassion and dedication to caring for the sick and elderly. They were highly motivated to improve their standard of living while also supporting their families back home. An influx of immigrants filled the vacancies in nursing often at a lower cost for hospitals. Today, the number of nursing schools in the Philippines has exceeded 400 and Filipinos continue to make up the majority of foreign-trained nurses in the U.S. (Jurado & Saria, 2018).
Would this be my destiny? With a natural proclivity toward science and a genuine desire to help others, I went on to study nursing in college. I ultimately followed in my mother’s footsteps and landed my first job in critical care rotating through surgical and medical intensive care units. I was passionate about analyzing patient data and managing complex medical conditions. Over the years my curiosity led me down a variety of professional paths. I was fortunate to have worked on information systems implementation projects as well as pharmaceutical vaccine research after completing my Master’s in Healthcare and Nursing Administration. With the technology boom in the early 2000’s, I worked for a start-up creating simulation training platforms for medical devices and today I am a clinical editor for NursingCenter.com. My career has taken many twists and turns but at the core remains the legacy of my mother and the tradition of the Filipino nurses that came before me.
References:
Brice, A. (2019). Why are there so many Filipino nurses in the U.S.? Retrieved from https://news.berkeley.edu/2019/05/28/filipino-nurses-in-the-us-podcast/
Jurado, L.M. & Saria, M.G. (2018). Filipino nurses in the United States. Nursing Management, 49(3): 36-41. doi: 10.1097/01.NUMA.0000530423.71453.58
Did I always want to be a nurse? No. First I wanted to be a Rockette. Many years of dancing school and several trips to New York City planted the seed of being a dancer at a young age. But as that childhood dream faded, I realized that my passion for science, especially biology, would turn my dreams in another direction.
As soon as I turned 14, I started volunteering at a local hospital, and when college application time came around, nursing school was high on my list. A visit from a recruiter sealed that decision. One meeting and I was convinced that nursing was the only profession for me. I was lucky to go to my dream school and be taught and mentored by excellent professors and nurses. The plan was to finish my degree and specialize in pediatrics or labor and delivery.
Much to my surprise, it was my critical care clinical rotation, not maternal-child, that called to me. During my junior year, I got a job as a nursing assistant in the Medical Intensive Care Unit (MICU) at the university hospital. After completing my BSN program, I began working as an RN in that same unit. As a new grad in the ICU, I had a lot to learn. The nurses, many who knew and guided me as a student, taught me so much about caring for the critically ill, collaborating with others, and advocating for patients. As I expanded my role to charge nurse, preceptor, and clinical leader, I thought that the MICU would be my home for the duration of my career.
However, after a few years, I decided to return to school and further my education. I considered a critical care nurse practitioner (NP) program, but ultimately decided to study women’s health. It took me about 4 years to get my master’s degree – working weekends while attending classes and clinicals during the week. Caring for women, mostly healthy and many pregnant, in an outpatient setting was a very different experience than caring for critically ill patients in the hospital.
As I was searching for a job as an NP, I happened to see an ad for a position in a local nursing magazine, and although I wasn’t entirely sure what a
clinical editor was, I decided to apply for the job and find out. What a change I was in for! I was in an office setting and wearing real clothes. I spent my first 6 months in a film studio helping to produce nursing videos. If anyone had ever said that as a nurse, I could someday be writing scripts on ECGs and I.V. insertion, recruiting talent, and spending time in an edit suite, I would not have believed them! I went on to work on book and web products, learning so much while still using my clinical knowledge and experience.
Around this time, I was starting my family. Pregnant with twins, I was working full time as a clinical editor and continuing part-time as an RN in the MICU. I had taken advantage of the hospital’s tuition benefit for graduate school and I was committed to working there to pay off my education. When my twin sons were born 11 weeks early, everything came to a halt. I was fortunate to be able to stop working to focus on being a mom. However, switching gears to be a mom to critically ill babies was not easy. Ventilators, vasoactive medications, and all that I was used to as an adult critical care nurse, were very different in the neonatal ICU as a mom.
Fortunately, my boys overcame many obstacles and as they grew and developed, I was able to get back to work, albeit from home and very part time. Again, I was so fortunate that a degree in nursing offers so many flexible opportunities. I began to freelance as a clinical editor for Lippincott NursingCenter, and as my boys, and their younger sister, have grown, so has my role as a clinical editor, which I continue in still today.
The story doesn’t end there, however. Itching to get back to a clinical setting, my eyes were open for new opportunities in nursing. At one “Hospitality Sunday” at our church, a nurse was at a table with flyers for the “Nurses Center.” I learned about this nurse- and NP-run clinic which serves our community and decided to get involved. Again, this new opportunity taught me so much about being a nurse and making a difference, this time in my own community where I didn’t know how great of a need there was for care and education to the uninsured and underinsured. At this time, the clinic is closed, but the directors are keeping in touch with patients via telehealth as needed. I look forward to the day when we are back up and running!
I’m not sure what is next for me…but I do believe I will be back in the hospital at some point. The COVID-19 pandemic has inspired me and triggered my inner critical care nurse. I’ll have to keep you posted!
That’s my story. What’s yours?
Six months ago, our view about healthcare and community in this country was very different. Nurses recognized the importance of addressing the social determinants of health as part of the admission process and we would dutifully ask questions about occupation, marital status, where they lived, who they lived with, if they had steps to navigate, if they had a primary care provider, and if they felt safe in their current arrangement. Sometimes nurses would ask about the patient’s ability to afford food and medications. Hospitals were beginning to realize the importance of caring for the community as well as individual patients because addressing chronic conditions in primary care or clinics was much more economical then addressing them as part of an acute care admission; keeping acute care for emergencies and for elective procedures, which were revenue drivers.
Fast forward to May 2020; we are in the middle of a COVID-19 pandemic. Many people have been furloughed or completely lost their jobs. With their jobs went their health insurance if they were lucky to have it in the first place. Lack of childcare is preventing people from working and social distancing adds to this dilemma, and now parents have to be teachers to their children as well. Basic food and supplies are at a premium in many areas and the costs have been inflated due to the supply/demand chain. While the restrictions are necessary to limit viral spread, the impact to the community cannot be underestimated.
Community is defined as a group of people who share something in common, have a purpose and work together to plan and build for the future. Healthcare organizations are key contributors to successful communities and history has shown that when healthcare organizations and jobs leave a community, the community will no longer thrive. COVID-19 has changed the landscape of our communities.
Healthcare systems are integral in community engagement. We need to ask our patients about economic, food, housing, and neighborhood security as well as healthcare access. Healthcare systems have been on the frontline screening patients for COVID and we must continue screening for other conditions as well. Assisting the community with the establishment of food banks, healthcare and mental health clinics will be paramount to getting communities back on firm footing.
For many years, nurses have been the most trusted profession; our ability to gain trust is because we earn it. Nurses are the one’s venturing out into the community to assess needs. We need to take a more in-depth look at the social determinants of health and assist our healthcare institutions with defining where they can make the most difference.
The World Health Organization designated 2020 as the “Year of the Nurse and Midwife,” honoring the 200
th birth anniversary of Florence Nightingale. Nurses have always served on the frontline of health crises, natural disasters, and epidemics, and today it’s no different. Comprised of dedicated and compassionate individuals, nurses are present at birth and in death, in moments of great joy and in times of unspeakable sorrow – they are the backbone of the health care system. Let’s take a look at the latest U.S. data and statistics of a profession that has come a very long way over the last two centuries.
Demographics
With approximately 4 million registered nurses (RNs) in the United States, nursing is our country’s largest healthcare profession (American Nurses Association [ANA], 2020). Results from a 2018 national survey conducted by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) (2019) provided basic demographic data from over 50,000 registered nurse (RN) respondents:
- Average age of RNs is 48-50, nearly half of all nurses are over the age of 50
- Growing number of male RNs – 9.6% in 2018
- 26.7% of RN respondents were minorities.
- The RN population in the U.S. is comprised of the following racial backgrounds:
- 73.3% White/Caucasian
- 7.8% African American
- 5.2% Asian
- 10.2% Hispanic
- 0.3% American Indian/Alaskan Native
- 0.6% Native Hawaiian/Pacific Islander
- 1.7% Two or more races
- 1.0% Other
- Approximately 5% of RNs in the U.S. completed their training in other countries and nearly half were from the Philippines, followed by Canada and India.
Education (Campaign for Action, 2020)
The Campaign for Action (2020), an organization co-founded by the Robert Wood Johnson Foundation and the American Association of Retired Persons (AARP) has been tracking the progress of efforts to implement recommendations in the 2010 Institute of Medicine’s (IOM)
The Future of Nursing: Leading Change, Advancing Health. One IOM goal focused on increasing the proportion of nurses with baccalaureate degrees to 80% by 2020. As of 2018, the percentage of nurses that have graduated with a Bachelor of Science degree in nursing (BSN)
or higher is about 57% (Campaign for Action, 2020). A recent American Association of Colleges of Nursing (AACN) report found nursing schools could not accept over 75,000 qualified applicants for baccalaureate and graduate nursing programs in 2018 due to inadequate faculty, clinical sites, classroom space, clinical preceptors and budgets (AACN, 2019).
Approximately 18% of nurses hold a graduate level degree such as a Master of Science in Nursing (MSN). Another IOM recommendation involved doubling the number of nurses with a doctorate by 2020. This target has been met as the number of nurses with a doctoral degree increased from just over 10,000 in 2010 to over 33,000 in 2018, roughly 1% of the nursing workforce (Campaign for Action, 2020).
Salary
Salaries for nurses vary based on level of education, experience, role and geographic location. The demand for RNs will continue to increase. Nurses with a baccalaureate degree will be in higher demand than those without a BSN. Employers may also prefer nurses with work experience or certification in a specialty area. Data from the U.S. Bureau of Labor and Statistics (2019a) found:
- RN median pay = $73,300/year ($35.24/hour)
- Typical entry-level education: Bachelor’s degree
- Number of jobs (2018) = 3,059,800
- Job outlook: growth rate projection between 2018-2028 = 12% (average for all occupations is 5%)
- Employment change: projected numeric change = +371,500 over 10 years (between 2018 – 2028)
- This projected job growth, while positive, will not be enough to offset the projected job openings of approximately 210,400 RNs each year, on average, over the next decade due to retirement or change of occupation.
Employment
Where do nurses work? Nurses provide healthcare services in a variety of settings. The U.S. Bureau of Labor and Statistics (2019a) breaks down these workplaces into the following categories:
- Hospitals (state, local, private): 60%
- Ambulatory healthcare services (including physicians’ offices, home healthcare, and outpatient centers): 18%
- Nursing and residential care facilities: 7%
- Government: 5%
- Educational services (state, local, private): 3%
However, there are a significant number of employment opportunities for nurses beyond these environments. The medical knowledge, clinical skills, time management and problem-solving abilities of nurses can be applied to a variety of fields. Examples include:
- Administration and management positions – another IOM goal was the advancement of nurses as Board Members for corporations and institutions and to increase that number to 10,000. As of January 28, 2020, the number of nurses on boards was 7,100 (Campaign for Action, 2020).
- Certified registered nurse anesthetists (CRNAs) administer anesthesia and other medications during surgical, obstetric and other procedures.
- Forensic nurses assist with death or crime investigations.
- Informatics nurse specialists support selecting and implementing technology in an institution.
- Legal nurse consultants interpret medical terminology for legal professionals, serve as expert witnesses during legal trials and consult with insurance companies and law enforcement agencies.
- Mental health nurses may work in addiction treatment clinics and psychiatric facilities.
- Nurse educators are often employed within hospitals to provide clinical staff training or in private and public academic institutions to educate future nurses.
- Occupational health nurses assist corporations in improving the health and safety of their workforce.
- Public health nurses provide health and wellness education programs to communities and may work in schools, non-profit organizations, and government agencies.
- Research nurses investigate the development and improvement of medical treatments and may work in academic institutions, pharmaceutical and biotechnology companies.
- Medical sales/marketing opportunities exist for nurses within research and manufacturing industries.
- Writers and clinical editors publish content in medical and nursing journals, textbooks, training manuals, digital resources, and marketing materials.
Advanced Practice Nurses
Many of the roles listed above require specialized training or certification and, in some cases, an advanced practice degree. Advanced practice nurses account for approximately 11.5% of the nursing workforce with nurse practitioners (NPs) accounting for 68.7% of advanced practice licenses, followed by 19.6% clinical nurse specialists (CNS), 9.3% certified registered nurse anesthetists and 2.4% certified nurse midwives (U.S. Department of Health and Human Services, 2019). Let’s take a closer look at advanced practice nurses.
Advanced Practice Role |
U.S. Numbers |
Nurse Anesthetists |
54,000Ŧ |
Nurse Practitioners (NP) |
290,000§ |
Clinical Nurse Specialists (CNS) |
70,000¥ |
Nurse Midwives |
11,826Ɛ |
Ŧ American Association of Nurse Anesthetists (2020)
§ American Association of Nurse Practitioners (2020)
¥ National Association of Clinical Nurse Specialists (2020)
Ɛ American College of Nurse-Midwives [ACNM] (2017)
Conclusion
Over the last few months, nurses, alongside other health care providers, have been lauded for their courage and commitment during the COVID-19 pandemic. The role that nurses are playing during this public health crisis underscores the importance and critical need for a sustained workforce. While registered nursing is expected to be one of the leading occupations in terms of job growth, it may not be enough to offset the high numbers of nurses exiting the profession. It will be interesting to monitor the trajectory of nursing school enrollment following one of the most devasting natural disasters of our time.
As I think about healthcare and nursing from when I graduated over 30+ years ago, I never imagined we would be fighting a foe we can’t see but, whose effects are relentless and omnipotent. Nature is clearly showing us she has the upper hand. As we conclude Nurses Month, I want to share a few things I’ve learned from being on the frontline with you.
Be open to learning and sharing knowledge.
We are all in the same situation, learning everyday to manage the next curve ball this virus throws at us. As we learn to manage the acute hypoxemic respiratory failure, this virus decides to teach us a lesson about coagulopathy, and so on and so on. One thing is abundantly clear, in order to beat this thing, we need to be open to learning and sharing knowledge. We need to use the evidence and best practice we know but, realize the evidence will be changing frequently and we need to be okay with it.
This is a team sport.
Everyone is in scrubs and behind personal protective equipment (PPE). You can’t tell who is the physician, nurse, nurse practitioner, physician assistant, respiratory therapist, etc. unless they have their badge in clear view or have their name or a picture taped to their isolation gown. Everyone is equally important, and we all have a role to play. And in case you didn’t realize it, caring for these patient’s is a team sport (especially proning).
We are family.
Perhaps the saddest part of this pandemic is that patients are without their family or loved ones. They say good-bye at the door, and they may or may not see each other again. Notice I didn’t say “they are alone.” Healthcare professionals are treating these patients as if they were our sister, brother, mother, father, or significant other. We are with the patient during intubation, proning, procedures and even when death is inevitable. We celebrate the wins and cry with the losses.
Phoning home is the next best thing.
We have become adept with using tablet devices and smart phones to improve communication between patients and their families. As ET asked Elliott to “phone home,” that is exactly what we are doing. Though not the same as being there in person, families are grateful for the chance to see their loved one and talk to those caring for them. Nurses have been at the core of making this happen.
Being a nurse is a calling and I am so glad I answered that call.
When I was a young girl, I always dreamed about being a nurse; it is who I am and I have never been more proud than I am today about being a nurse and nurse practitioner. Yes, I am afraid; I am afraid of the patients who I don’t know have COVID-19 and bringing it home to my family. I am sad when despite what we do for patients, some will die. I know I can’t dwell on what I can’t do for the patient, instead I focus on what I can do.
Nursing is resilient.
When I read the stories about nurses having to work without adequate PPE and staffing, it troubles me and I fully believe as a country we can do better. When I look in the mirror and see the marks from the mask on my face and on the faces of my colleagues, I wonder how much longer this situation will continue.
It brings tears of gratitude to my eyes when people donate PPE and food, bring thank you cards, and clap at change of shift. I wonder when this pandemic is over, how different our new normal will be.
Most of all, I wonder what the nursing profession will look like when this is over? I’m hopeful that as a profession we recognize the importance of selfcare so we can continue caring for others.
I believe nursing will be resilient because caring about people is at the core of who we are and what we do, and we wouldn’t have it any other way.
To put it mildly, the current climate of unrest in the United States is upsetting, but not surprising. From the beginning of time, racial disparities have existed. I cannot pretend to understand what I have not experienced, but I can support my fellow human beings using what I have learned from my nursing education and experience.
Certain communities are impacted differently by disease and infection, and racism itself is a public health issue. We have been trained as nurses to assess and continually reassess the
social determinants of health – neighborhood and built environment, security, prevention, education, and economic stability – as we care for patients. By doing so, we extend our plan of care to include not just the individual patient, but also their family and their
community.
COVID-19 has already changed the landscape of our community. Now, as violence permeates peaceful demonstrations following the death of George Floyd, the inequities in our country are front and center. As nurses, we are positioned to extend our impact beyond the clinical setting and be an example to those around us, demonstrating the basic tenets of respect and kindness. While not everyone can know everything about every culture and their beliefs, we can be open to learning and remain mindful that it is our differences that make us unique, our differences that join us together, our differences that are our strength.
And while we recognize that differences exist, we are all humans. We are all life. And we are all in this together. No matter your political affiliation, occupation, race or religion, think back to your nursing school days and remember the basics of cultural competence (Murphy, 2011):
- Knowledge – educate yourself on the healthcare practices and beliefs of others.
- Attitude – recognize your own biases and prejudices so you can avoid making assumptions.
- Skills – communicate in the way that best allows understanding, and always with respect.
“At this critical time in our nation, nurses have a responsibility to use our voices to call for change. To remain silent is to be complicit. I call on you to educate yourself and then use your trusted voice and influence to educate others about the systemic injustices that have caused the riots and protests being covered in the news. The pursuit of justice requires us all to listen and engage in dialogue with others. Leaders must come together at the local, state, and national level and commit to sustainable efforts to address racism and discrimination, police brutality, and basic human rights. We must hold ourselves and our leaders accountable to committing to reforms and action.
I have a deeper moral vision for society, one in which we have a true awareness about the inequities in our country which remain the most important moral challenge of the 21st century. This pivotal moment calls for each of us to ask ourselves which side of history we want to be on and the legacy we will pass on to future generations.” -- American Nurses Association (ANA) President Ernest J. Grant, PhD, RN, FAAN
Our support for our fellow human beings is more important than ever. Be there. Listen. Advocate. It’s what we do every day as nurses.
Between a lack of access, insufficient supplies, and inconsistent or inaccurate results, testing for SARS-CoV-2, the virus that causes COVID-19, remains a very controversial and confusing issue. Here’s a breakdown of the key concepts based on the evidence we have today.
Terminology (Mahutte, 2019)
There are several terms that you should understand that help describe the accuracy of a test, or its ability to measure what it was designed to measure.
- Sensitivity is the probability that an individual with the disease will test positive; high sensitivity will not miss patients who have the disease and decreases the risk of false negative results.
- Specificity is the probability that an individual without the disease will test negative; high specificity will infrequently provide a positive result in patients who do not have the disease and decreases the risk of false positive results.
An ideal test will be both highly sensitive and specific, yielding very few false positive and false negative results. In addition, the predictive value of a test is the proportion of positive and negative results that can be expected depending on the prevalence of a disease within a population. For example, a patient with a positive test is more likely to truly have the disease if the patient lives in an area, or belongs to a population, with a high prevalence of the disease.
Diagnostic Test
A diagnostic test will indicate whether an individual has a
current, active infection with the SARS-CoV-2 virus. There are two types available – molecular and antigen testing.
Molecular Test (U.S. Food and Drug Administration [FDA], 2020a)
- Molecular tests detect the presence of genetic material of the virus. Examples include:
- Nucleic acid amplification test (NAAT)
- Reverse transcription polymerase chain reaction (RT-PCR) test
- Specimen sources:
- Nasopharyngeal swab (preferred)
- Oropharyngeal swab
- Blood sample
- Stool sample
- The test is reasonably sensitive and specific, but laboratory analysis takes time.
- Positive results are typically verified with a confirmatory test.
- Negative results may be unreliable due to several factors:
- When the sample was obtained; peak viral shedding is unknown and the virus may not start replicating for a few days after the initial exposure, thus a sample collected too soon may not detect the virus (false negative result).
- Poor sampling procedure.
- Incorrect supplies; the swab should be made of Dacron or polyester material and placed in a viral transport medium.
- Delays in delivering the specimen to the lab.
- Molecular testing of respiratory tract samples is the recommended method to identify and confirm COVID-19 cases (World Health Organization [WHO], 2020).
Antigen Test (FDA, 2020a)
- Antigen tests detect the presence of viral proteins and are used in acute or early infection as the antigen is detected when the virus is actively replicating.
- Known as rapid diagnostic tests (RDT), these tests are not as sensitive as molecular tests.
- Positive results are highly accurate.
- Negative results do not rule out infection and may necessitate confirmation with a molecular test prior to making treatment decisions.
- Based on similar RDTs for influenza, the sensitivity may vary from 34% to 80%.
- Over 50% of patients with COVID-19 may be missed
- False positive results may occur if the tests detect other coronaviruses such as those that cause the common cold.
- Factors affecting test reliability include (WHO, 2020):
- Time from onset of illness
- Concentration of virus in the specimen
- Quality of the specimen collected
- How the specimen is processed
- Accuracy of the formulation of reagents in the test kits
- Advantages
- Rapid results within minutes; if ample concentration of the virus is detectable, it will bind to antibodies on the test strip and change color within 30 minutes.
- Can be manufactured at a lower cost than PCR tests.
- May be scaled to test millions of individuals per day due to simple design.
- Specimen sources:
- Nasopharyngeal swab
- Nasal swab
- While the FDA recently issued an emergency use authorization (EUA) for a COVID-19 antigen test (FDA, 2020b), the WHO (2020) does not currently recommend the use of antigen-detecting RDTs for patient care at this time. Based on current evidence, the WHO recommends these tests in research settings only.
Antibody Test
An antibody test will indicate whether an individual had a
previous infection even if the individual was asymptomatic.
- Does not indicate if an individual has a current infection and shouldn’t be used to diagnose COVID-19 infection.
- Detects antibodies called immunoglobulins:
- IgM – the body produces these initially during the acute phase of infection; these antibodies last for approximately 2 weeks before levels drop.
- IgG – the body produces these more slowly, within 2-3 weeks after initial infection, but can last for months or years.
- Neutralizing antibodies – inhibit viral replication; their presence correlates with immunity.
- Antibody response will depend on several factors (WHO, 2020):
- Age
- Nutritional status
- Severity of disease
- Immunosuppressing medications
- Immunocompromising conditions such as HIV
- Immunity based on the detection of SARS-CoV-2 antibodies is uncertain at this time, however these tests offer some public health advantages:
- Help determine the scope of infection within a population, potential herd immunity, and fatality rate (Centers for Disease Control and Prevention (CDC, 2020a).
- Assist in identifying individuals who had been infected with SARS-CoV-2 and now may qualify to donate convalescent plasma (CDC, 2020a).
- May support the development of vaccines (WHO, 2020).
- Varying false positive and false negative rates.
- The CDC (2020a) recently stated that serologic tests may be wrong “up to half the time” and should not be used to make policy decisions regarding the return to school or the workplace.
Binding Antibody Detection (CDC, 2020a)
- Enzyme-Linked Immunosorbent Assay (ELISA)
- Performed on blood sample and sent to a laboratory for analysis
- Detects IgG, IgM separately or combined as total antibody
- Results are more accurate, but require trained laboratory personnel and specialized instruments.
- Point-of-Care RDTs (WHO, 2020):
- Detect IgG or IgG and IgM, or total antibody
- Results are determined within a few minutes.
- Many of these tests have not been validated. The WHO (2020) does not recommend the use of antibody-detecting RDTs for patient care at this time, but supports their use in disease surveillance and epidemiologic research.
- Performed on the following samples:
- Serum, plasma, and whole blood which can be obtained by fingerstick instead of venipuncture
- Saliva, sputum or throat swab
Neutralizing Antibody Detection
- Determine the ability of antibodies to prevent infection of viruses in vitro.
- Testing outside of research settings is NOT authorized by the FDA at this time.
Who should be tested?
The CDC (2020b) outlined which individuals should be offered priority testing.
High Priority:
- Hospitalized patients with symptoms
- Healthcare facility workers, workers in congregate living settings, and first responders with symptoms
- Residents in long-term care facilities or other congregate living settings, including prisons and shelters, with symptoms
Regular Priority:
- Individuals with symptoms of potential COVID-19 infection, including fever, cough, shortness of breath, chills, muscle pain, new loss of taste or smell, vomiting or diarrhea, and/or sore throat.
- Persons without symptoms who are prioritized by health departments or clinicians, for any reason, including but not limited to: public health monitoring, sentinel surveillance, or screening of other asymptomatic individuals according to state and local plans.
“These recommendations have been made in the context of a shortage of tests. In an ideal world, repeat testing of all people who reside or work in nursing homes would be a high priority” - Betsy Todd, MPH, RN
How to Improve Testing Reliability (CDC, 2020a)
To minimize false positive results and optimize positive predictive value (95%), clinicians and health care organizations should consider the following:
- Choose tests with high specificity (99.5% or greater)
- Test populations with high prevalence or high pre-test probability of having antibodies (i.e. individuals with a history of COVID-19 symptoms or who are exposed to outbreak areas).
- Utilize a testing algorithm in which individuals who initially test positive are tested with a second, different test.
In an interview with Betsy Todd, MPH, RN, nurse epidemiologist and clinical editor for the
American Journal of Nursing, Ms. Todd recommended seeking tests offered in a hospital-based or public health setting as larger institutions are more likely to have conducted proper vetting to select the best tests. For more information on COVID-19 testing, listen to the
full podcast with Ms. Todd.
What has your experience been with COVID-19 testing? Please share in the comments below.
Some say nursing is their calling; for others it is a choice. In either case, we all have different stories of how we joined this profession and the turns our careers have taken. Last month, we shared some of our stories and you also shared some of yours. See them all below…
2020 Nurses Month Blog Series
Margaret Smith MJ, BSN, RN, CRNI
The biggest influence was my grandmother who was a Cadet Nurse in World War II…She was the first example, for me, that being a nurse means becoming a nurse; it is who you are.
Robin Haskell, MSN, RN, CRNP
About 18 months into my first nursing job, when the fear of making a mistake was replaced by confidence and critical thinking, I began to appreciate how creativity in nursing can enhance the patient experience as well as job satisfaction.
Myrna Buiser Schnur, MSN, RN
My mother was a nurse, an excellent, well-respected surgical intensive care nurse…While she loved her work, it was physically and emotionally demanding, so she often advised me not to follow in her footsteps. And frankly, I didn’t want to be another cliché as Filipinos are practically synonymous with the profession of nursing - it’s in our blood.
Lisa Bonsall, MSN, RN, CRNP
Did I always want to be a nurse? No. First I wanted to be a Rockette…But as that childhood dream faded, I realized that my passion for science, especially biology, would turn my dreams in another direction.
Anne Dabrow Woods DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Being a nurse is a calling and I am so glad I answered that call. When I was a young girl, I always dreamed about being a nurse; it is who I am and I have never been more proud than I am today about being a nurse and nurse practitioner.
Social Chatter
In response to these blog posts, we have been fortunate to hear from our followers on social media and learn some of their responses to the question,
“Did you choose nursing, or did nursing choose you?”
“Like Myrna, I am also Filipino. And similarly, I too was not too sure at first if nursing was for me. However, immersion in the world of caring drove me closer to the profession. There are many specialties of nursing available and as I ventured, I found my calling. I love what I do!”
“I've always believed that I was born to be a nurse”
“Nursing chose me. Was working in a LTC during college and changed my major senior year because I suddenly couldn’t imagine doing anything else. 20 years later and still love it despite all that is going on.”
Thank you to all who shared their stories! Let’s continue this momentum – please leave a comment and let us know, “Did you choose nursing, or did nursing choose you?”
Each week during Nurses Month 2020, we asked you a question. Here are some of your answers!
“I'm nursing faculty. We had to switch from teaching face-to-face on campus to distance learning, which I had never done. Even though it has taken some getting used to, I will be more valuable when we come out on the other side and finish my EdD. I'll have that online experience in my pocket.”
“The first patient you lose will be with you forever. Some managers use your talents to help you move in your career. Listen and others will teach you. They may be patients or colleagues. Listen and recall. Engage with your patients. Smile and be kind. Your actions and kindness will not be forgotten.”
“Staffing.”
“Being asked to provide excellence with inadequate resources.”
“Missing family events because I was working.”
“Seeing my growth and caring for my patients. I love what I do and I do what I do cause I love helping others.”
“Seeing my former students succeed and continue their nursing education.”
“When nurses I oriented to the ER tell me 'I learned so much from you. You are a great teacher.'”
“Leaving my shift and knowing, that I made a difference.”
“As a clinical nurse educator, COVID-19 has indeed made me more resilient and innovative in the sense that it pushed me to develop more innovative ways of training nurses in the clinical area while upholding infection prevention and control standards and ensuring staff and patient safety.”
Thank you for your thoughts and comments. Have something to add? Please leave a comment!
It goes without saying that this Year of the Nurse and Midwife is not one that any of us could have imagined. The goal of increasing our visibility as a profession has certainly come to fruition, but not in the way that we anticipated. The observance has changed from one of celebration to one of gratitude, especially for those on the frontlines of the COVID-19 pandemic. So, let’s look back at the past six months as it relates to nursing and healthcare…
January 2020
This was the official kickoff for the
Year of the Nurse and Midwife! Designated by the World Health Organization and key partners, 2020 was to be the year that we celebrate nurses’ contributions to improve global health; acknowledging, appreciating, and addressing the challenging conditions we face; and advocating for increased investments in the nursing workforce.
February 2020
In February, a novel coronavirus (SARS-CoV-2) was increasingly making headlines, and by February 28, there had been nearly 84,000 confirmed cases of the virus, now called COVID-19, worldwide. We didn’t know much about it other than that is was spreading quickly and easily.
March 2020
On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic. As we got deeper into the month, U.S. nurses and their colleagues in healthcare battled the virus head-on, despite shortages of personal protective equipment and limited testing. The innovation of nurses, along with other clinicians, became evident through
designing and producing face masks,
moving IV pumps outside of patient rooms to conserve PPE, and
forming interdisciplinary proning teams.
April 2020
On World Health Day, April 7
th, the World Health Organization (WHO), International Council of Nurses, and Nursing Now released the
State of the World’s Nursing 2020 report. This collaboration of over 170 countries serves to bring clarity on the state of the nursing profession today and the goals for the next ten years. The report recognizes the need for investments in nursing education, nursing jobs, and nursing leadership, and emphasizes the importance of a healthy workplace.
May 2020
In the United States, National Nurses Week was extended to
Nurses Month, and the American Nurses Association focused on weekly themes of self-care, recognition, professional development, and community engagement. We also celebrated the 200
th anniversary of
Florence Nightingale’s birthday!
June 2020
In June, we witnessed ups and downs with COVID-19. Most of the US was starting to see cautious lifting of stay-at-home orders, while some states experienced increasing numbers of cases and deaths. While the public health crisis due to the pandemic continued, acts of racism shined the light on inequities faced by people of color. Years of anger and cries for social justice rang out this month after the death of George Floyd on May 25
th, 2020.
As we head into the second half of 2020, I wonder what lies ahead? We are in no way through the COVID-19 pandemic and the work of the Black Lives Matter movement continues to gain momentum. I encourage everyone to become and remain educated and get involved.
Resources:
My first experience with extracorporeal membrane oxygenation (ECMO) occurred when I was a new nurse in the intensive care unit. ECMO therapy was being utilized as a bridge to left ventricular assist device (LVAD) placement for a patient in cardiopulmonary shock following open-heart surgery. This large academic hospital had the essential mix of clinical expertise and resources to employ the latest life-saving technologies.
To say I was in awe is an understatement. I knew patients were commonly placed on bypass for surgery, however implementing this high-risk machinery at the bedside for days, and sometimes weeks, was simultaneously fascinating and frightening. Even as I gained experience, it was always extremely stressful to care for patients on ECMO. Twenty years later, while ECMO remains a highly specialized therapy, more hospitals are adopting this temporary form of life support.
What exactly is ECMO? (Bartlett, 2020; Calhoun, 2018)
ECMO is used for both cardiac and pulmonary failure when conventional measures are no longer effective to support life. Rather than providing a cure for the underlying disease process, ECMO delivers oxygen-rich blood to vital organs, which gives the heart and lungs time to repair. During ECMO, blood is drained from the patient’s vascular system and then circulated outside the body by a mechanical pump through an oxygenator and heat exchanger. Carbon dioxide (CO
2) is removed and oxygen-saturated blood is returned to the body.
The one major contraindication for ECMO is a pre-existing condition that would prevent recovery, such as severe neurological injury or end stage cancer. Relative contraindications include uncontrolled bleeding and poor prognosis from a primary diagnosis. For patients with severe acute respiratory failure, research has shown that ECMO should be used early in the course of a patient’s illness (within the first seven days) rather than employing it as a rescue therapy.
Patients on ECMO are among the sickest of the sick. The patient’s room will be full of an array of highly trained staff and advanced life support technologies: the ECMO machine, a ventilator, continuous dialysis, infusion pumps, etc. This technology may be very intimidating, but it gets easier as you gain more experience managing patients on these life-support devices. Caring for ECMO patients is mentally and physically challenging, requiring nuanced monitoring as well as family support and education. Yet these challenges are offset by the rewards of caring for ECMO patients. ECMO nurses are in high demand and never stop learning. There is tremendous satisfaction in witnessing patients recover from such devastating illness.
To learn more, check out the additional reading and resources below as well as the
guidelines provided by the
Extracorporeal Life Support Organization.
References:
Bartlett, R. (2020). Extracorporeal membrane oxygenation (ECMO) in adults. UpToDate.
https://www.uptodate.com/contents/extracorporeal-membrane-oxygenation-ecmo-in-adults
Calhoun A. (2018). ECMO: Nursing Care of Adult Patients on ECMO. Critical care nursing quarterly, 41(4), 394–398. https://doi.org/10.1097/CNQ.0000000000000226
Naddour, M., Kalani, M., Ashraf, O., Patel, K., Bajwa, O., & Cheema, T. (2019). Extracorporeal Membrane Oxygenation in ARDS. Critical care nursing quarterly, 42(4), 400–410. https://doi.org/10.1097/CNQ.0000000000000280
A colleague recently mentioned using the phrase “physical distancing” in place of “social distancing” after listening to this
podcast with epidemiologist Michael Osterholm, PhD, MPH. (Osterholm is the founder and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.) In the current context,
social distancing means staying at least 6 feet away from one another to decrease the spread of COVID-19. But doesn’t this mean keep 6 feet of
physical distance between each other? This struck a chord with me and I wondered, “Why
don’t we just say what we mean?”
I did a little research and saw that the use of “social distance” versus “physical distance” has been addressed and written about, but until the media and our leaders make this transition, it is unlikely to catch on. However, after over four months of distancing here in the U.S. and the effects of quarantine and isolation taking a toll on many, it does seem like it’s time to make this shift in terminology. If it can help mitigate some of the mental health consequences of this pandemic, isn’t it worth it?
Hidden dangers
The hidden dangers of social distancing come in many forms. Large scale disasters are almost always accompanied by short- and long-term consequences for mental health and well-being. Substantial increases in anxiety and depression, substance use, loneliness, and domestic violence, and possibly, child abuse, are anticipated during and in the wake of COVID-19 (Galea et al., 2020; Venkatesh & Edirappuli, 2020).
Messaging matters
In this
Health Affairs blog, the authors stress that, “Messaging matters greatly, especially during a global emergency,” and that “‘Social distancing’ blurs the critical distinction between physical and social proximity. It also does little to shape social psychological dynamics that boost public resilience to sustain required behavior change.” They go on to recommend a change to “physical distancing, social connection” as a solution to differentiate social activities that maintain physical distance while fostering social connectivity.
Humans are social beings
According to
John M. Grohol, Psy.D., “‘social distancing’ is not only a misnomer, it is exactly the opposite of what we want people to do during any type of natural disaster.” Social interaction is necessary for our mental health and well-being. Social interactions can continue during this pandemic; they will just look and feel different. More than ever before in our history, we have ways to remain social, while maintaining physical distance. We are fortunate to have the means to stay virtually connected through social networks, video and phone calls, and even mailing letters. It is especially important to ensure continued connection with people who are typically marginalized and isolated, including the elderly, undocumented immigrants, homeless persons and those with mental illness (Galea et al, 2020).
Maintaining physical distance is an important strategy to slow the spread of COVID-19, but please stay socially connected. It’s how we will get through this – together.
References:
Allen, H., Ling, B., & Burton, W. (2020, April 27). Stop Using The Term ‘Social Distancing’ -- Start Talking About ‘Physical Distancing, Social Connection.’ Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20200424.213070/full/
Galea, S., Merchant, R. M., & Lurie, N. (2020). The Mental Health Consequences of COVID-19 and Physical Distancing: The Need for Prevention and Early Intervention. JAMA internal medicine, 10.1001/jamainternmed.2020.1562. Advance online publication. https://doi.org/10.1001/jamainternmed.2020.1562
Grohol, J. (2020, April 7). Alone, Together: Why It’s Physical Distancing, Not Social Distancing https://psychcentral.com/blog/alone-together-why-its-physical-distancing-not-social-distancing/
Venkatesh, A., & Edirappuli, S. (2020). Social distancing in covid-19: what are the mental health implications?. BMJ (Clinical research ed.), 369, m1379. https://doi.org/10.1136/bmj.m1379
There has been a great deal of discussion around the term herd immunity and whether it can be achieved in the current setting of COVID-19. What is herd immunity, and can we count on it to halt the spread of this novel coronavirus? Fine, Eames & Heymann (2011) outline several definitions for herd immunity including: a threshold proportion of immune individuals that should lead to a decline in incidence of infection, or a pattern of immunity that should protect a population from invasion of a new infection. In her blog entitled “
What is Herd Immunity?,” Lisa Bonsall, MSN, RN, CRNP, discusses how “herd immunity, or community immunity, makes it less easy for communicable diseases to spread, especially to those for whom vaccination is contraindicated.”
How does a community achieve herd immunity?
Herd immunity is achieved when a population becomes immune either from previous infection or by vaccination (World Health Organization [WHO], 2020). Individual natural immunity occurs after direct exposure to a pathogen. Upon contracting a viral or bacterial infection, the body develops antibodies to fight the microorganism and memory cells are generated to help protect a person from re-infection in the future. In some diseases like the measles, immunity will last a lifetime, however in other illnesses such as influenza, immunity will only last six months to a year. Individuals recovering from COVID-19 produce antibodies to the virus, but unfortunately, we don’t yet know how long that protective response will last.
When does a community reach herd immunity?
Herd immunity occurs when the number of individuals with immunity reaches a point at which the virus can no longer find susceptible hosts to infect and therefore can no longer spread. The herd immunity threshold depends on transmissibility of the disease and can be calculated using the reproduction number, R0 (“R zero” or “R naught”) which tells us the average number of people that an individual with the virus can infect in a completely susceptible population (Randolph & Barreiro, 2020). The higher the R0, the more contagious the disease and thus the more people need to be resistant to the virus to stop transmission. R0 will depend on population density, population structure and contact rates across demographic groups (Randolph & Barreiro, 2020). While the R0 will vary by city, state and country, scientists believe the R0 for COVID-19 falls between two and three; in other words, one person can infect two to three people (WebMD, 2020). This translates to approximately 50% to 70% of the population (over 200,000,000 Americans) that would have to contract the virus and recover in order to achieve herd immunity in the U.S. alone. Exposing a significant proportion of the population is unrealistic and ethically questionable as COVID-19 has caused serious illness resulting in excessive hospitalizations, stress on the healthcare system and above all a significant loss of life.
The second and preferred way to establish herd immunity is through vaccination which provides immunity without causing severe illness or side effects. When enough people get vaccinated to meet the herd immunity threshold, individuals who aren’t able to get vaccinated such as newborns or those with compromised immune systems are then protected (Mayo Clinic, 2020). Vaccines have been successful in controlling contagious diseases such as smallpox, polio, diphtheria, measles, mumps, rubella, varicella zoster and influenza, to name a few (Amanna & Slifka, 2018).
The biggest challenge is that we are still months away from an approved vaccine to fight this novel coronavirus. No one vaccine will be 100% effective in every single individual. Efficacy will depend on the strength and duration of the immunity acquired from the vaccine (Randolph & Barreiro, 2020). Once developed, approved, and manufactured, distribution of the vaccine to billions of people worldwide will be the next hurdle. Other issues involve poorly administered vaccines outside of recommended schedules (Fine et al., 2011) and immunity from vaccination may fade over time, requiring a booster. Viruses are also known to mutate, which necessitates the reconfiguration of vaccines based on new viral strains. Finally, some people are reluctant to get vaccinated either because of religious reasons, fear of vaccine side effects, uncertainty about the safety and benefits, lack of time or money, or a sense that it is inconvenient.
While natural herd immunity is not the answer to halting the spread of COVID-19, even if we have an approved vaccine by early 2021, we will continue to face many challenges in eradicating the virus. As a society, we need to be patient, stay the course and individually take responsibility to mitigate the transmission of this disease. Remember to avoid mass gatherings, maintain
physical distancing, wear a face mask in public spaces and when you can’t physically distance, wash your hands often, avoid touching your eyes, nose, and mouth, and stay home if you are sick. Be sure to follow your local public health guidelines.
Accurately assessing and managing oxygenation disturbances is critical to optimal patient outcomes. The alveolar to arterial (A-a) oxygen gradient, which is the difference between the amount of the oxygen in the alveoli (the alveolar oxygen tension [PAO
2]) and the amount of oxygen dissolved in the plasma (PaO
2), is an important measure to help narrow the cause of hypoxemia. It describes the overall efficiency of oxygen uptake from alveolar gas to pulmonary capillary blood.
The Calculations
The basic formula is:
A-a oxygen gradient = PAO2 - PaO2
PaO
2 is measured by arterial blood gas, while PAO
2 is calculated using the alveolar gas equation:
PAO2 = (FiO2 x [Patm - PH2O]) - (PaCO2 ÷ R)
In this equation, FiO
2 is the fraction of inspired oxygen (0.21 at room air), Patm is the atmospheric pressure (760 mm Hg at sea level), PH
2O is the partial pressure of water (47 mmHg at 37⁰C), PaCO
2 is the arterial carbon dioxide tension, and R is the respiratory quotient (approximately 0.8 at steady state, but varies according to the relative utilization of carbohydrate, protein, and fat.)
In addition, the A-a gradient varies with age and can be estimated from the following equation:
A-a gradient = 2.5 + FiO2 x age in years
Important Notes
- In healthy patients, there is generally a small difference between PAO2 and PaO2 because PAO2 is approximately 100 mm Hg and PaO2 is about 95 mm Hg.
- Proper determination of the A-a gradient requires exact measurement of FiO2, most easily done when a patient is breathing room air or receiving mechanical ventilation. The FiO2 of patients receiving supplemental oxygen by nasal cannula or mask can be estimated, but this does limit the usefulness of the A-a gradient.
- The A-a gradient increases with higher FiO2. When a patient receives a high FiO2, both PAO2 and PaO2 increase. However, the PAO2 increases disproportionately, causing the A-a gradient to increase.
Clinical Implications
Measuring the A-a gradient helps narrow the cause of hypoxemia as either extrapulmonary (outside of the lungs) or intrapulmonary (inside of the lungs); in other words, to distinguish hypercapnic respiratory failure due to global hypoventilation (extrapulmonary respiratory failure) from respiratory failure due to abnormal gas exchange from intrinsic lung disease. An A-a gradient within the normal range (< 20 mm Hg) in the setting of an elevated PaCO
2 is highly suggestive of global hypoventilation, whereas a widened gradient (> 20 mm Hg) suggests that underlying lung disease may be contributing to the measured hypercapnia.
Let’s consider two patients…
Case #1
A young, healthy patient comes in with drug overdose and his respiratory rate is 8. His arterial blood gas (abg) on room air reveals a respiratory acidosis with hypoxemia 7.31/55/65/24/88%. Assuming the Patm
, PH
2O, and R are constant, we calculate his A-a gradient:
A-a oxygen gradient = [(FiO2 x [Patm - PH2O]) - (PaCO2 ÷ R)] - PaO2
A-a gradient = [(0.21) x (760-47) – (55 ÷ 0.8)] – 65
A-a gradient = [(149.73) – (68.75)] – 65
A-a gradient = 80.98 – 65
A-a gradient = 15.98
Since his A-a gradient is < 20 mm Hg, we conclude that his hypoxemia is caused by hypoventilation due to his central nervous system depression; his alveolar oxygenation and arterial oxygenation are both decreased, so the gradient between the two remains within normal limits. Use of the appropriate reversal agent is indicated to arouse him and stimulate his respirations; intubation and mechanical ventilation is indicated if reversal is not possible or is ineffective.
Case #2
A patient with pneumonia who is mechanically ventilated, is developing worsening hypoxemia. His FiO2 on the ventilator is increased to 80% and his abg also reveals a respiratory acidosis with hypoxemia: 7.31/55/65/24/88%. Again, assuming the Patm, PH2O, and R are constant, we calculate his A-a gradient:
A-a oxygen gradient = [(FiO2 x [Patm - PH2O]) - (PaCO2 ÷ R)] - PaO2
A-a gradient = [(0.80) x (760-47) – (55 ÷ 0.8)] – 65
A-a gradient = [(570.4) – (68.75)] – 65
A-a gradient = 501.65 – 65
A-a gradient = 436.65
In this patient, the increased A-a gradient (> 20 mm Hg) is due to his pneumonia creating a physical barrier within alveoli, limiting the transfer of oxygen into the capillaries. His alveolar oxygenation is normal, however his arterial oxygenation is decreased, so the gradient between the two is widened. This is an example of an intrapulmonary cause of hypoxemia. For this patient, treatment of his pneumonia will be critical to improving arterial oxygenation, while supportive pulmonary hygiene measures are provided.
It’s good to be familiar with this measurement and to feel comfortable recognizing what a normal or elevated A-a gradient indicate. Also, there are
tools and calculators for calculating the A-a gradient to help!
We all know the importance of using the best available evidence to support our clinical practice to improve outcomes. While there is a set of nurses and other healthcare professionals who actually complete research or implement it into practice, the truth is, we need more healthcare professionals to join the effort. The issue with evidence synthesis and dissemination, along with working clinically or teaching, is time. Our days are packed, we’re running around trying to get more done and don’t we have enough stress?
Searching for evidence takes time and can be intimidating. Have you identified a clinical practice issue or problem that needs improvement? Reducing healthcare-associated infections, decreasing falls, minimizing medication errors, or improving hand hygiene are among some examples.
Ovid (Ovid and Lippincott NursingCenter are both subsidiaries of Wolters Kluwer) is excited to introduce a new program –
SPEED: Superior Practice: Expediting Evidence Dissemination –
to provide expertise in finding current evidence, identifying its quality and helping to assess the relevance for your setting. Run by Elaine Larson, PhD, RN, CIC, FAAN, this program is designed to save you time and improve outcomes. You are invited to propose to conduct a pilot project, using an evidence-based practice (EBP) model of your choosing (e.g., Iowa, Melnyk, or your own model). And don't worry, you don’t have to be an Ovid customer to participate!
Proposal Instructions
- Identify a clinical practice issue or problem which needs to be improved.
- Select an EBP model to use as a template. If your institution has adopted/adapted a model, use that one. If not, select a model such, as the Iowa model or the Melnyk model.
- Prepare the proposal using the components of that model (maximum of 4 pages, excluding references and figures/tables).
Expected Outcomes
- Maintain currency and keep abreast of literature of clinical relevance
- Identify gaps and needs for practice improvement
- Assess the relevance of evidence to improve patient care in their setting
- Develop a plan for implementing appropriate policy and practice changes
- Define measures of success (processes and outcomes)
- Assess the impact of changes
- Prepare a manuscript for publication
For more information, contact Rachel Dicker, Wolter Kluwer Health, Ovid Product Strategy at [email protected].
As September begins, it’s important to remember that it’s Sepsis Awareness Month, and while the
International Guidelines for Management of Sepsis and Septic Shock 2016 direct sepsis care, there are some caveats to the guidelines when caring for coronavirus disease 2019 (COVID-19) patients who develop sepsis. In fact, specific
guidelines on managing critically ill patients with COVID-19 were published in June 2020. The most significant difference in caring for COVID-19 patients with sepsis is recommendation #9:
“For the acute resuscitation of adults with COVID-19 and shock, we suggest using a conservative over a liberal fluid strategy (Alhazzani et al., 2020).”
In a
recent conversation with Anne Dabrow Woods, Chief Nurse of Wolters Kluwer, Health Learning, Research & Practice; adjunct faculty for Drexel University; and critical care nurse practitioner for Penn Medicine, Chester County Hospital, we dug a little deeper into fluid resuscitation for COVID-19. Here are some highlights from our conversation:
“COVID-19 patients don’t like a lot of fluid because it will flood their alveoli. We are using a more conservative versus liberal volume resuscitation strategy.”
“The other caveat is that we use a buffered crystalloid, and in this case, it would be Lactated Ringers.”
“If the patient develops a secondary bacterial pneumonia…we want to figure that out quickly…and get them on empiric antibiotic coverage for gram-positive and gram-negative organisms.”
“If they still have a ‘soft’ blood pressure, meaning that they’re hypotensive…we’re going to go ahead and start them on vasopressors, and the recommendations are the same as for regular sepsis, meaning norepinephrine is going to be your first-line agent, followed by vasopressin as your second-line agent.”
Listen to our whole conversation
here; we discuss all of the latest updates in managing critically ill patients with COVID-19. Also, explore these resource centers for more on the topics of
sepsis and
COVID-19.
You may also want to listen to the following podcast...
References:
Alhazzani, W., Moller, M., Arabi, Y., Loeb, M., Gong, M., Fan, E.,…Rhodes, A., (2020). Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine, 48(6), e440-e469. https://www.doi.org/10.1097/CCM.0000000000004363
Rhodes, A., Evans, L., Alhazzani, W., Levy, M., Antonelli, M., Ferrer, R., . . . Dellinger, R. (2017). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Critical Care Medicine, 486-452. https://www.doi.org/10.1097/CCM.0000000000002255
Woods, A. (2020). Latest Updates in COVID-19 Management. Lippincott NursingCenter. https://www.nursingcenter.com/journals-articles/podcast-library/latest-updates-in-covid-management
Nursing students are back to learning, but not necessarily back to school in the traditional brick and mortar building. In a profession such as nursing, where so much of our learning happens with hands-on experiences, how is nursing education changing in the current climate of physical distancing due to COVID-19? How are institutions and educators adapting to maximize student success?
Virtual learning
Virtual learning is not new for nursing. This
2018 Wolters Kluwer survey found that 65% of nursing education programs were adopting virtual education technologies.
The increased use of new technologies in education comes in response to a shortage of clinical trial sites and demonstrates a progressive approach to meeting the demand for practice-ready nurses – prepared not just to pass board exams, but also to deliver hands-on patient care. Across the world, healthcare practice is becoming more technology driven. Digital learning is growing in popularity and with it, new and creative ways to engage students in acquiring, managing and using knowledge.
It turns out that nurse educators are adopting new technologies faster than those in general education.
Simulation
Simulation has also been used for years in nursing education, but it has definitely changed over time. Changes in technology are allowing incredible advances in simulating real-life scenarios and teaching electronic health record (EHR) use. According to Dr. Desiree Hensel, Dean of the Curry College, in this video,
Integrating Clinical Judgement Skills in Nursing Curriculum and Improving Entry-Level Nursing Practices, with simulation, students can learn from their mistakes; in real-life scenarios, instructors step in to ensure patient safety, but in a simulated experience, students are allowed to make those mistakes and learn from them.
“When I'm in a clinical setting and I'm the nurse or the faculty member who's supervising a student and I look and I see she's going to make mistake, I step in right away to stop; safety comes first. In simulation, the student gets to make the mistake and then they get to understand what the mistake causes and that imprints in a very different way to help them understand the consequences and to help them not make that mistake again.”
-Dr. Desiree Hensel
Also, according to Hensel,
“What you see in simulation is what students are really thinking,” and this in turn is useful for testing, and opens up conversations to help learning.
In 2014, the National Council on State Boards of Nursing published
The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. The results of this study provided “substantial evidence that substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice.”
Academic/practice partnerships
Academic/practice partnerships are becoming more common as a mechanism to address the recommendations Institute of Medicine (2010) report,
The Future of Nursing: Leading Change, Advancing Health. These partnerships create systems for nurses to achieve educational and career advancement, prepare nurses of the future to practice and lead, provide mechanisms for lifelong learning, and provide a structure for nurse residency programs (AACN, 2012).
Key principles that guide the relationships between academic institutions are care settings (AACN, 2012) include:
- Collaborative relationships through formal relationships, shared vision and expectations, and mutual goals
- Mutual respect and trust
- Knowledge sharing
- Shared commitment to maximize the potential of each registered nurse to reach the highest level within his/her individual scope of practice
- Collaboration to determine an evidence-based transition program for students and new graduates that is both sustainable and cost effective
- Development, implementation, and evaluation of organizational processes and structures that support and recognize academic or educational achievements
- Support of opportunities for nurses to lead and develop collaborative models that redesign practice environments to improve health outcomes
- Establishment of infrastructures to collect and analyze data on the current and future needs of the RN workforce
In addition, the National Council on State Boards of Nursing has developed a model on
Practice/Academic Partnership During the COVID-19 Crisis to benefit both students and hospitals during this time.
How else can we support students during this time?
A recent
tweet from biology professor, @FiRawle, reminds us that students have more on their shoulders now than ever before. Dr. Rawle asked students,
"What is your biggest worry right now?" Responses included worry about parents who are essential workers, uncertainty about life, and inability to pay for both rent
and food. I encourage you to read this
thread to keep perspective and search for innovative solutions to engage and educate during these challenging times.
References:
Wolters Kluwer (2018, November 28). 65% of nursing education programs adopting virtual simulation. https://www.wolterskluwer.com/en/expert-insights/65-percent-nursing-education-programs-adopting-virtual-simulation
American Association of Colleges of Nursing. (2012). Guiding Principles to Academic-Practice Partnerships. https://www.aacnnursing.org/Academic-Practice-Partnerships/The-Guiding-Principles
Hayden, J.K., Smiley, R.A., Alexander, M., Kardong-Edgren, S.K., Jeffries, P.R. (2014). The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. Journal of Nursing Regulation, 15(2), S4-S41. https://www.ncsbn.org/JNR_Simulation_Supplement.pdf
This blog is part of the series, Nurses on Boards: Building a Healthier America. Wolters Kluwer is a Founding Strategic Partner of the Nurses on Boards Coalition.
Do you recall a time when serving on a commission, taskforce, or board that you recognized that you did not have a clear understanding of the topic at hand? Albert Einstein stated,
“In matters of truth and justice, there is no difference between large and small problems, for issues concerning the treatment of people are all the same.” The same is true when we serve on a board. A key element of board service is our personal responsibility to seek and fully understand the truth. The truth allows us to advocate for positive change and outcomes that benefit organizations and all they serve. To ensure you have the context and understanding to meaningfully contribute to the board discussion, consider asking these questions:
5 Key Questions to Capture the Truth
- How does the agenda topic align, influence or impact the organization’s mission, culture, values and reputation?
- What does the evidence say? What data is available to inform the board’s perspective?
- What is the best possible outcome for all stakeholders?
- What are the potential risks and how might they be mitigated?
- Has the topic been addressed previously by the board? If so, what were the outcomes and lessons learned?
As a board member, it is one's duty to fully understand the strategic implications of every decision. By asking these questions, you will be in a great position to meaningfully contribute to the boardroom, with truth and transparency.
“Nurses routinely interact with people and systems during times of vulnerability and stress, giving us tremendous insight into the problems that challenge families, organizations, and communities. Importantly, it is this insight that can inform the path to effective and viable solutions. Therefore, when serving on boards, it is vitally important for nurses to share their insight in a way that is courageously truthful, transparent, and honest. The same reasons that make nurses the most trusted profession, also make nurses an authentic, transparent, and trusted member of the board.”
Linda Flynn, PhD, RN, FAAN, Dean & Professor, Rutgers School of Nursing, Rutgers, The State University of New Jersey
Molly K. McCarthy MBA, RN-BC is the Managing Director, US Provider/Plans and Chief Nursing Officer for Microsoft. I had the pleasure of speaking with Molly about her journey in nursing, her work for Microsoft, nurses and board membership, and the future of nursing.
I was very curious not only about Molly’s role at Microsoft, but also how she came upon that position. Like many of us, Molly’s journey is not one that could have been predicted, and to me, that is one of the biggest advantages of our profession: opportunities truly abound in both clinical and nonclinical roles.
Please
listen to our full conversation and learn about Molly’s transition from majoring in French to nursing, then working in NICU and pediatric settings, followed by business school, and the path to her current career at Microsoft.
Additional highlights from our conversation include:
- Finding your “sweet spot” in nursing
- The importance of “branding” yourself as a nurse
- Having a “growth mindset”
- Following the “MSH” (make stuff happen) line of thinking
- The collaboration between Microsoft and the Nurses on Boards Coalition
- The importance of nurses on all types of boards
Molly also enlightened me on initial planning for Year of the Nurse and Midwife, and how Microsoft pivoted with the arrival of COVID-19. In May 2020, Microsoft, Johnson & Johnson, the Society of Nurse Scientists Innovators Entrepreneurs and Leaders (SONSIEL), and DevUP held the first
NurseHack4Health: COVID-19 Virtual Hackathon. The virtual hackathon convened nurses and other frontline healthcare professionals, developers, and engineers to help solve COVID-19 healthcare challenges using technology. With over 900 registrants, this event highlighted how nurses have been instrumental at solving problems during the pandemic. Next month, the event will focus on
Pandemic Management--Improving Education & Communication.
Listen now...
If healthcare and tech is something you are interested in learning more about, I encourage you to also check out the
Microsoft US Health and Life Sciences Confessions of Health Geeks podcast!
Molly K. McCarthy MBA, RN-BC is the Managing Director, US Provider/Plans and Chief Nursing Officer for Microsoft. With over twenty-five years’ experience in the healthcare industry, Molly is passionate about uniting technology, clinicians, and patients to improve care delivery, safety and outcomes. Molly joined Microsoft in 2013, and now leads a team of industry subject matter experts across the US to help both health provider and health plan organizations digitally transform.
Molly graduated with a Bachelor of Science in Nursing from Georgetown University, and began her career as a nurse in Neonatal Intensive Care Unit and Pediatric Units. Upon receiving her Master of Business Administration from the University of San Francisco, she combined her clinical and business backgrounds within the medical device and clinical informatics industry. Molly started in a product and market development role at Natus Medical, Inc, in Silicon Valley. She furthered her career in a business development role for the Association for Women’s Health, Obstetric and Neonatal Nurses (AWHONN), where she was responsible for piloting a benchmark database that extracted data from hospital EHRs in order to provide business intelligence to hospital leadership. Immediately prior to joining Microsoft, she worked with Philips Healthcare’s Patient Care and Clinical Informatics Divisions, where she orchestrated large enterprise system integrations of patient monitoring networks into hospital EMRs.
Connect with Molly on LinkedIn and Twitter @MSFTMollyRN.
What started out as an email exchange about how we are feeling and coping these days, Lippincott NursingCenter’s clinical editor, Lisa Bonsall and managing editor, Kim Fryling-Resare, started our personal lists of 10 ways we try to stay positive. The COVID-19 pandemic, current events, and natural disasters have permeated our lives in the past eight months more than any other time in recent history. Many of us are feeling overwhelmed and even helpless but shifting to a more positive outlook can help get us through these tough times. This, of course, is not always so easy to do; it takes a conscious effort, and sometimes amazing co-workers to bring positivity about.
See our lists below. We think you’ll see some common themes between our lists and be sure to let us know some of the ways you’re staying positive in these times of high strain. Creating your list may be very therapeutic for yourself or may help others see the positives during this time.
Lisa Bonsall, MSN, RN, CRNP, Senior Clinical Editor:
- Find inspiration. I recently watched the documentary, In Case of Emergency, from filmmaker Carolyn Jones, and read The Wisdom of Frontline Nurses Report: 14 Solutions. Both remind me why I became a nurse and reinforced my pride in our profession.
- Consider the source. It’s easy to get pulled into discussions on social media or spend a lot of time tuned into the news. Stay updated from reputable sources; go right to the source. Read the studies and interpret the data and consult with trusted colleagues.
- Practice gratitude. Consider starting each day, recognizing/writing 3 things you are thankful for.
- Use your voice. As nurses, we are educators, and we are trusted. Share the facts, focusing on the evidence, and be honest about how much remains unknown about COVID-19. And of course, get out and vote!
- Avoid engaging. While we can’t control the actions of others, we can control our own reactions.
- Surround yourself with positive people. When you are presented with negativity, take a deep breath and listen. Often, that is enough. If not, see #4!
- Escape. Make time for the things that bring you joy, whether it’s getting outside, reading a novel, or cooking something new. Self-care is more important than ever.
- Look for the silver lining. For me, my college-aged kids returning home last spring gave us time together as a family that we would not have otherwise had. I will treasure the memories that we made during that time.
- Smile. Even behind your mask 😊
- Say hello. Reach out to others, whether greeting them during your walk, making a call or text, or sending a note in the mail. Stay connected.
Kim Fryling-Resare, Managing Editor:
- Take breaks from social media. Sometimes the social platforms can easily turn contentious. For me, it can be too much, and I must take breaks from time to time.
- Exercise. Take a walk, hike, or bike ride. Perform some sort of movement that you enjoy, especially outside. Be sure to pay attention to nature and life all around you.
- Write/journal. Writing things down can be a great outlet for emotions and a great way to reveal to you all the things to be grateful for in this life.
- Have a cup of tea – meaning slow down and take a moment. Make time for yourself each day, even if it is only 10 minutes. Check in with yourself and do something for you.
- Set limits on how much news you’re consuming. The modern-day news programs are designed to hook viewers and keep them coming back for more. Get what you need to stay informed and then shut it down. Also, consider the sources and make sure they are reputable.
- Focus on your 4 walls. Things can sometimes seem so out of control; focus on what you can control. Take care of yourself and your immediate family first, and then everything outside your four walls will become so much easier to handle.
- Seek out “your squad” or those people who lift you up and who will listen if you need to vent and get out any negativity. Then leave it there. Get it out and then let it go.
- Cook and eat food that is healthy and nutritious. It will make you feel good that you’re taking steps to take care of yourself and your family.
- Get proper sleep. This one is a no-brainer for me. It just makes day-to-day life easier to handle with a proper night’s sleep.
- Try to take it moment by moment. Something I learned a long time ago is to focus on your current situation. You can’t do anything about the past and you can only do your best in the moment for whatever may come.
We hope you find these ideas helpful. How do you keep a positive outlook? What would you add to these lists?
Karen Cox, PhD, RN, FACHE, FAAN is the President of
Chamberlain University. As President, Dr. Cox is responsible for managing all undergraduate and graduate programs, which includes 22 physical campuses, as well as online programs.
Dr. Cox’s advice for being an effective leader in nursing centers around lessons she learned at an early age: be kind and helpful; develop trust; and live life as a staff nurse.
Listen to our full conversation to understand just what that means and learn about Dr. Cox’s journey in nursing, from volunteering in a hospital 40 hours/week one summer to attaining her degrees one step at a time.
We also discuss:
- Social justice and racism as a public health crisis
- Servant leadership
- Student success models and the future of nursing education
- Using the evidence within ones’ spheres of influence
- The difference between trying to make change and trying to change minds
- The importance of including the nursing perspective in all settings, including the boardroom
Listen now...
Dr. Karen Cox was appointed President of Chamberlain University in 2018. She is responsible for managing all undergraduate and graduate programs, which includes 22 physical campuses, as well as online programs.
Prior to joining Chamberlain, Dr. Cox served as Executive Vice President and Chief Operating Officer of Children’s Mercy–Kansas City, an independent, academic medical center. Dr. Cox led the organization to receive Magnet designation by The American Nurses Credentialing Center, becoming the first hospital in Missouri and the region in 2003 when she was Senior Vice President for Patient Care Services and Chief Nursing Officer. Dr. Cox started her healthcare career as a licensed practical nurse. Read more…
This week, we take the time to celebrate nurse practitioners and the value they bring to healthcare. The World Health Organization designated 2020 as the Year of the Nurse and Midwife; little did we know how impactful this designation would be as we were faced with the COVID-19 pandemic. This year challenged our strength, courage and resilience in ways we never thought possible, yet we rose to the occasion and continued to care for people in need.
State governments temporarily lifted many of the restrictions around collaboration, supervision, and licensure so nurse practitioners were able to provide patients access to care during the pandemic. Care was not delivered in a silo; nurse practitioners have worked and continue to work collaboratively with other healthcare providers to deliver high quality, equitable care that addresses the social and behavioral health needs of our patients. We must not forget that healthcare is “person-centered,” and it takes an interdisciplinary, collaborative team to help patients discover their optimum health potential. There is room in healthcare for medicine and advanced practice nursing.
Nursing is one of the most dynamic professions in healthcare. We have the opportunity to practice as direct-caregivers, leaders in healthcare organizations, faculty, researchers, and advanced practice nurses, just to name a few of our many roles. I have enjoyed being a nurse practitioner for over 22 years and it gives me great joy to support nurses on their career journey to become nurse practitioners. While we may experience uphill battles defending our practice to those who don’t understand collaboration is at the center of all we do, we cannot let that deter us. We must support each other and recognize the value we bring as leaders in clinical practice. Never forget our patients recognize the difference we make in their lives every day.
COVID-19 has infected over 11.2 million in the U.S. and 248,000 have died (Johns Hopkins University & Medicine, 2020). We are not alone; globally 55.3 million have been infected and over 1.3 million have died (Johns Hopkins University & Medicine, 2020). Health care workers are faced with fighting an invisible foe that keeps on coming day after day. We don’t have a cure, we have few therapies that curtail symptoms, and we are waiting for the vaccine. We are heading into the peak season of influenza and many people who had put off care due to the pandemic are now at our doors with higher severity of illness and more complications. So, not only are we caring for complex COVID-19 patients, we are caring for complex patients with other conditions. We are exhausted, morally injured, and feeling burned out because the patients keep on coming! What makes matters worse, we hear from people that COVID-19 is not real; it’s a hoax. How can people ignore the science and evidence?
I listened this week to nurses and physicians from around the country who spoke about patients who were diagnosed with COVID-19 and the patients
still didn’t believe it. Even as they were being placed on higher level oxygen therapy and being intubated, they were still saying it was a hoax or they had “the flu, pneumonia, or cancer.” How can people ignore the evidence of refrigerator trucks for dead bodies? Can’t everyone see that our faces are lined with marks from wearing our masks for hours at a time? Can people see the fatigue as we trudge back and forth to the hospital or our practices? Can people see the tears in our eyes as another patient dies from this infection? Can people see the devastation in the eyes of the loved one’s who’ve lost family and friends to COVID?
How do we continue delivering care to those who continue to not wear a mask, say COVID-19 is a hoax and everyone is overreacting? First, we need to remember we have some of the brightest minds in medicine and nursing in this country. Even though some have been silenced or even lost their jobs because they spoke the truth, these are the people we need to continue to support. We must support the medical and nursing societies, publications, and mainstream media that speak the truth and present the evidence. We need to frame our discussions based on science and make examples of virus transmission understandable to everyone.
We understand that people have a right to believe in what they choose; but when those rights impinge on our liberties, we need to speak up. But let’s be clear, at the heart of who we are as nurses and what we do is caring. We will still care for people regardless of their belief that COVID is a hoax. We are used to caring for people in difficult times; think about the patients you’ve cared for who are angry, acting out or combative. Without a doubt, taking care of these patients is one of the most difficult things we do. As healthcare professionals, we deliver care without judgement. Our institutions and our colleagues need to support us as we are taking care of those patients and recognize that healthcare professionals may need a respite from caring for these patients.
Healthcare systems need to recognize that resiliency is and will be an even bigger issue than we anticipated as we continue through the COVID-19 surges. We will be experiencing the roller-coaster of COVID-19 for quite a while. All healthcare professionals need to feel valued and supported, not only now, but also into the future.
Reference:
Johns Hopkins University & Medicine. (2020, November 17). Coronavirus Resource Center. Retrieved from Johns Hopkins University & Medicine: https://coronavirus.jhu.edu/
Burnout, compassion fatigue, and
moral distress – we use these terms often when talking about the effects of nursing job stress. The COVID-19 pandemic has brought so much into perspective, including the trauma that those on the frontlines experience during ‘normal’ times. Now, as nurses and other clinicians are battling COVID-19, that trauma has increased exponentially.
Too often, use of the terms
burnout and
compassion fatigue leads us to believe that the problem is coming from within; that we are not strong enough to handle the issue at hand. In reality, a better term to use and understand is
moral injury. This
2018 article in STAT clarifies the difference in terminology and why it is so important distinguish those differences.
The term “moral injury” was first used to describe soldiers’ responses to their actions in war…The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care (Talbot & Dean, 2018).
Solutions such as implementing self-care strategies, strengthening resilience, and employing better coping mechanisms are not to be minimized, however when institutional or social factors prohibit health care providers from providing appropriate care with adequate resources or safety precautions, solutions need to shift to remedying those factors. A meditation app won’t fix staffing issues. Debriefing sessions won’t secure adequate personal protective equipment (PPE). A yoga session won’t increase access to COVID-19 testing. Don’t get me wrong, there is value in these and other self-care strategies, but at this moment our health care providers are facing the worst of the worst, and help is needed.
Workload, schedules, staffing, inefficiencies, and lack of resources have been long-standing issues. Now, clinicians on the front line of the COVID-19 crisis are putting their physical and mental well-being on the line each and every day. Add in the acuity of the COVID-19 patients, witnessing patients dying without family and friends nearby, and the stress of watching life on the “outside” where others are questioning the reality of this virus and disregarding the important role that each citizen must play in putting an end to the pandemic. Our clinicians – those who we depend on at the most vulnerable times in our lives – are at risk.
How can we understand what clinicians are most concerned about? The easiest and best way is to simply ask. Last April, researchers held
eight listening sessions with groups of physicians, nurses, advanced practice clinicians, residents, and fellows. The areas of focus were what health care professionals were most concerned about, what messaging and behaviors they needed from their leaders, and what other tangible sources of support they believed would be most helpful. Eight sources of anxiety were identified (Shanafelt, Ripp, and Trockel, 2020):
- Access to appropriate personal protective equipment
- Being exposed to COVID-19 at work and taking the infection home to their family
- Not having rapid access to testing if they develop COVID-19 symptoms and fear of propagating infection at work
- Uncertainty that their organization will support/take care of their personal and family needs if they develop infection
- Access to childcare during increased work hours and school closures
- Support for other personal and family needs as work hours and demands increase
- Being able to provide competent medical care if deployed to a new area
- Lack of access to up-to-date information and communication
It is eight months later, and for many, these issues remain. We have learned a lot about this virus and how it is transmitted. We have identified some strategies for supporting patients and treating the virus. We are so close to beginning vaccinations here in the U.S. Why are we still reusing PPE? Why don’t we have widespread testing for our workforce?
In August 2020,
Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being was published in the
New England Journal of Medicine. The authors call for five high priority actions at the organizational and national levels to protect our clinicians during and after this crisis (Dzau, Kirch, & Nasca, 2020):
- Integrate the work of chief wellness officers or clinician well-being programs into COVID-19 “command centers” or other organizational decision-making bodies for the duration of the crisis.
- Ensure the psychological safety of clinicians through anonymous reporting mechanisms that allow them to advocate for themselves and their patients without fear of reprisal.
- Sustain and supplement existing well-being programs.
- Allocate federal funding to care for clinicians who experience physical and mental health effects of covid-19 service.
- Allocate federal funding to set up a national epidemiologic tracking program to measure clinician well-being and report on the outcomes of interventions.
Even before the pandemic, so many health care providers were experiencing burnout, compassion fatigue, and yes, moral injury. We can’t continue to ask so much of our frontline providers without giving them the resources and support they desperately need.
There is no simple solution, but we need leadership willing to focus on a culture of safety and ethics. Time is running out; we need to protect and support our clinicians. When the pandemic is a memory and COVID-19 is something we jot down in a patient’s history, we will still need nurses.
References:
Dzau, V.J., Kirch, D.K., & Nasca, T. (2020). Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being. New England Journal of Medicine, 383. https:///www.doi.org/10.1056/NEJMp2011027
Shanafelt, T., Ripp, J., & Trockel, M. (2020). Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA, 323(21). https://www.doi.org/10.1001/jama.2020.5893
Talbot, S.G. & Dean, W. (2018, July 26). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/
Back in March, during the first surge of COVID-19 patients,
alternative staffing and onboarding models were implemented by some institutions to improve care and maximize patient and staff safety. Now, as hospitals are in the midst of another surge, the team nursing model may be considered necessary and effective as intensive care units increase their number of beds to accommodate more patients while the number of critical care nurses often remains the same, or even decreases as staff are exposed to COVID-19 or infected, and not able to work.
Team Nursing in Action
In the team nursing model, a shift in mindset from “I” to “we” is necessary. Rather than thinking “
I will do x, y, and z for this patient today,” as is typical when using the primary nursing care model many of us are used to, we must pivot to “
We will do x, y, and z for this patient today,” while defining exactly who will be responsible for each of those actions.
Roles & Responsibilities
In the team nursing model, an experienced nurse for the unit or floor oversees the work of a team of clinicians and support staff for a group of patients. What this looks like and how it works will vary by hospital and by floor, acuity, and number of patients.
This video from the American Association of Critical Care Nurses (AACN) by Rose O. Sherman, EdD, RN, NEA-BC, CNL, FAAN outlines the roles and responsibilities for an ICU as described below.
Team Leader
The team leader should be an experienced critical care nurse with clinical and organizational knowledge. This person must be a critical thinker not only about patient care, but also about patient assignments. Excellent interpersonal skills are a must for effective delegation and conflict management.
Team Members
The team members will vary depending on availability and redeployment of staff and resources, but may include:
- Medical/surgical nurses
- Perioperative nurses
- CRNAs
- Pediatric nurses
- Pharmacists
- Respiratory Therapists
- Physical Therapists
- Dietary
- Unlicensed assistive personnel
- Certified Nursing Assistants
- Personal Care Assistants
- Nursing students
- Patient Care Technicians
Responsibilities
With the team approach, it’s important to consider the skills and strengths of each team member. For example, CRNAs and respiratory therapists will often take on the role of ventilator management and pediatric nurses may be the go-to resources for family communication. The team leader will be responsible for the delegation of responsibilities but must remember that scope of practice does not necessarily equal competency, so communication among the team is essential to appropriately define roles and responsibilities, such as:
- Assessment
- Medication administration
- Oversight of PPE, including donning and doffing
- Ventilator management
- Repositioning, including prone positioning
- Activities of daily living (ADLs)
- Communication with family
Dos and Don’ts of Delegation
While most of us know by heart the rights of medication administration, these rights of delegation may be less familiar (NCSBN & ANA, 2019):
- Right task
- Right circumstance
- Right person
- Right directions and communication
- Right supervision and evaluation
When delegating to unlicensed assistive personnel, remember these dos and don’ts:
Do delegate
- ADLs
- Range of motion/positioning
- Data collection (intake and output, weight, etc.)
Don’t delegate
- Assessments and reassessments
- Care planning and evaluation
- When to contact physician, nurse practitioner, or physician assistant
Looking ahead
Increasing numbers of patients, variations in acuity, and fluctuating staffing needs require us to be flexible in our approach to patient care. One unit that employed team nursing due to turnover, an influx of new nurse hires, and a decrease in staff morale reported increased nurse satisfaction because nurses felt supported, the environment was collaborative, and staff communication improved (Dickerson & Latina, 2017).
“One of the most positive outcomes so far from this crisis has been the high level of teamwork and collaboration. Crises have a funny way of forcing all of us to focus on a purpose and work together more harmoniously. We don’t worry as much about power and control because we have so little against this virus.”
Rose O. Sherman, EdD, RN, NEA-BC, FAAN
Will team nursing become the standard of care? That remains to be seen, but for now the approach is one to be considered as we continue the fight against COVID-19. There are endless variations to the model and its flexibility allows the leveraging of existing expertise to serve larger numbers of patients. If you are using the team nursing model, please leave a comment and share your experiences.
As a leading provider of learning content for nurses, Lippincott® has earned numerous awards and honors, including the American Nurses Credentialing Center’s (ANCC) Premier Award and Accreditation with Distinction. To further our commitment to improving nursing practice, we will implement the internationally recognized language that ANCC has adopted. Nursing Continuing Professional Development (NCPD) will replace continuing nursing education (CNE) on professional development activities, including print and online journals. As we move into 2021, you will begin to see a new NCPD logo on journal NCPD activities.
Another formal change includes a slight revision to the provider accreditation statement which appears on all NCPD articles and courses. All courses will still be valid while new courses will have the following statement: “Lippincott® Professional Development is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center Commission on Accreditation.”
Most importantly, we aim to improve the quality of your learning experience by implementing ANCC’s outcomes-based CE model. You will see a noticeable difference in the post tests as we incorporate application-based questions and clinical scenarios. This new format will support retention of learning and improvement in nursing practice for a variety of nursing roles including clinician, nurse leader, educator, and professional development practitioner.
As a Lippincott NursingCenter member, you will continue to have access to the largest collection of nursing NCPD in one location. We are happy to continue to grow, develop, and support you in your professional nursing career.
It’s no surprise that many of our most-read blogs of 2020 were related to COVID-19. We are glad and grateful that you found this information valuable to read and share. We are looking forward to staying connected in the coming year and we wish you a safe, healthy, and happy 2021!
Here is our ‘Top 10’ list from 2020.
10
9
8
7
6
5
4
3
2
1
Nurses, you rose to the challenges of 2020 and deserve so much recognition as we move on to 2021. Here are the “official” nursing recognition dates for the upcoming year, but please know that you are appreciated and celebrated every day. Stay #NurseStrong!
*Dates and links will be updated as they become available.
January
National CRNA Week January 24-30
IV Nurse Day January 25
February
PeriAnesthesia Nurse Awareness Week February 1-7
Critical Care Transport Nurses Day February 18
March
Certified Nurses Day March 19
GI Nurses & Associates Week March 22-28 (2020)
April
Wound, Ostomy and Continence (WOC) Nurse Week April 11-17
Transplant Nurses Week April 27-May 4 (2020)
May
Oncology Nursing Month all month
National Nurses Week May 6-12
National Nurses Day May 6
National Student Nurses Day May 8
International Nurses Day May 12
National School Nurse Day May 12 (always the Wednesday of NNW)
National Skilled Nursing Care Week (NSNCW) May 9-15
Neuroscience Nurses Week May 9-15
September
National Clinical Nurse Specialist Recognition Week September 1-7
National Pediatric Hematology/Oncology Nurses Day September 8
Vascular Nurses Week September 6-12 (2020)
Nephrology Nurses Week September 12-18
Nursing Professional Development Week September 12-18
Neonatal Nurses Week September 13-19
October
National Midwifery Week October 3-9
National Pediatric Nursing Week October 5-9 (2020)
Emergency Nurses Week October 11-17 (2020)
Emergency Nurses Day October 14 (2020)
National Case Management Week October 11-17 (2020)
International Orthopaedic Nurses Week October 26-30 (2020)
November
Medical-Surgical Nurses Week November 1-7
National Clinical Nurse Specialist Recognition Week November 1-7
Urology Nurses and Associates Week November 1-7
Forensic Nurses Week November 9-13 (2020)
Perioperative Nurses Week November 8-14 (2020)
National Nurse Practitioner Week November 7-13
Let us know how you will celebrate or how you plan recognize your colleagues. Wishing you safety, health, and happiness in the coming year!
To be successful nurses, there is no doubt that we need specialized skills to perform clinical tasks. These are often referred to as “hard” skills – those things that we learn through our education programs and on-the-job training. They are measurable and we are tested on these competencies both in school and at our places of employment. But how important are skills such as teamwork, communication, and work ethic? Often termed “soft” skills, it’s important that we recognize that these skills are anything but soft. These skills are just as crucial – sometimes even more so – to our professional success.
A better word to describe these skills would be essential. So here’s a look back at this previous blog post, with some thought-provoking questions as to why these skills are essential, and not soft at all.
Ten Essential Skills for Nurses
1. Communication
What if you were excellent at inserting IVs and the nurse your colleagues came to when they had a patient with “impossible veins,” but you could not effectively communicate important details about your patient’s care at change of shift hand-off?
2. Attitude and confidence
What if you knew your patient was exhibiting the classic signs and symptoms of heart failure, but you did not have enough self-confidence to alert the nurse practitioner of the ominous change in your patient’s clinical condition, due to the fear of being incorrect in your clinical assessment?
3. Teamwork
What if your colleague admits a new patient while you chat with colleagues about your weekend plans and later you need assistance during a rapid response event?
4. Networking
If you are considering a career change now or in the future, what role could colleagues in nursing and other disciplines play? Do you routinely introduce yourself to new team members and collaborate?
5. Critical thinking and creative problem solving
How have nurses risen to the challenges due to COVID-19? Think about personal protective equipment and limited family visitation. What innovations have you witnessed or been a part of?
6. Professionalism
Your words and actions speak volumes to your character and our profession. How do you portray yourself as a nurse?
7. Empathy
What if a patient with addiction relapses and is admitted to your unit for the second time this month? Do you reserve judgement and show empathy?
8. Conflict resolution
When an issue arises, do you address it with the involved persons or vent your frustrations to others?
9. Adaptability
When a change in policy or practice is instituted, are you open to the evidence supporting the change?
10. Initiative and strong work ethic
What if you frequently left tasks undone for the next shift and arrived late for work, and then you applied for a charge nurse position? Would you expect to get the job?
These essential skills can have an enormous impact on patients and colleagues, and on our own well-being and satisfaction. They are hard to learn and they require practice. What other essential skills would you add to this list?
Page reviewed and updated: August 2023
We’re hiding behind masks these days and for all the right reasons: to protect ourselves and to protect others from infectious diseases. Health care professionals are required to wear masks and personal protective equipment (PPE) for prolonged periods of time, often for their entire shift whether it’s 8 hours, 12 hours or more. This extended use practice was employed during the COVID-19 pandemic to conserve the supply of PPE (Centers for Disease Control and Prevention [CDC], 2020). Today, clinicians continue to wear PPE for long hours which places them at high risk for developing skin complications such as face mask dermatitis, also known as irritant contact dermatitis. Symptoms will manifest as dryness, peeling, mild erythema, rashes, swelling, inflammatory pustules, maceration and skin breakdown on the nasal bridge, forehead, cheeks and behind the ears (Kelechi, Brunette & Lee, 2020).
Pacis, Azor-Ocampo, Burnett, Tanasapphaisal & Coleman (2020) conducted a quality improvement program to assess the use of prophylactic dressings to prevent skin breakdown when using N95 respirators. They assessed six different types of dressings that were designed to protect the skin from friction, pressure, or moisture; comfortable to wear; and easy to apply and remove without aerosolizing particles that could cause self-contamination. The only dressing that met all these criteria was the Adapt No Sting Skin Protective Wipe, an alcohol-free liquid acrylate dressing. The researchers found that applying this product to areas of friction before putting on the N95 respiratory mask will provide comfort, prevent skin friction, and maintain an adequate seal. Use of topical dressings with padding (i.e., foam, hydrocolloid) should be avoided with tight-fitting respirators as they may affect the fit and seal and reduce its effectiveness (Wound, Ostomy and Continence Nurses Society [WOCN] Board of Directors Task Force, 2020). You may use padded dressings under face shields that don’t require a seal against the skin if it does not compromise mask functionality (Kelechi, Brunette & Lee, 2020).
Preventing and Treating PPE-Related Skin Injuries
Several strategies to prevent and treat PPE-related skin injuries specifically for health care professionals are outlined below (Kelechi, Brunette & Lee, 2020; WOCN Board of Directors Task Force, 2020).
Prevention strategies include:
- Wash your face with a gentle face wash prior to applying the mask, and be sure to dry well.
- Apply a thin moisturizing facial lotion to the entire face.
- Use a noncomedogenic product if you are prone to acne.
- Use an alcohol-free barrier film (cyanoacrylate-based moisture barrier) if you tend to sweat or develop excessive moisture.
- Apply where the facepiece is likely to touch the skin or cause friction such as the nose bridge, cheeks, tops of ears, or forehead; avoid the eye area.
- Allow the products to dry for at least 90 seconds prior to putting on your mask.
- Barrier films do not need to be removed.
- Apply daily but decrease use if buildup occurs.
- Avoid petrolatum-based products as these may affect the seal of the mask; these products may be applied to broken skin when not wearing a mask.
- Watch for allergic reactions to the following materials:
- Glue strips or rubber along the nosepiece
- Metal wire, sometimes made of nickel
- Sterilizing sprays that are applied to reuse masks
Treatment strategies include:
- If contact dermatitis develops, a low-potency topical corticosteroid should be applied to decrease skin inflammation.
- For skin loss, apply a breathable, no-sting cyanoacrylate-based skin protectant/sealant up to 3 times per day.
Maskne
The COVID-19 pandemic has resulted in an increase in mask-associated acne and the birth of a new term: “maskne.” Maskne is a form of “facial dermatosis that occurs in areas of friction from the use of masks, respirators, and PPE” (Sinha & Singh, 2020). According to Teo (2020), maskne is likely due to follicular occlusion and directly related to mechanical stress such as pressure, occlusion, or friction, also known as acne mechanica, and changes in the skin microbiome including heat, pH, and moisture. Contributing factors include a genetic predisposition, older age, prior skin issues, long hours of PPE use, improper PPE sizing, tighter PPE and use of adhesive tape (Sinha & Singh, 2020).
The American Academy of Dermatology Association ([ADA], 2021), recommends several tips to help prevent maskne not only for health care professionals but for the general population:
- Cleanse and moisturize daily.
- Cleanse with an antibacterial, mild, fragrance-free cleanser.
- Moisturizers add a protective layer and decrease dryness.
- Look for moisturizers that include ceramides, hyaluronic acid, dimethicone.
- Apply before and after wearing a mask.
- Apply petroleum jelly to your lips after washing your face, before you put on your mask, and before bedtime.
- Avoid wearing makeup under your mask.
- If makeup is necessary, use products that are non-comedogenic and that won’t clog pores.
- Avoid new skin care products that can be irritating to your skin, such as chemical peels, exfoliants or retinoids for the first time.
- Decrease use of certain skin care products if your skin becomes irritated, such as leave-on salicylic acid, retinoid, or aftershave.
- Choose masks that (Teo, 2020):
- Are comfortable, with a snug fit.
- Have smooth surfaces without folds.
- Have a minimum of two layers of fabric.
- Are made of natural, breathable UPF 40+ fabrics such as cotton.
- Include adjustable ear loops.
- Don’t have metallic parts at nose bridge.
- Take a 15-minute break from your mask every 4 hours.
- Wash your fabric masks after each use.
Hydration and a daily skin care routine are both important components that help maintain healthy skin. As health care professionals, we often neglect our own needs to care for others. Take care of yourself – and your skin.
References:
American Academy of Dermatology Association (ND). 9 ways to prevent face mask skin problems. Retrieved January 11, 2021, from https://www.aad.org/public/everyday-care/skin-care-secrets/face/prevent-face-mask-skin-problems
Centers for Disease Control and Prevention (2020). Coronavirus disease 2019 (COVID-19) strategies for optimizing the supply of N95 respirators. Retrieved January 14, 2021 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html
Kelechi, T.J., Brunette, G. & Lee, L.W. (2020). Personal protective equipment-related equipment dermatitis. Journal of Wound, Ostomy and Continence Nursing. 47(4), 324-325. https://www.doi.org/10.1097/WON.0000000000000673
Pacis, M., Azor-Ocampo, A., Burnett, E., Tanasapphaisal, C., & Coleman, B. (2020). Prophylactic dressings for maintaining skin integrity of healthcare workers when using N95 respirators while preventing contamination due to the novel coronavirus, a quality improvement project. Journal of Wound, Ostomy and Continence Nursing, 47(6), 551-557. https://www.doi.org/10.1097/WON.0000000000000713
Sinha, A. & Singh, A.R. (2020). An unforeseen hazard of masks being in vogue. International Journal of Occupational and Environmental Medicine, 11, 213-214. https://www.doi.org/10.34172/ijoem.2020.2211
Teo, W. (2021). Diagnostic and management considerations for “maskne” in the era of COVID-19. Journal of the American Academy of Dermatology, 84(2), 520-521. https://doi.org/10.1016/j.jaad.2020.09.063
Wound, Ostomy and Continence Society (WOCN) Board of Directors Task Force. (2020). Guidance for maintaining skin health when utilizing protective masks for prolonged time intervals. Journal of Wound, Ostomy and Continence Nursing, 47(4), 317-318. https://www.doi.org/10.1097/WON.0000000000000677
More Reading and Resources
The absolute neutrophil count (ANC) is the total number of neutrophils in the white blood cell (WBC) count. It’s typically part of the complete blood count (CBC) with differential. While some labs calculate the ANC for us, it’s important to know just what is involved in the calculation as this number is often used to assess infection risk and guide cancer treatment.
Remember that neutrophils are the most common type of WBC and they lead the immune response. A decrease in the number of neutrophils typically means a patient is at increased risk of infection.
You can calculate the ANC by multiplying the total number of WBCs by the percentage of neutrophils and dividing by 100 (Coates, 2019). Sometimes, you may see the percent of neutrophils referred to as polymorphonuclear (PMN) cells and you may have young neutrophils (also called bands) on your laboratory report. In this case, add the percent of neutrophils (PMNs) and percent of bands (and divide by 100) before multiplying by the WBC.
ANC = WBC (cells/uL) x [percent (PMNs + bands) ÷ 100]
Let’s try an example.
If the WBC count is 6.3 thousand/uL, and neutrophils are 56.1% and bands are 3%, what is the ANC?
ANC = WBC (cells/uL) x [percent (PMNs + bands) ÷ 100]
ANC = 6,300 cells/uL x [(56.1%+3%) ÷ 100]
ANC = 6,300 cells/uL x (59.1% ÷ 100)
ANC = 6,300 cells/uL x 0.591
ANC = 3,720 cells/uL
So, what does this mean?
As we mentioned, the ANC is an indicator of infection risk. Neutropenia (decreased neutrophils) is usually defined as an ANC less than 1,500 cells/uL in an adult and can be categorized as mild, moderate, or severe.
Categorizing Neutropenia (Berlinger, 2020) |
Category |
ANC |
Mild |
1,000 to less than 1,500 cells/uL |
Moderate |
500 to less than 1,000 cells/uL |
Severe |
Less than 500 cells/uL |
Example #2
JD is a 42-year-old who presents with progressive fatigue. Physical examination is notable for splenomegaly and lymphadenopathy. Results from his CBC with differential are:
White Blood Cells 1.2 THO/uL
Hemoglobin 10.7 g/dL
Hematocrit 31 %
Platelets 262 THO/uL
% Neutrophils 70.1 %
% Lymphocytes 30.8 %
% Monocytes 9.5 %
% Eosinophils 2.4 %
% Basophils 1.2 %
% Bands 3%
Based on these results, let’s calculate JD’s ANC.
ANC = WBC (cells/uL) x [percent (PMNs + bands) ÷ 100]
ANC = 1,200 cells/uL x [(70.1%+3%) ÷ 100]
ANC = 1,200 cells/uL x (73.1% ÷ 100)
ANC = 1,200 cells/uL x 0.731
ANC = 877.2 cells/uL
JD has moderate neutropenia and will need further evaluation to uncover the cause.
Neutropenia may be discovered while evaluating other signs and symptoms, as in the case of JD, or as an incidental finding on a routine CBC. In either circumstance, further evaluation to determine any underlying pathology and potential medical emergencies is necessary. It’s also important to be aware that most patients on chemotherapy will experience a
nadir, or lowest value, in ANC five to ten days after completion of a chemotherapy session.
Page reviewed and updated: August 2023
During the COVID-19 pandemic, nurses and other health care providers sought out some new accessories and tools to add to our work uniforms. In addition to scrubs and comfortable shoes, many of us are now wearing full personal protective equipment (PPE) for our entire shifts. While many may find that hospital-provided PPE is required, accessories to improve the look and feel of PPE is in high demand.
Ear-Savers
Elastic or plastic from masks with ear loops puts pressure on the back of the ear and can even lead to skin issues and breakdown. Nurses and others have found creative ways to ease that pressure, from looping the elastic around strategically placed hair buns and the advent of ear-savers.
Surgical Caps and Headbands
Also, while not new on the scene, surgical or scrub caps are now also being worn
outside of the surgical suite to cover exposed hair. And while function and durability are the priority, there are many fashionable options.
Added bonus: some have buttons that you can loop your masks around!
Feeling Crafty?
If you are creative and crafty, there are also DIY instructions and videos. Search “ear-savers” or “make your own scrub caps” and you are sure to find ideas ranging from simple no-sew options to more challenging patterns for expert crafters and sewers.
As with any piece of apparel or tool, make sure it is facility approved.
Nursing history is fascinating. There are so many nurses who have influenced our profession and paved the way for us. This Black History Month, here are 10 nurses whose stories are critical to nursing’s past and future.
Sojourner Truth (1797-1883)
Born into slavery, Sojourner Truth, served as a nurse to the Dumont family. After escaping slavery, she was an advocate for women’s rights and later became a member of the National Freedman’s Relief Association, dedicated to improving Black lives. Truth also promoted nursing education and training programs before Congress.
Learn more.
Harriet Tubman (1820-1913)
Well-known for her role in the Underground Railroad during the Civil War, Harriet Tubman also used home remedies to nurse soldiers in the hospitals, without pay or pension.
Learn more.
Mary Eliza Mahoney (1845-1926)
Mary Eliza Mahoney was the first Black RN in the United States. In 1908, she helped establish the National Association of Colored Graduate Nurses (NACGN).
Learn more.
Jesse Sleet Scales (1865-1956)
Jesse Sleet Scales was a Black public health nurse pioneer who contributed to the practice of public health nursing in New York City during the early 20
th century. Scales set the foundation for Black nurses in community and public health nursing.
Learn more.
Martha Minerva Franklin (1870-1968)
An 1897 graduate of nursing school – for which she had to attend out-of-state since Black nursing students were not allowed in Connecticut at the time – Martha Minerva Franklin was one of the first to campaign for racial equality in nursing. Franklin later founded the National Association of Colored Graduate Nurses (NACGN) and served as its first president.
Learn more.
Mabel Keaton Staupers (1890-1989)
Mabel Keaton Staupers was an advocate for racial equality in the nursing profession. She was active in ending the U.S. Army’s policy of excluding Black nurses from its ranks in World War II, and successfully lobbied for full integration of the American Nurses Association in 1948.
Learn more.
Lillian Holland Harvey (1912-1994)
Lillian Holland Harvey was the director of nurse training at the Tuskegee School for Nurses in 1945, and became the dean of the school in 1948, later transforming the program into a baccalaureate one. Harvey is credited as a “crusader for unrestricted professional recognition during times of racial discrimination and segregation.”
Learn more.
Hazel W. Johnson-Brown (1927-2011)
Hazel W. Johnson-Brown also faced racial discrimination and had to travel away from home to attend nursing school. She later became the first Black female general in the U.S. Army and the first Black chief of the U.S. Army Nurse Corps.
Learn more.
Goldie D. Brangman (born 1920)
Goldie D. Brangman was co-founder, and later, director, of the Harlem Hospital School of Nurse Anesthesia, which opened in 1951. In addition to her many achievements there, Brangman was the first Black CRNA to become a nationally recognized leader in the field; in 1959, she was elected president of the New York Association of Nurse Anesthetists and later served as treasurer and president of the American Association of Nurse Anesthetists.
Learn more.
Betty Smith Williams (born 1929)
A champion for diversity, Dr. Williams led a steering committee of Black nurses in 1968 to organize the Council of Black Nurses in Los Angeles. She is a founding member and leader of the National Black Nurses Association and cofounder and first president of the National Coalition of Ethnic Minority Nurse Association.
Learn more.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Certified Nurses Day
March 19, 2021
Are you certified or considering certification? Don’t miss our
Guide to Certification to help you on your journey. Learn about the pioneer and inspiration behind nurse certification,
Margretta "Gretta" Madden Styles, RN, EdD, FAAN. And save
this page for a special offer coming up on 3/19!
GI Nurses & Associates Week
March 21-27, 2021
#ProudtobGI
This year’s theme is “Honoring and Celebrating Community.” If you are a GI nurse or interested in GI Nursing, here are some resources:
Healthcare Observances
March is a busy month! Here are some of the healthcare observances being recognized.
Multiple Sclerosis (MS) Awareness Week
March 7-13, 2021; World MS Day: May 30, 2021
Patient Safety Awareness Week
March 14–20, 2021
World Tuberculosis Day
March 24, 2021
Theme: The Clock is Ticking
National Colorectal Cancer Awareness Month
National Endometriosis Awareness Month
National Kidney Month
National Nutrition Month
Brain Injury Awareness Month
#MoreThanMyBrainInjury
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
Page reviewed and updated: August 2023
We know that nursing is demanding work – mentally, emotionally, and physically – but did you know that musculoskeletal injuries in health care occupations are among the highest of all US industries? Both the
American Nurses Association and
The National Institute for Occupational Safety and Health (NIOSH) are working to establish a safe environment for nurses using Safe Patient Handling and Mobility (SPHM) programs and advocacy.
Safe Patient Handling and Mobility
Standardized mobility protocols and guidance from SPHM programs include prioritizing the use of available equipment over manually moving a patient. When available, use ambulation aids (such as gait belts with handles, canes, walkers, or crutches), transfer devices (such as slide boards or friction reducing slide sheets), manual standing aids, shower chairs or benches, and raised toilet seats or convertible commodes. Powered equipment should also be used, when possible, such as height-adjustable beds and stretchers, bed-wheelchair transfer systems, ceiling-mounted lifts, portable floor lifts and powered air-assist inflatable transfer systems (Beauvais & Frost, 2014; Dickinson et al., 2018).
Proper Body Mechanics
Even when using equipment – and especially if you do need to move a patient without equipment – it is important to use proper body mechanics to reduce your risk of injury. Here are some tips to keep you safe:
- Set your feet in a solid wide base.
- Keep your head upright and hold your shoulders back.
- Keep the patient close to your body to minimize forces on it.
- Bend your knees and use the momentum from your legs (not your back) to move or lift the patient.
- Don’t twist; pivot instead.
- Pay attention to your limits; don’t try to do more than you can handle.
- Work together with your colleagues, including those in other disciplines, such as physical therapy.
What else can you do?
Take your own advice and follow the recommendations we regularly give to patients: eat well, get enough rest, exercise, and maintain a healthy weight. Also, invest in shoes that are comfortable and good shock absorbers.
Back pain and injury can be debilitating so be sure to use the equipment and programs available at your facility, and if necessary, get involved in developing programs to keep you, your colleagues, and patients safe.
References:
Bayada. (2016, September 16). 6 Nurse-approved Ways to Protect Your Back on the Job. https://blog.bayada.com/work-life/6-nurse-approved-ways-to-protect-your-back-on-the-job
Beauvais, A., & Frost, L. (2014). Saving our backs: safe patient handling and mobility for home care. Home Healthcare Now, 32(7), 430–436. https://doi.org/10.1097/NHH.0000000000000110
Dickinson, S., Taylor, S., & Anton, P. (2018). Integrating a Standardized Mobility Program and Safe Patient Handling. Critical Care Nursing Quarterly, 41(3), 240–252. https://doi.org/10.1097/CNQ.0000000000000202
Nurses have topped the list for the most honest and ethical profession for nearly two decades, and in 2020, we earned a record 89% very high/high score, four percentage points greater than last recorded in 2019 (Saad, 2020). In fact, since 1999, when nurses were added to the poll, there has been only one year when we were not ranked the most honest and ethical; that was 2001, when firefighters topped the list.
While this validates our level of respect from the public, many of us realize how much our voice resonates with those close to us in our day-to-day lives. Do family, friends and neighbors come to you with health-related questions? When an acquaintance learns that you are a nurse, are you then asked, “What do you think about…?” These days, more than ever, I am asked about COVID-19, vaccines, travel and return to school.
Our voice is important, and it pleases me to see an increase in nurses addressing our current health care crisis in the media. Our own Chief Nurse, Anne Dabrow Woods, has written for
Fierce Healthcare and
MedCity News, the
Swab Squad from Thomas Jefferson University Hospital appeared on Ellen, and more and more nurses are being interviewed on major news outlets. For example, here’s a clip of
NYC nurse, Sandra Lindsay, the first person to receive the COVID-19 vaccine in the U.S. on MSNBC. There are also more
nurses on boards and
nurses in the U.S. Congress than ever before.
It is important to keep up this momentum, but how?
- Stay informed on how nurses are being represented in the media. The Woodhull Study on Nursing and the Media: HealthCare’s Invisible Partner was published in 1998 and replicated in 2018. Here are the details.
- Seek out opportunities to share your story. Whether within your institution or community, or on a national or global stage, speak up. It’s important to share the work and innovation of nurses, especially now caring for COVID-19 patients. Remember to always prioritize patient and family privacy.
- Educate those around you. There are still many who don’t understand the work of nurses and the many roles we have. Whether you are in a clinical or nonclinical role, let others know how your work impacts health. Social media is another outlet to inform and educate, but again, use caution to maintain privacy and remain professional.
- Write for publication. Whether it’s a research study or narrative, publish your work! We are very familiar with the old adage, “If it wasn’t documented, it wasn’t done.” Publication is a way of documenting your knowledge and experiences. Wolters Kluwer offers many author resources and here’s a comprehensive list of nursing journals from the International Academy of Nursing Editors.
Here’s a glance at what’s happening in nursing and healthcare during April 2021, along with some resources for your learning and professional development.
Nursing Recognition Dates
Wound, Ostomy, and Continence (WOC) Nurse Week
April 11-17, 2021
#WOCNurseWeek2021
If you are a WOC nurse or interested in WOC Nursing, here are some resources:
Transplant Nurses Week
April 25-May 2, 2021
Are you a transplant nurse or interested in transplant nursing?
Healthcare Observances
Alcohol Awareness Month
#AlcoholAwarenessMonth
Autism Acceptance Month
#StandUpForAutism #celebratedifferences
National Donate Life Month
#DonateLife
Theme: Garden of Life
STD Awareness Week
April 11-17, 2021
World Immunization Week
April 24-30, 2021
Theme: Vaccines Bring Us Closer
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
Aromatherapy is the use of inhaled essential oils to improve health and overall well-being. This is not a new practice, in fact, essential oils were used dating back to about 5,000 years ago in ancient Egypt. Even Florence Nightingale applied lavender to wounded soldiers during the Crimean War.
An increasing focus on integrative health is prompting a resurgence in the use of essential oils for personal use, as well as in acute care settings. The care we provide in acute care focuses on easing patients’ experiences during illness or injury. As holistic providers, if the evidence shows that essential oils can play a role, it makes sense that we educate ourselves so we can provide the best patient experience and improve outcomes.
What are essential oils?
Essential oils are extracted from the stems, leaves, bark, flowers, roots, seeds, resins, or peels of aromatic plants. Their therapeutic actions and effectiveness depend on the chemical substances within the plant, the method used to obtain them and where the plants were grown (Perkins, 2020). When considering essential oils, remember that aromatherapy blends, or combining different oils together, can be considered for a complementary effect.
After inhalation, physiologic effects have been documented; it is not just the perception of the aroma. Olfactory pathways closely associated with the brain’s limbic system are affected, influencing heart rate, blood pressure, respiratory rate, memory, and hormone levels (Allard & Katseres, 2016).
When should aromatherapy be considered?
Pain
As a complementary intervention in pain management, studies show that aromatherapy seems to have beneficial effects on pain severity, and positively influences mood and quality of life (Starkweather, 2018). In their systematic review and meta-analysis, Lakhan et al. (2016) reported a significant positive effect of aromatherapy on reducing pain severity, most consistently with postoperative pain and obstetric and gynecologic pain. In the literature, lavender aromatherapy has been shown to have both analgesic and anti-inflammatory effects, making it an option to help manage pain (Silva et al., 2015; Kim et al, 2007; Starkweather, 2018).
Anxiety
Several studies looked at the use of aromatherapy to decrease anxiety in the perioperative period. Braden et al. (2009) looked at the use of olfactory and topical
lavandin, and using the vertical visual analog scale (VAS), reported significantly lower anxiety at the time of transfer into the operating room. In 2016, a randomized trial provided evidence that aromatherapy using
Satureja (savory), alone or concomitantly with mindfulness meditation, could reduce general anxiety levels (Soto-Vasquez & Alvarado-Garcia, 2017). One review documented effectiveness of
Lavandula,
Rosa damascena,
Citrus aurantium Duh,
peppermint, Valeriana officinalis, and
Matricaria chamomilla in reducing anxiety before surgery (Abed et al., 2020). Another study revealed that the use of lavender oil on patients undergoing hemodialysis decreased fatigue and anxiety levels (Karadag & Samancioglu Baglama, 2019).
Nausea
Research supports the use of essential oils for managing postoperative nausea and vomiting, as well as other gastrointestinal issues, such as dyspepsia and irritable bowel syndrome. Hunt et al. (2013) conducted a randomized trial of aromatherapy with patients who reported nausea in the postanesthesia care unit at one ambulatory surgical center and found significant changes in nausea level and request for antiemetic medications in the group who received aromatherapy with ginger or blend aromatherapy. Karaman et al. (2019) compared the effects of ginger, lavender and rose oils on postoperative nausea and vomiting, and concluded that ginger and lavender were superior to rose oil and pure water.
What do nurses need to know?
Only those with knowledge of safety, clinical protocols, appropriate product selection and administration should use essential oils. There are educational programs for nurses and other health care providers, and some provide continuing education hours and/or certification.
Assessing patients’ use of essential oils should be part of the conversation while taking health histories. Many patients don’t disclose use of complementary or alternative therapies unless asked. Some essential oils can potentially interact with medications, so it’s very important to integrate related questions into this part of your assessment.
Here are some more key points to keep in mind:
- Tinctures and essential oils aren’t the same. Tinctures are made with alcohol as the solvent, and are typically given orally or sublingually, and are less concentrated than essential oils (Perkins, 2020).
- Essential oils should never be applied undiluted, with the exception of lavender and tea tree oil (Perkins, 2020).
- Make sure patients know that essential oils should be applied topically or diffused into the air; they should not be taken orally unless under the supervision of a healthcare provider (Perkins, 2020).
Best Practices
- A well-developed protocol is essential to support safe and sustainable use of essential oils in the hospital setting (Allard & Katseres, 2016).
- Use only therapeutic grade essential oils (Perkins, 2020). Since essential oils are not regulated by the FDA, it is the responsibility of the facility or practitioner to ensure the quality of products (Allard & Katseres, 2016).
- Assess patients for allergies and sensitivities (Perkins, 2020).
- Encourage patients to ask questions and provide evidence-based answers and information.
- Ensure essential oils are stored appropriately to minimize degradation.
- Follow your facility’s policy regarding single-use products to prevent infection.
- Include use of aromatherapy in your documentation, including the use of scales to evaluate effectiveness (i.e., pain scales or nausea scales).
Research has shown the benefits of aromatherapy for certain indications in the acute care setting. In general, its use is well tolerated and inexpensive, and can lead to decreased use of pharmacologic agents. As with any intervention, it’s important to be well-educated in the use of aromatherapy before administering any essential oils.
Please explore the references and additional resources below for more information. Also, leave a comment to share your experiences – let’s learn from each other!
References:
Ebrahimi, A., Eslami, J., Darvishi, I., Momeni, K., & Akbarzadeh, M. (2020). Investigation of the Role of Complementary Medicine on Anxiety of Patients Before and After Surgery: A Review Study. Holistic Nursing Practice, 34(6), 365–379. https://doi.org/10.1097/HNP.0000000000000414
Allard, M. E., & Katseres, J. (2016). Using Essential Oils to Enhance Nursing Practice and for Self-Care. The American Journal of Nursing, 116(2), 42–51. https://doi.org/10.1097/01.NAJ.0000480495.18104.db
Braden, R., Reichow, S., & Halm, M. A. (2009). The use of the essential oil lavandin to reduce preoperative anxiety in surgical patients. Journal of Perianesthesia Nursing: Official Journal of the American Society of Perianesthesia Nurses, 24(6), 348–355. https://doi.org/10.1016/j.jopan.2009.10.002
Childers, P. M., & Aleshire, M. E. (2020). Use of Essential Oils by Health Care Professionals for Health Maintenance. Holistic Nursing Practice, 34(2), 91–102. https://doi.org/10.1097/HNP.0000000000000367
Cho, E. H., Lee, M. Y., & Hur, M. H. (2017). The Effects of Aromatherapy on Intensive Care Unit Patients' Stress and Sleep Quality: A Nonrandomised Controlled Trial. Evidence-Based Complementary and Alternative Medicine: eCAM, 2017, 2856592. https://doi.org/10.1155/2017/2856592
Ebrahimi, A., Eslami, J., Darvishi, I., Momeni, K., & Akbarzadeh, M. (2020). Investigation of the Role of Complementary Medicine on Anxiety of Patients Before and After Surgery: A Review Study. Holistic nursing practice, 34(6), 365–379. https://doi.org/10.1097/HNP.0000000000000414
Hunt, R., Dienemann, J., Norton, H. J., Hartley, W., Hudgens, A., Stern, T., & Divine, G. (2013). Aromatherapy as treatment for postoperative nausea: a randomized trial. Anesthesia and Analgesia, 117(3), 597–604. https://doi.org/10.1213/ANE.0b013e31824a0b1c
Karadag, E., & Samancioglu Baglama, S. (2019). The Effect of Aromatherapy on Fatigue and Anxiety in Patients Undergoing Hemodialysis Treatment: A Randomized Controlled Study. Holistic Nursing Practice, 33(4), 222–229. https://doi.org/10.1097/HNP.0000000000000334
Karaman, S., Karaman, T., Tapar, H., Dogru, S., & Suren, M. (2019). A randomized placebo-controlled study of aromatherapy for the treatment of postoperative nausea and vomiting. Complementary therapies in medicine, 42, 417–421. https://doi.org/10.1016/j.ctim.2018.12.019
Kim, J. T., Ren, C. J., Fielding, G. A., Pitti, A., Kasumi, T., Wajda, M., Lebovits, A., & Bekker, A. (2007). Treatment with lavender aromatherapy in the post-anesthesia care unit reduces opioid requirements of morbidly obese patients undergoing laparoscopic adjustable gastric banding. Obesity Surgery, 17(7), 920–925. https://doi.org/10.1007/s11695-007-9170-7
Knoerr K. (2018). Essential Oils: An Adjunct to Holistic Nursing. Gastroenterology Nursing: The Official Journal of The Society of Gastroenterology Nurses and Associates, 41(3), 250–254. https://doi.org/10.1097/SGA.0000000000000360
Lakhan, S., Sheafer, H., & Tepper, D. (2016). The Effectiveness of Aromatherapy in Reducing Pain: A Systematic Review and Meta-Analysis. Hindawi Publishing Corporation Pain Research and Treatment, 8158693. http://dx.doi.org/10.1155/2016/8158693
Meghani, N., Tracy, M. F., Hadidi, N. N., & Lindquist, R. (2017). Part II: The Effects of Aromatherapy and Guided Imagery for the Symptom Management of Anxiety, Pain, and Insomnia in Critically Ill Patients: An Integrative Review of Current Literature. Dimensions of critical care nursing : DCCN, 36(6), 334–348. https://doi.org/10.1097/DCC.0000000000000272
O'Malley P. A. (2016). Aromatherapy for Postoperative Nausea in Acute Care-Evidence and Future Opportunities. Clinical Nurse Specialist, 30(6), 318–320. https://doi.org/10.1097/NUR.0000000000000254
Perkins. A. (2020). Have you considered aromatherapy? Nursing Made Incredibly Easy!, 18(6), 20–24. https://www.doi.org/10.1097/01.NME.0000717688.95931.da
Silva, G. L., Luft, C., Lunardelli, A., Amaral, R. H., Melo, D. A., Donadio, M. V., Nunes, F. B., de Azambuja, M. S., Santana, J. C., Moraes, C. M., Mello, R. O., Cassel, E., Pereira, M. A., & de Oliveira, J. R. (2015). Antioxidant, analgesic and anti-inflammatory effects of lavender essential oil. Anais da Academia Brasileira de Ciencias, 87(2 Suppl), 1397–1408. https://doi.org/10.1590/0001-3765201520150056
Soto-Vásquez, M. R., & Alvarado-García, P. A. (2016). Aromatherapy with two essential oils from Satureja genre and mindfulness meditation to reduce anxiety in humans. Journal of Traditional and Complementary Medicine, 7(1), 121–125. https://doi.org/10.1016/j.jtcme.2016.06.003
Starkweather, A. (2018). Aromatherapy: Does It Make “Scents” as Complementary Therapy in Pain Management? Topics in Pain Management, 34(1), 1–8. https://www.doi.org/10.1097/01.TPM.0000544120.47075.8e
Board members are often asked to envision new ways to shape strategies to fulfill the board’s mission. For nurses, this is a natural role to contribute to board discussions. Nurses have significant and lived experience encountering challenges and opportunities, using their creativity to problem solve, develop ideas, and/or innovate.
So, what is innovation?
Innovation is discovering new possibilities through a new mindset triggered by a different context to enable new, useful, creative, and unexpected linkages that often generate a new solution or unique adaptation, resulting in optimal outcomes to benefit all stakeholders.
The SCAMPER technique
When faced with a request to contribute new ideas or solutions, it is important to be intentional as different perspectives are considered. It’s about making connections across seemingly unrelated things, people, and problems. The
SCAMPER technique, developed by Bob Eberle, is a tool that provides reflective questions to help drive innovative thinking in the boardroom.
- Substitute – Should we consider changing the name?
- Combine – Which are the best elements to include for a particular result?
- Adapt – Can we adapt the context or target group?
- Modify – What might we remove or make smaller, condensed, lower, shorter or lighter?
- Purpose – How might this be adapted for another purpose?
- Eliminate/Minify – What’s non-essential or unnecessary?
- Rearrange/Reverse – Can we change the pace or schedule?
Remember, innovation is about being intentional to problem solve or develop unique solutions. It is particularly relevant in the boardroom today with the fast-paced and dynamic environment all organizations are operating in.
How did nurse leaders innovate during COVID?
"The peak of the first wave of COVID was an unbelievable time of nursing innovation. Nurses reacted to evolving patient care needs and evolving knowledge of the disease in real time. One such example was the creation of special care teams that became expert in focused patient needs and providing much needed support to inpatient nursing staff. What this looked like for us, nurses from ambulatory care and procedural areas formed teams that provided technology-enabled family connections and proning teams. These teams provided critical care elements for the patients but also supported the ICU staff to provide other specialized care for the many patients under their care. A true example of innovation and teamwork!"
Debra Albert, Senior Vice President for Patient Care Services and Chief Nursing Officer, NYU Langone Health
References:
Huber, D., Bair, H., & Joseph, M. L. (2019). Roadmap to Drive Innovativeness in Health Care. Nurse Leader, 17(6), 505-508. https://doi.org/10.1016/j.mnl.2019.09.007
Mulder, P. (2018). SCAMPER Technique by Bob Eberle. Retrieved April 15, 2021 from ToolsHero: https://www.toolshero.com/creativity/scamper-technique-bob-eberle/
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
May is National Nurses Month!
#NursesMonth2021
Check our
Nurses Month page for:
- Nurses Month 2021 Series: Sharing What We’ve Learned
- FREE webinar, Lessons Learned: Calming the COVID-19 Storm
- FREE NCPD and Lippincott journal content
- ...and more!
National Student Nurses Day
May 8, 2021
National School Nurse Day
May 12, 2021
Theme: Championing the Whole Student
International Nurses Day
May 12, 2021
Theme: A Voice to Lead - A Vision for Future Healthcare
Neuroscience Nurses Week
May 9-15, 2021
Oncology Nursing Month
#OncologyNursingMonth
Healthcare Observances
Here are some of the healthcare observances being recognized in May.
Skin Cancer Awareness Month
#SharetheFacts #ThisIsSkinCancer
Mental Health Month
#MHAM #NotAlone
Theme: You Are Not Alone
American Stroke Month
#StrokeMonth
Critical Care Awareness Month
#NCCARM #BLUEICU
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
It’s Nurses Month again, and as we celebrate the anniversary of Florence Nightingale’s birthday, the founder of modern-day nursing, we can’t help but note that the many nursing practices she developed during her time are not only still relevant today, but in fact, have become important weapons in the fight against the COVID-19 global pandemic. What a year it’s been, caring for the sickest patients we’ve ever encountered, fighting an insidious, mutating virus, invisible to the eye but with effects unmistakable to all our senses.
Even as our country experiences social injustice on a scale not seen in decades, we still provide care without judgement to all of our patients. Nurses are over-spent, overwhelmed, exhausted and morally injured, frustrated that we can’t provide the care we’ve been trained for—yet we keep going. We recognize our calling is to care for those in need; to be champions for those whose voices are silenced or muted, and to use science to inform our decision-making, while fighting our own fears and acting as the bedrock of healthcare.
How have we accomplished so much in such a challenging year as 2020? When I look back in history to learn lessons from the past, it’s clear that Florence Nightingale also fought many overwhelming challenges throughout her life and career as a nurse. In her own words, “
I attribute my success to this – I never gave or took an excuse.” How true these words ring today. As nurses we don’t ever make excuses or take them from others. We simply rise to the occasion, no matter what, and get the job done. After all, the job is about caring for people.
We recognize that healthcare as a profession, needs to change and adapt to the consequences we’ve experienced this last year. We simply weren’t ready for pandemic. But we worked to cross-train and upskill nurses and other staff quickly to care for patients with COVID-19. In doing so, we brought care delivery systems from years past into the future, by creating an interdisciplinary care team model and shifting how we educate practicing and student nurses, to optimize a practice-ready workforce. And through our own ingenuity, innovation and creativity, we embraced change, and viewed it as merely another challenge to overcome, not an insurmountable obstacle.
Throughout this past year, we rediscovered our voice as nurses too. It’s a voice that not only speaks for those in need, but as leadership in healthcare, and one that can transform care delivery, with the insurance that every individual will have access to the best evidence-based, quality care. We’ve looked fear full in the face and said, “we will not be daunted.” As nurses, we represent quality care and are a vital part of the leadership team that transforms healthcare into the future.
As a nurse, I honor your dedication to those in need, this month and every month, and am humbled to be your colleague. Together, we can and will create a vision for healthcare’s future because “we never took or gave an excuse.” We simply just do what needs to be done for the good of all. We are nurses, after all.
Kristle Akau is a recent ADN graduate and a current RN-to-BSN student. Kristle is also the Resolutions Chairperson for the National Student Nurses' Association (NSNA).
Finishing up a nursing program during a pandemic was not only challenging, but also uncertain as students, faculty, and institutions fought to meet the required clinical hours for graduation.
Listen to our full conversation to learn how Kristle and those in her cohort pushed past their limits to be successful.
We also discuss:
- The week-by-week, then hour-by-hour, changes at the beginning of the pandemic
- Clinical simulation
- Showing up and being vulnerable
- The benefits of service opportunities
And much more…
Listen now...
Dr. Elizabeth Tomaszewski is the Program Director and Assistant Clinical Professor in the Adult-Gerontology Acute Care Nurse Practitioner Program at Drexel University, an active critical care nurse practitioner, and one of our Lippincott authors.
As an educator and clinician, Dr. Tomaszewski has had unique experiences and offers several perspectives of the COVID-19 pandemic.
Listen to our full conversation to learn how Dr. Tomaszewski adapted clinically, and led a team of educators to set the bar higher to ensure quality education.
We also discuss:
- Mailing procedural models to facilitate online learning
- Thinking outside of the box
- Remaining student-centric
- And much more…
Listen now...
Dr. Rosanne Raso is the Chief Nursing Officer and Vice President at New York-Presbyterian/Weill-Cornell Medical Center, as well as the Editor-in-Chief of
Nursing Management.
As a nurse leader in New York City, the responsibilities that Dr. Raso faced during the height of the COVID-19 pandemic in the spring of 2020 were unimaginable, but like any nurse, Dr. Raso faced this challenge with authenticity and grit, putting staff first while balancing accountability with prioritizing patient care.
Listen to our full conversation to learn how Dr. Raso, the medical center, and frontline clinicians managed issues such as staffing, personal protective equipment (PPE) shortages, and moral injury.
We also discuss:
- ‘Pop-up ICUs’ and specific resources and strategies used when NYC was the epicenter of the pandemic in the U.S.
- Leadership during times of crisis
- Self-care as a building block for resilience
- The effects of the pandemic across the country
- Advice for those considering a nursing leadership role
And much more…
Listen now...
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Dates
National Time Out Day
June 9, 2021
#AORNTimeOut2021
Healthcare Observances
Here are some of the healthcare observances being recognized in June.
Alzheimer's & Brain Awareness Month
#ENDALZ
Men’s Health Month
International Men’s Health Week, June 14-20, 2021
#MENSHEALTHMONTH #MHM2021 #MENSHEALTHWEEK #SHOWUSYOURBLUE #WEARBLUE #WEARBLUEFORMEN
Myasthenia Gravis Awareness Month
#MGStrong
National Safety Month
Themes: Week 1 - Prevent Incidents Before They Start; Week 2 - Address Ongoing COVID-19 Safety Concerns; Week 3 - It’s Vital to Feel Safe on the Job; Week 4 - Advance Your Safety Journey
Pride Month
#PrideMonth
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
In May of this year, the National Academies of Sciences, Engineering and Medicine, released, “The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.” This long-awaited blueprint for the future of nursing, along with two other instrumental reports, “The Future of Nursing: Leading Change, Advancing Health,” published in 2011, and “Assessing Progress on the Institute of Medicine Report on the Future of Nursing,” published in 2016, focus on the role of nursing to address the problem of health equity for all people in the United States. What makes the 2021 report unique is that it comes to us during the greatest healthcare crisis the U.S. has experienced since 1918 with the COVID-19 pandemic. Health inequity is a catalyst fueling our already broken healthcare system, with the issue needing to be addressed head on by nurses, if we are to find a remedy. But how can we do that? The answer is innovation.
Innovation is defined as creating something new or different, or introducing something known in a new or different way. It’s not always about inventing a light bulb. Innovation often adds efficiency or effectiveness to current processes or technology, and then brings renewed value. Sometimes innovation can be unsettling, taking a known situation and adding in a new element to disrupt and upset in order to add a perceived value. Innovation may borrow knowledge from one discipline and move it to another. And while sometimes innovation must and can be radical, it may focus on creating a completely new concept or system from which to transform the situation or process.
Without a doubt, innovation involves change, but nurses are experts at implementing change. We’ve demonstrated this over and over again throughout the past year and half, battling a raging pandemic. We’ve had to innovate new ways to provide care to the sickest patients through new care delivery models. We repurposed known technologies and integrated new ones into our current practice and in our clinical education methodologies so that nurses could be quickly cross trained to care for these new COVID patients.
As we look to address the issue of health equity in this country, we need to be innovative in our thinking too, to bring about change. We need to think differently about how we educate our nursing students and practicing nurses alike about the social determinants of health, inclusion, diversity and equity. We need to find new ways to continually support these concepts in our workplace and intuitions, for all of our clinicians, administration, faculty and students. Without this innovation of thought we will never be able to fully address the underlying issues of our patients.
We need to change our current care models and shift from disease-focused to wellness- and prevention-focused models, as we transform the where and the how we deliver care, as the care setting moves from an acute environment into the community and into peoples’ homes, in some cases with telehealth. Our healthcare organizations need to catch up and begin to focus more on immersing themselves into the community to provide support services for all of the diverse populations living there.
Health equity is a right for all persons. And as nurses we care for all without judgement. Nurses can and will lead a disruptive, and possibly radical innovation movement that’s needed to ensure health equity is available not just for some, but for all.
In case you missed it, last month I had the pleasure of interviewing four nurses to learn how they are doing after a year of COVID-19, what they learned, how they persevered, and what advice they have for others. I encourage you to read and/or listen to these interviews. They are encouraging and inspiring – nurses are pretty amazing. I’m also including my favorite quote from each of these nurses; they had so many wise words, it was hard to choose!
“This year has been lots of fear, lots of faith, marked by lots of personal and professional growth as well, pushing passed what I thought my limits were…getting uncomfortable and growing immensely along the way.”
Kristle Akau, ADN, RN
Listen to podcast.
“I’m proud to say that not one patient in my ICU died alone. There was always someone behind the door with them, holding their hand.”
Elizabeth Tomaszewski, DNP, CRNP, CCRN, ACNP-BC, ACNPC
Listen to podcast.
“One of the things that I really learned during this experience was the awesomeness of nurses. I always knew it, but now I really know it. Nurses responded fearlessly and courageously with grit and perseverance and innovation and I was never so proud to be a nurse and of nursing.”
Rosanne Raso, DNP, RN, NEA-BC, FAAN, FAONL
Listen to podcast.
“A big thing for me was…during a pandemic, nothing is an emergency. And what I mean by that is…you know, if your patient codes, you go running into the room; but during a pandemic – when you have a COVID-positive patient in a negative pressure room – it’s vital that you care for yourself and get that PPE on correctly.”
Wendy Hutchison Palma, BSN, RN
Listen to podcast.
A big thank you to these nurses for sharing their stories. I hope that you all had a good
Nurses Month and were recognized and applauded for your hard work each and every day. Please leave a comment and let us know how you are doing and/or share what you’ve learned through this pandemic.
Nursing2022 Drug Handbook® is nursing’s #1 drug guide.
It’s not easy being on the frontline of today’s time-stressed and rapidly-evolving healthcare environment. Every clinician needs to stay current on the newest drug therapies.
Administering the newest drugs with confidence — including remdesivir for the treatment of COVID-19 — is crucial in the defense against medication errors. For example, are you aware that remdesivir (Veklury) may cause acute kidney injury?
What is the Nursing2022 Drug Handbook?
Lippincott® — the most trusted source in nursing — has been publishing the most current drug information in annual editions of the Nursing Drug Handbook for over 40 years. Over 5 million nurses have relied on this comprehensive reference throughout every stage of their careers. Whether just entering the workforce or after years in the field as an experienced clinician, nurses trust Nursing Drug Handbook to include every need-to-know fact for safe drug administration.
As this reviewer of a recent 5-star rated edition states, Nursing Drug Handbook is “an RN must have! There’s no way to practice in today’s nursing world without a great drug reference at your fingertips and available when Wi-Fi is not!”
The first drug reference developed BY nurses, FOR nurses.
Unlike many other drug guides, only nurses guide a team of drug experts ... not physicians … not pharmacists … not consumers … to provide objective drug facts with NO drug company bias.
This comprehensive reference includes 3,500 generic, brand-name, and combination drugs — including 32 new FDA-approved drugs.
From administration guidance for every possible route to knowing when risks may call for changes to prescribed therapies, users can easily find answers to these new-drug questions …
- Which new drug approved to treat acute migraine with or without aura in adults has a maximum dose of 75 mg in 24 hours?*
- Which new drug is used in combination with trastuzumab and capecitabine to treat advanced unresectable or metastatic HER 2-positive breast cancer?*
- Which new drug is indicated for relapsing forms of MS, including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease?*
Nurses know best what nurses need, so the 2,071 clinical updates to 2022’s edition are included within nursing-focused sections for new dosages and indications, Black Box warnings, genetic-related information, adverse reactions, nursing considerations, clinical alerts, and patient teaching information.
Where can I buy the Nursing2022 Drug Handbook?
The brand-new edition can be ordered at 30% savings from publisher Wolters Kluwer. Learn more here.
We know that
qSOFA can be used to identify patients at risk for clinical decline and sepsis-related organ dysfunction (Singer et al., 2016). It encompasses three clinical variables:
- Respiratory rate > 22
- Altered mental status (Glasgow coma scale [GCS] < 15)
- Systolic blood pressure ≤ 100
The presence of any two of these criteria in a patient with a known infection should prompt further evaluation for organ dysfunction.
To remember these variables, use the acronym HAT:
- Hypotension (systolic blood pressure ≤ 100)
- Altered mental status (GCS < 15)
- Tachypnea (respiratory rate > 22)
Mnemonics are helpful – and often simple – ways to help remember complex things! Do you have a favorite mnemonic that you use regularly, or one that perhaps you learned a long time ago that still sticks with you?
Reference
Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J. D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J. L., & Angus, D. C. (2016). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.0287
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Here are some of the healthcare observances being recognized in July.
Juvenile Arthritis Awareness Month
#CUREARTHRITIS #KIDSGETARTHRITIS
World Hepatitis Day
July 28, 2021
Nursing Events
Anything missing? Please let us know in the comments!
Have a good month!
As we move away from the pandemic crisis into a time of healing and rebuilding, many nurses ask, “what can we do at this time to further build our own resilience?”
That question should not be how can
nurses can further build their resilience, but instead, how healthcare organizations can collaborate more efficiently with their workforce to foster resiliency and promote the wellbeing of their staff. Both the healthcare organization and the workforce need to work together to be part of this solution. But what are the necessary steps that must be taken?
Step 1: Recognize the value of the workforce
Recognize that the workforce as the most valuable commodity in a healthcare organization. Without a workforce, there will be no one to care for the people who need help the most—your patients. Health care leaders must be visible and up on the units to see, hear and talk to their staff, and then determine if the culture is one of support or in need of transformation. Social workers and mental health providers must also be available to identify the silent issues like burnout and moral distress, and then implement plans to help the individuals experiencing the distress, as well as for all other staff on that unit.
Employee assistance programs must also be easy to access and utilize, or they are of no help to anyone. Too many times, the solutions we put in place hinder progress instead of helping it, by over-complicating procedures.
Step 2: Meet basic needs of staff
The basic needs of staff must be regularly provided for. Things like healthy food options and accessibility to healthy food, along with adequate time to break for meals or other personal needs is essential.
Documentation burden is also a big issue for many nurses. You can start addressing this by having nursing represented on committees where documentation and additions to the electronic health record are being discussed.
And if staff are struggling financially or with family care responsibility burdens, recommendations for family care and financial counseling can, and should be part of the employee assistance resources. But most importantly, all individuals must be encouraged to recognize if and when they need help, and then assured that it’s OK to ask for it.
Step 3: Institute flexible care models
Institute agile, flexible care models. This should be done to ensure staffing is based on severity of illness/patient acuity, and not just on the number of patients. Primary nursing models are most often used during non-crisis times while team models are best utilized during crisis. However, if an organization has insufficient staffing, the team model of care is a good stop gap measure until the staffing issue is addressed.
Cross-training nurses on similar units (such as Progressive Care and Critical Care) can help increase the ability to move staff around where and when they are needed quickly. Remember that 12-hour shifts might not work for everyone, so it’s best to consider shorter shifts to add flexibility to scheduling.
Step 4: Invest in recruitment, orientation and retention strategies
Invest in recruitment, orientation, and retention strategies to promote workforce fit. Hire the best candidates not only for the job, but for the institution, and keep the talent where it belongs – as a valued part of the institutions’ current workforce. That means taking a serious look at the type of candidates you hire. While skill and experience are important, don’t forget that attitude and the ability to develop innovative solutions to solve a patient’s problem, is equally important.
Develop and invest in preceptors as well as current staff, so they can work together to develop and invest in the nurses who are newest to the profession. Support career and professional development by instituting career ladders and by providing continuing professional development educational activities, so your staff doesn’t have to look elsewhere for it.
Without a doubt, the workforce is a healthcare system’s most valuable asset. Resilience in the workforce is key to ensuring its health and staff wellbeing in order to optimize patient outcomes. However, commitment to improving the workforce well-being must be a collaborative approach between the organization and the individual. Together we can then make the necessary changes that will foster resiliency, improve workforce agility, and drive quality patient outcomes, now and into the future.
I experienced the feeling but didn’t know it had a name. How was
I qualified to be titrating life-sustaining medications and managing airways of critically ill patients? What right did
I have to be educating family members on end-of-life care? And should
my assessment really be used to make decisions that influence care?
What I was experiencing was
impostor syndrome.
What is impostor syndrome?
First defined in 1978 by Clance and Imes, the impostor phenomenon is used to “designate an internal experience of intellectual phoniness that appears to be particularly prevalent and intense among a select sample of high achieving women.” Now updated, the definition from Merriam-Webster is “a psychological condition that is characterized by persistent doubt concerning one's abilities or accomplishments accompanied by the fear of being exposed as a fraud despite evidence of one's ongoing success.”
So, what does this mean for nurses?
As a profession where transitions and advancement are often sought after, nursing is not immune to the effects of impostor syndrome. From the start of our careers as new graduates, we are thrust into a role where others rely on us for expert knowledge and skills. It takes time to develop those skills with much “on-the-job” training, so it stands to reason that as new nurses, developing feelings of impostor syndrome is a real threat. As we transition in new specialties and roles, advance our education, or switch paths from a clinical setting to an educational or business setting, for example, we are again faced with new challenges and experiences which take time to grow into.
In nursing, the reality is that time, staffing, and other workforce issues don’t usually allow us the time to develop our skills and confidence at our own paces. We quickly try to get up to speed, even concealing inadequacies at times, but low self-esteem is a breeding ground for impostor syndrome. We must recognize these real feelings and do something to combat them. If we don’t, burnout and job dissatisfaction are likely to ensue, and our own well-being is at risk.
Impact on certain populations
Interestingly, in a systematic review looking at prevalence, predictors and treatment of impostor syndrome, numerous studies found impostor syndrome to be prevalent among ethnic minorities. “A key finding from one of these studies is that impostor syndrome is a stronger predictor of mental health issues than minority status stress. This is particularly significant given that research on ethnic minority populations tends to focus on their minority status and presumed experiences of discrimination, rather than the individual differences within a minority group such as the impostor syndrome” (Bravata et al., 2020).
Overcome self-doubt and recognize your strengths
It is not unusual to doubt ourselves when facing new challenges, but impostor syndrome can generate an all-encompassing fear of being discovered as a fraud. The
American Psychological Association offers this advice for overcoming the fear associated with impostor syndrome:
- Talk to your mentors.
- Recognize your expertise.
- Remember what you do well.
- Realize no one is perfect.
- Gradually reframe your thinking.
- Get professional help.
Impostor syndrome is real. In fact, it’s believed that up to 70% of people have feelings of impostor syndrome at some time in their life (Haney et al., 2018). Don’t let these feelings derail your goals and achievements. Believe in yourself, get help when you need it, and spread awareness to help others.
References:
Bravata, D. M., Watts, S. A., Keefer, A. L., Madhusudhan, D. K., Taylor, K. T., Clark, D. M., Nelson, R. S., Cokley, K. O., & Hagg, H. K. (2020). Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. Journal of general internal medicine, 35(4), 1252–1275. https://doi.org/10.1007/s11606-019-05364-1
Clance, P. R., & Imes, S. A. (1978). The imposter phenomenon in high achieving women: Dynamics and therapeutic intervention. Psychotherapy: Theory, Research & Practice, 15(3), 241–247. https://doi.org/10.1037/h0086006
Haney, T. S., Birkholz, L., & Rutledge, C. (2018). A Workshop for Addressing the Impact of the Imposter Syndrome on Clinical Nurse Specialists. Clinical nurse specialist CNS, 32(4), 189–194. https://doi.org/10.1097/NUR.0000000000000386
John, S. (2019). Imposter syndrome: why some of us doubt our competence. Nursing Times [online], 115(2), 23-24.
Merriam-Webster. (n.d.). Impostor syndrome. In Merriam-Webster.com dictionary. Retrieved June 24, 2021, from https://www.merriam-webster.com/dictionary/impostor%20syndrome
Weir, K. (2013). Feel like a fraud? American Psychological Association. Retrieved July 12, 2021 from https://www.apa.org/gradpsych/2013/11/fraud
Regulation and release of the thyroid hormones occurs as a
negative feedback loop. What does this mean?
In simple terms, a negative feedback loop means that as something increases, the production of whatever is causing the increase slows down. So, picture a bowl of water that you want to keep full, but not let overflow. When it’s full, you stop adding water. If there’s a leak, you add water slowly to maintain the level. If it spills, you quickly add more. So when the volume of water
increases, you
decrease the addition of more water; if the bowl empties (the volume
decreases), you
increase the addition of more - hence the term,
negative feedback.
The thyroid hormones, T3 and T4, are regulated in much same way. When levels of T3 and T4 decrease below normal, the hypothalamus releases thyroid regulating hormone (TRH), stimulating the pituitary gland to produce thyroid stimulating hormone (TSH), which acts on the thyroid gland to produce more hormones and raise the blood levels. Once the levels rise, the hypothalamus “shuts off” and stops secreting TRH, which in turn inhibits the pituitary gland release of TSH.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Here are some of the healthcare observances being recognized in August.
National Breastfeeding Month
Theme: Every Step of the Way
World Breastfeeding Week
August 1-7, 2021
#WBW2021 #WABA #ProtectBreastfeeding
National Immunization Awareness Month
Psoriasis Action Month
National Health Center Week
August 8-14, 2021
Theme: The Chemistry for Strong Communities
#NHCW2021
International Overdose Awareness Day
August 31, 2021
#EndOverdose
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
The COVID-19 pandemic had a massive effect on learning and academic organizations. Undergraduate nursing programs had to pivot quickly from providing in-person education to digital or hybrid models. Clinical partners were forced to suspend in-person clinical encounters due to the patient surge, lack of personal protective equipment, resources, and preceptors, as well as the choice to not expose inexperienced students to critically ill COVID-19 patients. However, students still needed to continue the clinical learning experience. So, how did they do it?
Simulation. Healthcare simulation in nursing education is not a new concept. It’s been used historically to teach and verify competency through the creation of real-world situations and experiences. The simulation-based learning framework focuses on a learner-centered approach to teaching skills, collaboration, clinical decision making, prioritization, communication, and critical thinking to support clinical judgement in patient care (Kubin, et al, 2020; Lee, et al., 2019).
There are several types of healthcare simulation tools and scenarios used in education today, including whole-body manikins—either static, where the manikin does not respond to the learner, or high-fidelity where it does—to task trainers or actors who portray patients, to simulated healthcare scenarios using augmented and virtual reality software platforms.
With the move from in-person to the virtual classroom settings due to the pandemic, virtual simulation (VS) has moved front and center and enabled many students to experience a realistic experience through digital tools, from the comfort and safety of their homes. These programs provide authentic experiences for students to interact, learn and enhance their clinical decision making, collaboration, and clinical judgement skills (Lioce et al., 2020). Schools of nursing have adopted virtual simulation tools as their go-to alternative to clinical experience. Responding to the needs of educators and students, VS product developers have collaborated with many educators to synthesize new and enhanced simulation programs that optimize the student learning experience.
Forethought and the move to utilizing healthcare simulation as part of the curriculum made a big difference in how many nursing schools responded to the pandemic. The Society for Simulation in Healthcare supported the use of simulation as a viable, evidence-based, alternative to in-person clinical experience several years earlier (Foronda, et al., 2018; Foronda, et al., 2020; Verkuyl and Hughes, 2019), while the National Council of State Boards of Nursing had previously recognized that in-person clinical experience could be difficult to obtain, even before the pandemic, so recommended that simulation could be used as substitute for up to half of the clinical hours of experience required in undergraduate education (Hayden, et al., 2014).
Both these decisions enabled clinical experiences to continue for nursing students despite the COVID-19 pandemic. As researchers start to look at the clinical competence of the students who graduated during this historical time, it will be interesting to see how simulation and virtual education stacks up against in-person learning and clinical experiences.
Now that students are headed back to in-person, hybrid learning, and clinical experiences, simulation will continue to evolve and be adopted. In fact, healthcare organizations have recognized that simulation is an effective way to teach new skills and assess and insure competency of all nursing staff.
Nursing education demonstrated it could evolve quickly to meet the needs of its students during a health crisis. And the collaboration and innovation of simulation product developers, educators, learning management systems and technology has positioned nursing education well to support the future of healthcare.
References
Foronda, et al., (2018). Student preferences and perceptions of learning from vSIM for Nursing. Nurse Education in Practice, 33, 27-32.
Foronda, et al., (2020). Virtual simulation in nursing education: A systematic review spanning 1996 to 2019. Simulation in Healthcare, 14(1), 46-54.
Hayden, et al., (2014). The NCSBN national simulation study: A longitudinal randomized controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5: S1-S40.
Kubin et al., (2020). Fostering prioritization using a blended group and individual simulation approach. Nurse Educator, 45(1), 7-8.
Lee, et al., (2019). Effects of simulation-based learning on nursing student competencies and clinical performance. Nurse Education in Practice, 41, 102646.
Lioce, et al., (2020). The Terminology and Concepts Working Group(eds). Healthcare Simulation Dictionary (2nd ed.). Rockville, MD: Agency for Healthcare Research and Quality.
Verkuyl M., and Hughes, M. (2019). Virtual gaming simulation in nursing education: A mixed-methods study. Clinical Simulation in Nursing, 20(C), 9-14.
We thought it was over. We thought we had won. We got the vaccine! It became widely available. Everyone was going to get this vaccine, and we were going to be rid of COVID. No more masks, no more restrictions. We could visit our families. We could go on vacation. Right?
Then the public’s attitude changed. “Well, if everyone else is getting a vaccine, then I shouldn’t have to.” “It doesn’t align with my political views.” “I don’t believe in vaccines.” More and more Americans came up with a reason not to get the vaccine. We did not hit the magic number for herd immunity, and here we are: the Delta Variant. It’s more virulent and transmissible than the first, and maybe breaking through those vaccines that we thought were going to be the answer (CDC, 2021).
Masks are back in vogue, but are they? Now people are making the argument that we shouldn’t have to wear masks. It’s a restriction of our freedom and personal rights. We should be able to make up our own minds. There is no team effort anymore, or so it seems.
Nurses shake their heads. Here we go again. Many don’t feel that they can make it through another surge. Yes, we have the supplies now, but do we have the stamina? Can we listen to another person deny COVID‘s existence with their last breath? Can we hold up that iPad one more time so someone can say goodbye? Once held as heroes, the accolades seem to have faded for those who are still fighting for their patients. Now there’s another wave nursing must worry about. Compassion fatigue. How do we continue giving our best care for our patients, our families, and ourselves?
What is compassion fatigue? Figley & Figley (2017) describe this as a secondary traumatic response to witnessing another’s suffering. When nurses couple these feelings onto their own suffering, which many feel is on a “back burner,” the result is often a combination of emotional and physical exhaustion. Although this alone can seem daunting, so is the great responsibility nurses feel to their patients and coworkers leaving themselves taking care of themselves last. Nothing could be further away from what needs to happen.
Have you ever heard the announcements as a plane is about to take off? “If it is necessary to deploy the emergency oxygen, the instructions are to place the mask on yourself before on those who require your assistance.” The reason is simple: if you have no oxygen, you cannot help those who need you. The same is very true about nurses and self-care. So, what measures can we take to care for ourselves when we have so little left at the end of the day? I have some suggestions:
Take five. Five minutes before and after your shift for you away from the unit. Try to find an uninhabited space to allow yourself to decompress. Perhaps pop in those headphones and listen to a favorite artist.
Breathe. In with peace, out with stress. Easier said than done but give it a try. It can be contagious in a group setting.
Aromatherapy. I often suggest this one to my students with test anxiety. Lavender, chamomile, and sweet orange are popular for stress relief. Dab a little on your wrist or a tissue in a (very) deep pocket to avoid contamination.
Wash the shift away. Decontamination after work always gives a sense of cleanliness, but what about psychological cleanliness? Along with breathing, try to envision the tension washing down the drain. When you step out, it’s a new feeling.
Encourage your health system to take measures to provide self-care for their staff. Examples include disposable adhesive aromatherapy stickers, a quiet room with soft instrumental music and dim lighting, and debriefing opportunities at popular shift changes. These can be over the phone and anonymous, perfect for the ride home. The interest a health system has in the mental and emotional health of their employees is priceless, but sometimes they need a little
guidance as to what the staff needs.
We will make it through to see the end of COVID-19. Nurses must stick together and take care of one another and remember that we need the oxygen first.
References:
Centers for Disease Control and Prevention (CDC). (2021). Variant of concern. Retrieved August 6, 2021from https://www.cdc.gov/coronavirus/2019-ncov/variants/variant-info.html
Figley, C.R. & Figley, K.R. (2017) Chapter 28: Compassion Fatigue Resilience, in The Oxford Handbook of Compassion Science by Sepala, E. (ed). Oxford University Press.
As if COVID-19 couldn’t be more complicated, now we have the delta variant. Many people have questions for nurses, and sometimes the answers aren’t as easy as a Google search. There is a lot of misinformation (and disinformation) out there plaguing the public. How can you better answer some of the most popular questions surrounding this variant? We have some answers for you from the Centers for Disease Control and Prevention (CDC).
Question: What makes the delta variant different?
Answer: COVID-19 is a novel virus, which is a new strain of a coronavirus that is capable of mutation. The virus responsible is SARS-CoV-2, which has developed several variants of its own. Delta is one of many variants, but only one of four variants of concern presently tracked in the United States (Alpha, Beta, and Gamma are others). The delta variant is known to be more than twice as contagious and has become the most predominant strain in the United States. This strain may also cause more severe illness. The COVID-19 vaccines have been shown to provide protection from this variant, thus making unvaccinated individuals a population of great concern (Centers for Disease Control and Prevention(a), 2021).
Question: Does the vaccine really offer protection against the delta variant?
Answer: The COVID-19 vaccines available in the United States have been shown to provide protection from severe illness leading to hospitalization and death from the delta variant. The mRNA vaccines (Pfizer-BioNTech or Moderna) require two injections, with full vaccination status occurring two weeks after the second dose. If opting for the Johnson & Johnson/Jansson single-dose vaccine, full vaccination status occurs two weeks after the dose. During this two-week period, there is still vulnerability as the immune system responds to the vaccines to produce antibody protection. Although breakthrough infections may occur, the resulting illness is less severe thereby producing significant benefit with vaccination when compared to those who are unvaccinated. It should also be noted that those who are immunocompromised or have weakened immune systems may require a booster 28 days after the last dose of vaccine, as their response to the vaccines may be blunted (Centers for Disease Control and Prevention(a), 2021; Centers for Disease Control and Prevention(b), 2021; Centers for Disease Control and Prevention(c), 2021).
Question: Can those who are fully vaccinated spread the virus?
Answer: Those who are vaccinated can still become infected with the delta variant. Those who do often have mild or no symptoms and may not realize they are infected with COVID-19 and are able to spread the virus through droplets.
Question: Do those who are fully vaccinated need to wear a mask again?
Answer: The CDC recommends those at high risk for COVID-19 illness, those who live with those at risk who cannot be vaccinated, or who are in substantial or high transmission regions should be wearing masks while indoors to prevent spread of the delta variant (Centers for Disease Control and Prevention(c), 2021; Centers for Disease Control and Prevention(d), 2021). You can use this
COVID Data Tracker to find your county’s status.
Question: What risks does the delta variant pose to children unable to be vaccinated?
Answer: Currently, children under 12 are unable to be vaccinated but studies are ongoing to present for emergency use authorization (EUA). As previously noted, the delta variant is very contagious, and children are at risk as they return to school. The CDC recommends children should continue to take preventative measures, including wearing masks, social distancing, disinfection, and avoiding crowded areas. Parents should also inquire what measures are being taken in schools and daycare settings to provide protection for their children (including vaccinations for teachers/daycare workers). The CDC currently recommends “universal indoor masking for all teachers, staff, students, and visitors to K-12 schools, regardless of vaccination status” (Centers for Disease Control and Prevention(d), 2021; Centers for Disease Control and Prevention(e), 2021).
The data on children with COVID-19 is limited. Children with disabilities or chronic medical conditions such as obesity, diabetes, asthma, and sickle cell disease who develop COVID-19 are at higher risk for more severe illness (Centers for Disease Control and Prevention(f), 2021). Some children who have been infected with COVID-19 have been diagnosed with a condition known as multisystem inflammatory syndrome in children, or MIS-C. Symptoms can be vague but may include chest pain, diarrhea, lethargy, fatigue, low blood pressure, neck pain, vomiting, or rash. A parent of any child with COVID-19 presenting with dyspnea, persistent chest pain, altered mental status, or cyanosis should seek immediate medical attention by calling 911. Care should be taken to advise the emergency operator of the COVID-19 diagnosis (Centers for Disease Control and Prevention(g), 2021).
The COVID-19 virus continues to challenge the healthcare community as new variants are discovered. The features of each variant can differ, and we need to stay informed on prevention and management options as updates are released. There will undoubtably be more questions; and as nurses we have a duty to provide consistent and accurate information from reputable sources.
References:
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Clinical Nurse Specialist Recognition Week
September 1-7, 2021
#CNSweek
Theme: RISE of the CNS
National Pediatric Hematology/Oncology Nurses Day
September 8, 2021
Vascular Nurses Week
September 5-11, 2021
Nephrology Nurses Week
September 12-18, 2021
Nursing Professional Development Week
September 12-18, 2021
#NPDWeek
Neonatal Nurses Week
September 13-19, 2021
#NeonatalNursesWeek
Healthcare Observances
Here are some of the healthcare observances being recognized in September.
Sepsis Awareness Month
#SAM2021 #SepsisAwarenessMonth
World Alzheimer’s Month
#KnowDementia #KnowAlzhemiers #WorldAlzMonth
Theme: Know Dementia, Know Alzheimer’s
National Ovarian Cancer Awareness Month
Prostate Cancer Awareness Month
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
Do new nurse graduates possess the competencies they need for practice? According to a recent survey, only 23% of new nurse graduates possess the necessary entry level competencies to practice in the U.S. while only 34% possess the confidence (Wolters Kluwer, 2020).
The COVID-19 pandemic has only made this issue more pressing with many clinical sites being forced to shut down because they did not want to exhaust their personal protective equipment on students, were uncomfortable having students care for COVID-19 patients and didn’t want to risk exposing students to COVID-19. And because of the lack of clinical sites available for students to train in, academic centers were then forced to ramp up simulation programs to meet the rising clinical needs of their students.
An Innovative Approach
Some healthcare organizations took a different approach, however. Instead of barring student nurses from entering the healthcare setting, they developed and fortified their practice/academic partnerships, based on the model from the National Council of State Boards of Nursing, and welcomed students into their clinical sites to assist the clinical workforce.
Practice/academic partnerships have been around for quite some time; however, the pandemic has brought them into the forefront more than they had been in recent years. In fact, NCSBN developed a new practice/academic partnership model to assist the nursing workforce during the COVID-19 pandemic (NCSBN, 2020), that was then endorsed by ten national nursing organizations.
How does the practice/academic partnership model work?
Simply put, healthcare organizations partner with an academic center and then employ their faculty to work in the practice setting as well as in the academic, to oversee the prelicensure students in their clinical training. In addition, the students are then compensated for their clinical time, and receive academic credit for their clinical requirements. Students enrolled not only receive comprehensive training on how to care for patients firsthand, but also learn how the organization works, how to use all the necessary equipment, as well as how to utilize protocols in the facility. And upon graduation, many of these students are hired to work in the same facility they trained, since they have effectively completed the facility’s orientation program while still in school. Think nurse “externship” program with clinical faculty present to observe and oversee care delivery.
These practice/academic partnerships are so successful because the collaboration between the practice and academic settings determines the knowledge and skills necessary for a “practice-ready nurse graduate” to possess.
Impact on the Nursing Shortage
As we begin to realize the full impact of the pandemic on the nursing workforce, one thing is clear—the nursing shortage is here to stay. As baby-boomers and other generational nurses opt to retire or leave the profession altogether, we will need more nurses to fill those gaps. Using a practice/academic partnership model essentially sets up a feeder for healthcare organizations to attract, train and orient new nurses simultaneously. And the plus side is that these newly licensed nurses will then have more clinical experience than their previous counterparts, who were not part of a practice/academic partnership and therefore unable to train in a clinical setting to the same extent.
Overall, if we want to ensure the nursing workforce stays strong, investing and supporting practice/academic partnerships is not only recommended, but beneficial for all.
References:
NCSBN, 2020. Policy brief: U.S. nursing leadership supports practice, academic partnerships to assist the nursing workforce during the COVID-19 crisis. National Council of State Boards of Nursing. https://www.ncsbn.org/14573.htm
Wolters Kluwer, 2020. Closing the education-practice gap: Building confidence + competence. New Nurse Readiness Survey. https://www.wolterskluwer.com/en/expert-insights/survey-nursing-readiness
Being confident means having a realistic sense of your abilities and feeling secure about the value of your contributions based on your knowledge and experiences. When assuming a new board role, it’s natural to have some anxiety about serving as a board director. To make meaningful contributions in the boardroom, it is imperative to project confidence.
5 Steps to Build Confidence:
- Focus on the competencies you have learned serving in nursing roles that will translate well into effective board service.
- Prepare in advance of board meetings, highlighting topics on the agenda where you can contribute to the discussions through your experience, knowledge, and unique insights.
- Make your comments succinct and to the point; prepare specific remarks in advance of the meeting.
- LISTEN. While you may have initial thoughts to share, remain open to what you hear from other board members that may further shape or change your point of view.
- Meet your board colleagues outside of the boardroom to get to know them and understand their reasons for serving.
Remember, you were asked to serve for a reason. Boards function as a collective governing body. No one board member needs to possess all the skills and competencies required to fulfill its duties. As a board member, it’s important for you to project confidence so that your voice will be heard, considered, and acted upon.
Thought leadership includes mentoring organizational leaders, the value they each bring to boards in the community and across the nation. Developing nurse leaders to participate with confidence in the boardroom leads to diverse and inclusive solutions. Projecting this confidence in the boardroom builds the trust necessary to develop equitable solutions for future challenges.”
Tammy Simon RN, MSN, VP, Institute for Quality, Innovation & Patient Safety, Marshfield Clinic Health System
Our world changed 20 years ago with the terror attacks of September 11
th. On each anniversary, I remember where I was and what I was doing that day and during the following days, weeks, months. I was a new mother of twins, and my immediate thoughts were for the safety of my newborn babies. It was such a scary and emotional time.
Now, we remember the lives lost and the sacrifices made. In my memory, our country came together to mourn, pay homage, and rebuild. We were not divided by the events, but united. First responders worked together, putting their own lives on the line, to tackle the job at hand – first as rescuers, and later as they recovered the remains of victims from the rubble. Many still suffer health-related issues as a result.
Over the past 18+ months, we’ve been suffering again. This time by a pandemic. And racial divide. And political turmoil. And natural disasters. And again, my immediate thoughts are still for the safety of my “babies.” Like 20 years ago, there is no easy answer to successfully navigating these waters, however, we know that we are stronger together. My hope is that we find a way to again work together to control the pandemic, prioritize equity, respect our differences, and help one another recover.
As a nurse myself, the worry about my colleagues’ health and safety is front and center. How much more can this frontline endure? To my fellow nurses, thank you. You are doing work that many can’t even imagine doing yet they benefit greatly from your skills, knowledge and compassion. Keep your head up, take advantage of opportunities for self-care, and know you are valued and appreciated.
Late last year, my colleague and I wrote the blog post,
10 Ways to Stay Positive during Tough Times. It’s been read so many times that it really reinforces how many of us are struggling and searching for ways to cope. As we remember the events of 20 years ago, I encourage all of us to remember how far simple kindnesses can go. Remember to smile, share thoughtful words and gestures, offer and accept help, and look for ways to stay positive.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Midwifery Week
October 3-9, 2021
#NMW2021, #MidwivesforEveryCommunity
Theme: Midwives for Every Community
National Pediatric Nursing Week
October 4-8, 2021
#ProudPediatricNurse
Emergency Nurses Week
October 10-16, 2021
#ENWeek
Theme: Grit
National Case Management Week
October 10-16, 2021
#NCMW
Theme: Case Management: Care, Compassion, Community
International Orthopaedic Nurses Week
October 25-30, 2021
#OrthoNursesWeek2021, #IAmAnOrthoNurse.
Healthcare Observances
Here are some of the healthcare observances being recognized in September.
Domestic Violence Awareness Month
#WeAreResilient
National Breast Cancer Awareness Month
Theme: RISE
Mental Illness Awareness Week
October 3-9, 2021
Theme: Together for Mental Health
#Together4MH
National Healthcare Quality Week
October 17-23
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
The past two years have been some of the most challenging years many of us have ever faced in our lifetimes. States, cities and communities across the country have been rocked not only by the COVID-19 pandemic, but concurrently impacted by diversity, inclusion, and equity issues, social unrest and natural disasters to top it off.
We know that our healthcare organizations need to care for the entire community as much as they care for each individual patient. People need access to care, social support, education, safe housing, and jobs so they’re able to support themselves and their families. And as nurses we’ve known this fact to be true for decades. Just look at historical leaders like Lavinia Dock a trailblazer in nursing and social reform, and Clara Barton, founder of the American Red Cross, and many others who stepped up to address the healthcare, social, and equity issues of their day.
Affecting positive change
But what about today? How can nurses today be leaders within their communities and affect positive change?Nurses working in the public health and homecare sectors are experts in instituting change in communities, so maybe we can learn from their experiences. We can start by looking at what’s happened during the pandemic. Nurses in active practice and those who’ve been away from the bedside for years, stepped up, joined in, and started volunteering in vaccination centers and healthcare clinics around the country and the world. And if patients couldn’t get to the clinics, nurses went into the communities to bring care to them, breaking down access barriers and providing healthcare and education to the people who lived there so they could make more effective evidence-informed decisions.
In many states, nurses led and participated in teams that worked to clean up communities after natural disasters. Going door to door, nurses worked to make sure the people who were affected had a safe and clean place to live, food to eat, clothes to wear, and access to healthcare and necessary medications.
But most remarkably, over the past several years, we’ve started seeing more nurses serving on organizational boards than ever before. According to the Nurses on Boards Coalition, there are over 10,000 nurses serving on boards today around the country. Having a seat at the table where decisions are made, and important issues are discussed is paramount to addressing our community needs and affecting necessary change. And nurses are starting to take charge of policy too. Nurses are beginning to extend their reach in local, state, and federal government by being a voice and an advocate for the people they serve.
Making a difference in our communities
So, how can nurses make a difference in their communities? They can start by showing up where there is a need and then motivating others to join them in their important work. That’s what our communities need today – nurses who can and do advocate for others in need by being their voice, providing necessary health education, and breaking down the barriers to equitable healthcare. We know those we care for better than anyone else, so let’s use this opportunity to better know and serve our individual and collective communities too.
Diuretics are medications that are used to treat hypertension, and edema due to heart failure, liver failure, certain renal disorders, and some drug therapies. Specific classes of diuretics work differently, targeting different segments of the nephron, except for the osmotic diuretics, which work throughout the nephron. The most important thing to remember is that diuretics affect fluid and electrolyte balance, so it’s critical to monitor intake and output, weight, and electrolyte levels – especially potassium – closely. Let’s take a closer look at the classes of diuretics and how they work, and what nurses need to know.
Loop Diuretics
Loop diuretics have their effects in the ascending limb of the loop of Henle. They are first-line therapy for acute relief of pulmonary and peripheral edema due to heart failure but are also used to treat edema associated with liver cirrhosis, and renal disease, including nephrotic syndrome. The most well-known agent is
furosemide. Other drugs in this class include
bumetanide, torsemide, and
ethacrynic acid. Many loop diuretics are available in both oral and IV forms.
Loop diuretics are generally well tolerated. Diuretic-associated hypokalemia can lead to cardiac arrhythmias in patients with coronary or cardiac insufficiency, and loop diuretics are also associated with dose-related ototoxicity (co-administration with aminoglycosides should be avoided.)
Thiazides and Thiazide-Like Diuretics
Thiazide diuretics inhibit sodium chloride reabsorption in the distal convoluted tubule. They are first-line agents for the treatment of hypertension and are often used together with loop diuretics for their synergistic diuretic effects in heart failure. They are administered orally.
Hydrochlorothiazide is an example of a thiazide diuretic. In addition to its effects on renal electrolyte handling, hydrochlorothiazide decreases glucose tolerance and may unmask diabetes in patients at risk for impaired glucose metabolism. Hydrochlorothiazide should be taken several times a day. A longer acting thiazide,
chlorthalidone, can be taken once a day.
Thiazide diuretics should not be administered concurrently with antiarrhythmic agents that prolong the QT interval (i.e., quinidine, sotalol), due to the risk of torsades de pointes; this may be related to thiazide-induced hypokalemia, which increases the potential for cardiac arrhythmias. Patients should also be monitored for symptoms of acute pancreatitis.
Carbonic Anhydrase Inhibitors
Carbonic anhydrase inhibitors decrease sodium and bicarbonate reabsorption in the proximal tubule. While considered diuretics, these drugs are also used for glaucoma, idiopathic intracranial hypertension, altitude sickness, and epilepsy, among other diseases.
Acetazolamide is an example of a carbonic anhydrase inhibitor; it may be used as an adjunctive therapy to treat edema due to heart failure. It is available in both an oral and IV form.
Potassium-Sparing Diuretics
Potassium-sparing diuretics increase nephron reabsorption of potassium by interrupting sodium reabsorption in the collecting duct. They are typically used with a thiazide or loop diuretic to enhance its action, as potassium-sparing diuretics have weak diuretic and antihypertensive effects when used alone. Examples are
spironolactone,
amiloride, and
triamterene. In contrast to the other classes of diuretics, the risk of
hyperkalemia is increased.
Osmotic Diuretics
Osmotic diuretics increase urinary flow by osmotic retention of water throughout the nephron.
Mannitol is used to decrease intracranial pressure and cerebral edema. It is given by IV injection (intermittent bolus preferred), and preferably via a large central vein, as it is a vesicant.
Nursing Considerations
As with any medication, it’s important for nurses to be familiar with the specific diuretic(s) a patient is taking, including indication, dosage and administration, contraindications, interactions, and adverse effects. Below are some general considerations related to diuretics.
- Assess patients for sulfa allergies, as some diuretics are sulfonamide derivatives.
- Monitor weight, intake, output, and serum electrolyte levels.
- Monitor blood glucose levels (some agents may cause hyperglycemia).
- Follow blood urea nitrogen and creatinine levels regularly.
- Administer diuretics in the morning to prevent nocturia.
- Educate patients on the agent(s) they are prescribed and review adverse effects of therapy.
I had waited for this day for years, I was finally an acute care nurse practitioner, beginning my first day of work as a trauma NP in a high acuity/volume level two trauma center. It had been years in the making, filled with what seemed like endless clinical hours, SOAP notes, lectures, hours and hours of studying, research papers, and let’s not forget the tears! I finished my program, passed my boards, made it through what seemed like YEARS of credentialing, and I was finally here – I had done it! I made my transition from a bedside emergency/trauma nurse to a trauma nurse practitioner, right where I wanted to be. I was fully equipped with all of the skills and knowledge that I needed to make this transition; I mean I did spend years in NP school, right? Well, truth be told there was nothing that I could have learned from a book or lecture during my schooling that would have prepared me for this role change. I went into this new career knowing what I was leaving behind. I was leaving behind my expert status as a bedside nurse and trading it for novice status as a brand-new nurse practitioner. I entered this new endeavor with enough self-realization that I knew nothing, and that my first years spent as a nurse practitioner would not be easy; it would require lots of patience and grace and most importantly, a lot of learning.
In the beginning
My first week in my new role was a huge eye-opener. As a bedside ED/trauma nurse, I knew exactly what I was doing; I could anticipate what needed to be done in a resuscitation and felt confident and calm in any given situation. Although my 9+ years of experience in this role did help me tremendously transition form RN to NP, I quickly realized there was so much that I didn’t know, and so much that goes into being a provider that you don’t realize. I think the biggest eye opener for me was the importance of time management and attention to detail. I would hardly order ibuprofen without a bit of hesitation and self-doubt. I spent my first year studying, listening intently during rounds, researching algorithms and treatment guidelines, and learning from everyone I could. Most importantly I spent my first year (and still do) constantly double and triple checking everything I did, because the most important thing as a new provider is to realize that your ego is never more important than your patients. I learned it is okay to not know everything, and it’s ok to ask questions and to constantly second guess yourself because at the end of the day every order you place and decision you make is now on you.
I have been a nurse practitioner for three years now, and I still see myself as a novice, but with every patient encounter my confidence grows just a tiny bit. I still find myself in a constant state of questioning and learning and to be honest I don’t see that ever changing in me. While this role has been a difficult transition, I have to say that it has been the most rewarding! I have finally found my niche, and a career that leaves me feeling fulfilled in every aspect of my professional life. I can’t say I am an expert anymore and that’s okay – maybe someday I will get there again like many of my co-workers. For now, I can leave you with some advice, just a few tips that I have picked up along this journey that I hope can help new NPs in their role change.
Advice for new NPs
- Never forget you’re a nurse. One thing that I will never ever forget is that I am a nurse. Always remember where you started. Now that you’re a provider doesn’t mean that you aren’t able to help your fellow nurses. You can and should help “give a boost,” cut up someone’s food and feed them, assist with a bedpan or a bed bath, and take the time to sit and hold someone’s hand and lend a listening ear when needed. Also, respect the nurses that carry out your orders. If they question what you order, be thankful and gracious, because someday they will save you from a mistake. Answer their questions and pages and be nice, be approachable and remember that you were once in their shoes.
- Stay current. Healthcare is constantly changing. Just because you now have your master’s degree and have passed your boards, your education isn’t over. Read new articles and treatment algorithms, stay up to date on new drugs/antibiotics, and always be open to learning.
- Listen. I can’t stress this enough. You have to always be listening and engaged. Listen to your patients, attendings, colleagues, nurses and everyone involved in the patient’s care. It’s important to remember that you aren’t treating a set of symptoms, you are treating a human being! Listen to them and listen to those around them.
- Double check yourself. It’s always a good idea, especially when you are first starting out, to constantly double check yourself. When ordering medications, consult with your pharmacist (I became best friends with our clinical pharmacist.) It is ok to ask questions to ensure you are providing the best care possible! At the end of the day or with any downtime I have, I always – still till this day – double check all my patient orders.
- Have confidence. Lastly, be confident! You have made it this far and that is something to be proud of. Trust your instincts and your gut and stand behind your decisions. No one will ever fault you for making a decision you took the time to think through! Have confidence, but don’t ever forget that asking questions and leaning on someone else for a second opinion is important.
Welcome back to our drug calculation series. In the first two installments we reviewed two common calculation methods - the
universal formula and
dimensional analysis (DA). In Part 3, we used DA to
calculate continuous intravenous (IV) drips, beginning with units per hour (u/hr). In this blog, we will now use the DA method to calculate continuous IV drips in micrograms per minute (mcg/min). Don’t forget, every nurse should be comfortable with basic metric conversions. You can find a handy conversion chart in our
Nursing Pocket Card: Common Calculations.
Intravenous Drips: Convert mL/hour to mcg/min
Example: You receive shift report that your patient is on a nitroglycerin drip for blood pressure control. You check the pump and it is running at 6 mL/hour. The label on the bottle reads 50 mg in 500 mL 0.9% sodium chloride solution. How many mcg/min is the patient receiving?
Step 1: What label is needed? Nitroglycerin is delivered in a continuous drip dosed at mcg/min. This is placed on the left side of the equation.
Step 2: Next we need to convert the concentration from mg/mL to mcg/mL in order to get the same label in the numerator. There are 50 mg in 500 mL. Convert the mg to mcg by multiplying by 1000.
The concentration is
100 mcg/mL.
Step 3: Place the same label in numerator on the right side of the equation then alternate labels in the numerator and denominator so the labels cancel out.
Step 4: Multiply numerators, multiply denominators, then divide numerator by denominator.
Answer: 10 mcg/min
Intravenous Drips: Convert mcg/min to mL/hr
Now let’s reverse the problem and convert mcg/min to find the pump rate mL/hr.
Example: The provider places an order for a nitroglycerin drip at 10 mcg/minute.The pharmacy delivers the infusion bag of nitroglycerin and the label on the bottle reads 50 mg in 500 mL 0.9% sodium chloride solution. At what rate should you set the IV pump?
Step 1: What label is needed? You want to set the IV pump in mL/hr. This is placed on the left side of the equation.
Steps 2: Next we need to convert the concentration from mg/mL to mcg/mL. There are 50 mg in 500 mL. Convert the mg to mcg by multiplying by 1000.
The concentration is
100 mcg/mL.
Step 3: Place the same label in numerator on the right side of the equation. Flip the concentration so that mL is in the numerator and 100 mcg is in the denominator. Then alternate labels in the numerator and denominator so the labels cancel out.
Step 4: Multiply numerators, multiply denominators, then divide numerator by denominator.
Answer: 6 mL/hour
Remember These Tips:
- Check that your answer makes sense clinically.
- Double check your work.
- Have a colleague or pharmacist check your work.
- Know general therapeutic drug doses for commonly administered medications
I hope this review has been helpful. Next month, we will review continuous IV infusions for weight-based drugs (mcg/kg/min) using dimensional analysis. Be sure to check back then!
References:
Cookson, K.L. (2013). Dimensional analysis: Calculate dosages the easy way. Nursing2013, 43(6), 57-62.
Koharchik, L.S. & Hardy, E.C. (2013). As easy as 1, 2, 3! Dosage calculations. Nursing Made Incredibly Easy!, 11(1), 25 – 29.
Wilson, K.M. (2013). The nurse’s quick guide to I.V. drug calculations. Nursing Made Incredibly Easy! 11(2), 1 – 2.
Didn’t we just learn the sepsis guidelines? It didn’t seem that long ago; however, the Society of Critical Care Medicine (SCCM) has been busy studying the evidence and ensuring that the best care possible can be delivered to those suspected of having sepsis. For many, reading through the 93 recommendations for 2021 can be cumbersome and confusing. How do they differ? Why are we changing them? Here are some of the highlights.
In terms of general recommendations, there are two updates. First, SCCM is recommending not only a performance improvement model, but also a standard operating system for the identification and treatment of sepsis. This may include identification tools, as well as standard order sets to facilitate implementation of the guidelines. The second may be surprising: SCCM no longer endorses the use of qSOFA as a single identification tool for those at risk for sepsis, in favor of multivariate instruments such as MEWS, SIRS, and NEWS. As a simple tool, qSOFA gained popularity, but there is strong evidence to support use of other tools that take other factors into consideration.
Now on to resuscitation. Fluid boluses of 30mL/kg within 3 hours are now
suggested, rather than
recommended. Why? Some patients, such as those with heart or renal failure, are not always the best candidates for these boluses. The language was adjusted to allow for clinical decisions based on individual patients. There is also a new suggestion to utilize capillary refill time to guide resuscitation, in addition to other assessments.
There have been some updates to how infection or suspected infection is to be treated. The new strategy seems to steer away from nonjudicious use of antibiotics, in favor of “time-limited” close monitoring for those with low risk of infection and deferring antibiotics in those patients. For those in septic shock or high suspicion of sepsis the recommendation remains antimicrobials be administered within one hour of identification, with a change in terminology from “sepsis without shock” to “high likelihood for sepsis.” For patients with a high risk of MRSA, antimicrobials with MRSA coverage are recommended over those without. For those patients with a low risk of MRSA, the suggestion is antimicrobials without MRSA coverage. In the same fashion, SCCM recommends those patients at high risk for fungal infection to be covered for same and suggests against antifungal coverage in those at low risk of fungal infection.
Moving on to hemodynamic management, SCCM has updated their position as a suggestion to use a balanced crystalloid approach, as opposed to normal saline; and suggests against using gelatin for resuscitation. For those with hypotension and cardiac dysfunction with persistent hypoperfusion despite euvolemia and adequate mean arterial pressures, SCCM is suggesting against the use of levosimendan due to low quality of evidence to support its use. When hypotension is present, SCCM suggests starting vasopressors peripherally rather than delay for central venous access. There has also been an about-face regarding hydrocortisone in those with adequate fluid volume and persistent hypotension despite vasopressors, now suggesting IV corticosteroids.
For those with sepsis-induced acute hypoxemic respiratory failure, high flow nasal oxygen is favored over conventional non-invasive positive pressure ventilation such as BiPAP. In those patients with sepsis-induced moderate to severe ARDS, Veno-Venous (VV) ECMO is recommended, provided the facility has the experience and resources to do so. This, of course, may not be available and transport may not be possible depending on the degree of hypoxemia.
Finally, there are two new recommendations regarding additional therapies that may be used in sepsis. PolymyxinB hemoperfusion and infusions of vitamin C in those with sepsis or septic shock originally had no recommendation. A low quality of evidence prompted SCCM to suggest against both practices.
The Society of Critical Care Medicine has continued to evaluate the evidence to improve the care of patients with suspected and confirmed sepsis. Although the changes may seem cumbersome, many involve a language change to better serve patients who may not always benefit from the full recommendation. In other cases, evidence supports a change in practice or advising against a practice. Another example of how evidence-based practice impacts our best patient care.
Reference:
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 1–67. Advance online publication. https://doi.org/10.1007/s00134-021-06506-y
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Medical-Surgical Nurses Month
#MSNW21
Urology Nurses and Associates Week
November 1-7, 2021
National Nurse Practitioner Week
November 7-13, 2021
#NPWeek
Theme: Advocacy
Forensic Nurses Week
November 8-12, 2021
#FNWeek
Perioperative Nurses Week
November 14-20, 2021
#periopnursesweek2021
Theme: Advocacy
Healthcare Observances
Here are some of the healthcare observances being recognized in November.
National Diabetes Month
#DiabetesMonth
Theme: Small Steps, Big Difference: Preventing diabetes is within your reach
National COPD Awareness Month
#COPDMonth, #BreatheBetter
Lung Cancer Awareness Month
#LCAM
National Family Caregivers Month
#CaregiverAnd
National Hospice Palliative Care Month
Theme: It’s About How You Live
National Family Health History Day
November 25, 2021
Nursing Events
See all events for 2021 here!
Anything missing? Please let us know in the comments!
Have a good month!
Health equity, or giving patients the best care, when and where they need it, is a simple, yet powerful sentiment. Those two words, “health equity,” conjure up an idea that everyone has equal value and deserves the highest quality care whenever and wherever they need it. It’s about ensuring access for all, to quality care, while understanding that “equal” care and “equity of care” are not the same things at all. Equality means everyone is treated the same exact way, regardless of their needs or any individual differences. Equity, on the other hand, means everyone is provided with what they need, when they need it, and considers social determinants.
Since people all have different and individual needs, the care they receive should also be adjusted to best fit an individual’s or community’s needs. Care should always be delivered without judgement. And to achieve that, we need to first recognize and then overcome our own inherent biases and beliefs. To deliver the best and most equitable care, we need to use the best available evidence to inform all of our clinical decisions, recognize when care variability is occurring, and then address it, while tailoring care to individual needs. All these things together foster equitable, best care everywhere.
What Needs to Change?
COVID-19 has brought clarity to a situation that we all knew existed – we’re not delivering equitable, evidence-informed healthcare consistently across the country. Resources aren’t allocated equitably so the most impoverished and marginalized populations don’t have the same access to healthcare and health professionals or facilities as others might and still deserve. This fact needs to change. Healthcare systems need to recognize that they are not only caring for individual patients, but also for the communities in which they serve. Healthcare organizations and public health agencies need to address the social determinants of health issues more frequently so they can recognize and intervene when necessary, and then provide optimal, equitable care with programs that support local clinics, social and mental health, grocery stores and food pantries, along with robust patient education, that includes afterschool programs for children.
In our healthcare institutions, we need to ensure that all healthcare professionals have the same access to the best evidence-based information across all disciplines. And that evidence needs to be used to inform all clinical decision-making at the bedside. Healthcare institutions need to also recognize and be more aware of care variability when it is occurring, and then implement quality improvement programs to change current practice and behaviors to optimize patient outcomes.
More Issues to Address
Organizations need to also recognize that many deviations from best practice may be systemic or process-based, so addressing these issues should not be punitive but instead fully investigated for root-cause analysis before being modified to support best practice and greater patient outcomes.
Data should be properly analyzed to discover opportunities for care improvement. And new technology should not be adopted into organizations without first performing due diligence to ensure new tools will support and enhance patient care. It’s also important that nurses and other frontline clinicians take part in the decision-making process.
Equitable, best care everywhere – simple yet powerful words that have the power to change how we practice and deliver care to those in need. Those words have the power to inspire innovation and creativity while guiding us to a better and more equitable future in healthcare.
Are you ready to deliver best care everywhere?
Welcome back to our drug calculation series. We’ve reviewed quite a bit of information so far including the
Universal Formula and
Dimensional Analysis (DA). We used the DA method to calculate tablet doses, intravenous bolus doses and continuous IV drip rates in
units per hours (u/hour) and
micrograms per minute (mcg/minute). We will now take the DA method one step further to calculate weight-based continuous IV drips. Don’t forget, every nurse should be comfortable with basic metric conversions. You can find a handy conversion chart in our
Nursing Pocket Card: Common Calculations.
Intravenous (IV) Drips in mcg/kg/minute
Example: Administer dopamine at 10 mcg/kg/min. The pharmacy provides dopamine 800 mg in 250 mL of D
5W. What is the hourly IV pump rate? The patient weighs 85 kilograms.
Step 1: What label is needed? We want to know what rate to set the IV pump.
Step 2: Place the same label in numerator.
Step 3: Alternate labels in numerator and denominator so labels cancel out.
We want to get to micrograms and we know 1 milligram (mg) equals 1000 micrograms (mcg). Place this in the equation so that milligram labels will cancel out.
Add the prescribed dose 10 mcg/kg/min, placing mcg in the numerator so that it will cancel out.
Add 60 minutes/hour next so that minutes cancel out.
Finally, add the patient’s weight in kilograms. If the weight is in pounds, you will need to convert it to kilograms before adding it to the equation.
Cancel out the labels until you are left with mL/hour.
Step 4: Multiply numerators, multiply denominators, then divide numerator by denominator.
Answer: 16 mL/hour
Now let’s reverse the calculation.
Example: You are waiting to receive shift report. In the meantime, you review the continuous drips that are running. You see your patient is on a dopamine drip and the pump rate is 16 mL/hour. The concentration of dopamine is 800 mg/250 mL. The patient weighs 85 kilograms. What dose is your patient receiving?
Step 1: What label is needed? Since we are looking for the dose in micrograms per kilogram per minute (mcg/kg/min) and it is difficult to solve with more than two variables, let’s first solve for mcg/min. Then we will incorporate the weight (kg) at the end.
Step 2: Place the same label in numerator. Before we can do this, we need to convert the concentration from miligrams (mg) to micrograms (mcg). Our concentration is 800 mg in 250 mL. Multiply this by 1000 mcg per mL and simplify the fraction to get 3,200 mcg/mL.
This can now be added to the right side of the equation.
Step 3: Alternate labels in numerator and denominator so labels cancel out. We know our current pump rate is 16 mL/hour. This is placed next in the equation.
We know there are 60 minutes in one hour. This is placed next in the equation.
Cancel out the labels until you are left with mcg/min.
Step 4: Multiply numerators, multiply denominators, then divide numerator by denominator.
Step 5: Divide by the weight in kilograms to get mcg/kg/min.
Answer: 10 mL/hour
General Tips:
- Check that your answer makes sense clinically.
- Double check your work.
- Have a colleague or pharmacist check your work.
- Know general therapeutic drug doses for commonly administered medications.
These calculations can be tricky but get easier with practice. In the next and final installment of this series, we will review how to calculate drops per minute which is a handy calculation to know when you are not using an IV pump. Be sure to check back next month!
References:
Cookson, K.L. (2013). Dimensional analysis: Calculate dosages the easy way. Nursing2013, 43(6), 57-62.
Koharchik, L.S. & Hardy, E.C. (2013). As easy as 1, 2, 3! Dosage calculations. Nursing Made Incredibly Easy!, 11(1), 25 – 29.
Wilson, K.M. (2013). The nurse’s quick guide to I.V. drug calculations. Nursing Made Incredibly Easy! 11(2), 1 – 2.
I’ve been a nurse for over 37 years and a nurse practitioner since 1998 and I have never been prouder of the NP profession. In 1965, Loretta Ford, EdD, RN, PNP, FAAN and Henry Silver, MD started the first NP program, and over the years we’ve grown to over 325,000 nurse practitioners in the U.S., according to the latest statistics from the American Association of Nurse Practitioners. The pandemic has solidified the truth about who we are as healthcare providers and professionals. These are things we’ve known for years, yet some are only beginning to recognize our worth.
What NPs Stand For
We believe health equity is a right of all people. To achieve health equity, we recognize that one size healthcare for all just doesn’t work. People are individuals and it’s important that healthcare is tailored to meet the needs of the person to ensure the highest quality care.
We know that all people deserve access to quality health care no matter their zip code, skin color, gender, identity, or sexual preference. We believe in equitable care without judgement.
We know that healthcare institutions must recognize they care for the community, not just individual patients, and as such must meet the community where care is needed. That means ensuring healthcare providers are out in the community providing care.
We believe healthcare needs to be multidisciplinary and each discipline is equally important. We are advanced practice nurses trained and educated to provide healthcare and ensure the highest quality care and life for people in need, and we do it by collaborating with all disciplines.
We know the patient is the “captain” of their health and we are there to help them make informed decisions along the way by educating them with the latest and best available evidence.
This week we celebrate Nurse Practitioner Week and all the great things we’ve accomplished in our profession. We are healthcare providers who deliver equitable care without judgement to all people! Thank you to all my nurse practitioner colleagues for your dedication to your patients and the profession.
In this final month of 2021, there are just two healthcare observances to share with you here.
World AIDS Day
December 1
#WorldAIDSDay, #RockTheRibbon
National Influenza Vaccination Week
December 5-11
#FightFlu
FREE WEBINAR!
Also, for those who like to start planning ahead, here’s a look at our
2022 Events Calendar!
Have a good month!
One thing life and the nursing profession has taught me is sometimes you need to look in the rearview mirror to see where we’ve been to really appreciate where were going in the future. 2021 has been a challenging year for many reasons, yet we’ve persevered and learned some valuable lessons along the way.
- Resilience is key. Burnout and exhaustion increased as the pandemic raged across the globe. It’s clear that healthcare institutions must recognize that the workforce is their greatest asset, and they must foster resilience to keep healthcare workers at the bedside. They need to address staffing, provide a safe work environment, and provide support for clinicians who are physically and emotionally exhausted, morally injured, and are having mental health issues.
- Safe staffing fosters resiliency and improves patient outcomes. The first step to addressing resiliency is addressing the need for qualified, competent staffing and providing a safe work environment. Nurses want to deliver high quality, evidence-based care but, they can’t do it without the right staff. Healthcare institutions need to find creative ways to retain their talent, bring new nurses into the organization, develop flexible care models and build up cross-trained float pools to provide agility and efficiency to care for patients.
- Health equity is the cornerstone to improving health for individuals and communities. Recognize and address health equity, diversity, and inclusion to improve health for all individuals and their communities. These are not new issues; they’ve been amplified by the pandemic. Healthcare organizations and academia need to recognize that equitable, care without judgement is necessary to improve individual and community health related outcomes.
- Academia and practice collaboration can improve the nursing shortage. The first step is to increase the number of full-time, part-time, and adjunct faculty and pay them what they’re worth. Develop academic/practice partnerships, transition to practice programs, and nurse internship programs and increase clinical sites to develop practice-ready nurses. Use simulation and advances in technology to educate students and practicing nurses on advances in healthcare standards. Reach people when they are making career decisions so they will consider nursing as a profession.
- Use science and evidence to address COVID-19 and vaccine misinformation. COVID-19 has been a charged topic from the beginning of 2020 and misinformation abounds. The only way to address misinformation about COVID-19 and the vaccines is to use science as the basis for discussions and interactions. COVID-19 is a public health issue; leave politics out of the equation. We are the most trusted profession and it’s our professional responsibility to speak the truth using evidence.
And finally, nursing is a profession that strives to provide evidence-based, high-quality care without judgement for all people no matter their beliefs. Be proud of the care you provide, the lives you have touched, and the impact you’ve made by providing equitable, best care everywhere.
We are glad and grateful that you found this information valuable to read and share! Here’s a look at our most-read blog posts of 2021. What would be on your “Top 10” list?
Here is our ‘Top 10’ list from 2021.
10
9
8
7
6
5
4
3
2
1
We are looking forward to staying connected in the coming year and we wish you a safe, healthy, and happy 2022!
Words matter. And when it comes to speaking about – or documenting – sensitive information, they matter even more. As patient advocates and providers of unbiased care, it’s important that we use the correct terminology related to substance use and addiction. Here’s a glossary of terms to know; it’s important that we use them correctly and encourage others to do the same. Note that in the American Psychological Association's
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, there was a change in the language used to describe addiction, using “substance use disorder” instead of “abuse” and “dependence.”
Addiction
Addiction is a disease that affects the complex interactions between biological and environmental factors. Recent evidence suggests that addiction is less identified by physical dependence and withdrawal, and more as a compulsive repetition of an activity despite life-damaging consequences. The behavior reinforces the pleasurable feeling derived from the substance and causes a loss of control in limiting its use (Murphy, 2018). Addiction may also be referred to as substance use disorder.
Alcohol use disorder
In alcohol use disorder (AUD), the impact of alcohol consumption on various neurotransmitters can cause changes to emotions, motivation, and cognitive processing. Repeated exposure to alcohol impacts the effectiveness of the neurotransmitters, causing a need for increased amounts of alcohol to produce similar effects (Walters, 2021).
Misuse
The term misuse often refers to prescription drugs. It means taking a medication in a manner or dose other than prescribed; taking someone else’s prescription, even if for a legitimate medical complaint; or taking a medication to feel euphoria (National Institute on Drug Abuse, 2020).
Opioid use disorder
Opioid use disorder is defined as chronic use of opioids to the extent that it causes clinically significant distress or impairment (Dydyk et al, 2021).
Substance abuse
As mentioned above, it is preferable to use the phrase “substance use disorder” as the word "abuse" implies that the person has choice and control over their behavior (Burda, 2020).
Substance use disorder
Substance use disorder (SUD) is a brain disorder that alters the circuitry of the basal ganglia, extended amygdala, and prefrontal cortex. These changes impact the processes of reward gratification, self-control, and stress (Walters, 2021).
More Resources
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National CRNA Week
January 23-29, 2022
#crnaweek #stepforward
Theme: Trusted Anesthesia Experts on the Frontline
IV Nurse Day
January 25, 2022
Healthcare Observances
Here are some of the healthcare observances being recognized in January.
National Birth Defects Prevention Month
Cervical Health Awareness Month
#CervicalHealthMonth
National Glaucoma Awareness Month
Thyroid Awareness Month
#thyroidawareness
National Slavery and Human Trafficking Prevention Month
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
As we emerge from the holidays and start 2022, many of us look forward to a different kind of year than we’ve experienced over the past 2 years. Without a doubt 2020 and 2021 were perhaps the most challenging healthcare has experienced in decades. We have seen the best and worst in humanity due to COVID-19 and racial unrest. Yet, the nursing and healthcare professions have continued to show up, be present, and care for those in need in the face of fear, uncertainty, and sheer exhaustion. As I look to 2022, I wish for a new reality for our profession; a spark to reignite our passion so we remember why we became nurses in the first place and the courage to start changing our reality into one where we can thrive.
We all know the obvious; we need to address the nursing shortage; strive for adequate, competent staffing; increase the number of faculty and clinical sites; increase salaries; improve diversity, equity and inclusion; and foster resilience. To do these things we need to institute change and change is challenging and hard work.
The Value of Nurses
However, before we get started on addressing these issues we need to get back to the fundamentals and be able to articulate the value nurses bring to healthcare. How can we articulate our value if we have no consistent method to measure what we do and the impact we make in care delivery and patient outcomes? Anecdotally, we know we are valuable. After all, our institutions receive letters from patients and follow Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and National Database of Nursing Quality Indicators (NDNQI) scores, and quality improvement projects show us if we improve care delivery behaviors, outcomes and care variability improve. But I challenge you – do nurses really know their value and can they articulate it? It’s hard to feel valuable when we are often faced with overwhelming documentation burden, inadequate staffing levels, plus burnout, exhaustion and violence from those we care for and worst yet, our own colleagues. Many nurses would say they’ve lost their spark for the profession.
Time for Change
We need a change, and the change needs to start within each one of us. Let’s start by focusing on our own well-being. We are a caring profession, and we need to start caring for ourselves or there will be no one left to care for those in need. We need to seriously look at the hours we work and the responsibility of our personal lives and try to get some balance back. We need to start prioritizing our other roles as significant other, mother, father, sister or brother. We need to build in time for our own self care and that may mean saying no when asked to work extra shifts. Healthcare organizations need to prioritize fostering resilience in their workforce.
Healthcare organizations can readily see the value of providers who bill for their services because it directly impacts revenue. Healthcare needs to find a better way to determine how quality nursing care impacts revenue and that can only be achieved through innovative change including legislation and implementing a unique nurse identifier like the National Provider Identification unique identifier for providers.
Nurses need a zero-tolerance environment for unsafe staffing, horizontal violence from coworkers and violence from patients and their families. All nurses have a right to practice in a safe environment.
Reignite the Spark
It’s time to heal and reignite our spark. We have to remember why we went into this profession in the first place and it’s because we wanted to help those in need. Right now, nursing is in need and we must start our own healing process so we can continue caring for others. We must reignite our passion for our profession. All we need to get this started is for each of us to ignite our own spark and soon our collective fire will return.
What happened? In many communities, including my own, the Omicron variant of COVID-19 has come in like a freight train. People scrambled for testing kits before the holidays, with few to be found. Many are now sick and/or quarantined. The local emergency department went from long wait times to
extremely long wait times to diverting to other hospitals.
The Good News?
With the rapid spread occurring in much of the U.S., it is logical that increased exposure will lead to increased immunity among those who are asymptomatic and those who experience mild or non-life-threatening symptoms. At the same time, however, increased exposure is also leading to more pediatric cases, as well as increased hospitalizations and death. A shortage of health care workers due to exposures, infections, and moral injury further complicates the ongoing crisis.
So, is it possible that this surge could get us to herd immunity? Time will tell – but we certainly are facing significant risks.
Controversial Guidance
Over the past two years, we have watched science evolve. We continue to learn more about COVID-19, treatments, and vaccinations, and we depend on the experts to keep us updated and safe. Recent updates from the Centers for Disease Control and Prevention (CDC) on quarantine and isolation for the
general population and
health care workers, and the
American Heart Association 2021 Interim Guidance to Health Care Providers for Basic and Advanced Cardiac Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19 have many scratching their heads. Why are we putting health care workers at risk? Who will be left to care for patients?
While I continue to struggle to understand these recommendations and have much concern for the ramifications, I found a resource to help make a little more sense of them. A group of researchers and clinicians, known as
Those Nerdy Girls, explains
health policy, and encourage us to keep a “cool head and a sharp mind when policy controversy flares.” Take some time to explore this post and others from these experts in nursing, mental health, demography, health policy/economics, and epidemiology.
What Now?
As we emerge from the holidays and return to work and school, it is critical to follow the data and continue to follow public health measures to prevent the spread of the virus – wash your hands, wear your masks, and avoid exposing others if you are sick.
We will make it through this pandemic. We are trusted, we are smart, and we are strong, but we must work as a team. Follow the evidence. Answer questions and share reputable resources. Encourage vaccinations. And my fellow nurses…please stick together and take care of one another.
Abnormal sounds are also called
adventitious breath sounds. Here’s a list of common adventitious breath sounds with explanations and causes. Become familiar with the sounds and how to correctly document them. When possible, seek out learning experiences to hear different breath sounds!
- Wheezing is a continuous high-pitched musical sound on expiration or inspiration. A wheeze is the result of narrowed airways. Common causes include asthma, emphysema, anaphylaxis, a foreign body in the mainstem bronchus, or a fixed lesion such as a tumor.
- Rhonchi are characterized by low pitched sounds heard on inspiration and expiration. Rhonchi are a lower pitched variant of the wheeze. It has a snoring, gurgling or rattle-like quality. Rhonchi, unlike wheezes, may disappear after coughing, which suggests that secretions play a role. Although many clinicians still use the term rhonchi, some prefer to refer to the characteristic musical sounds simply as high-pitched or low-pitched wheezes.
- Crackles or rales may be described as fine (soft, high-pitched) or coarse (louder, low-pitched). The sound of hair being rubbed between one’s fingers is often used as an example to describe these types of sounds. Crackles suggest the presence of intra-alveolar fluid as seen with congestive heart failure, pneumonia, and interstitial lung disease.
- Stridor is a high-pitched musical breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is often intense and can be heard without a stethoscope. Stridor usually requires immediate intervention.
- Inspiratory stridor suggests obstruction above the vocal cords (i.e., angioedema, epiglottitis, foreign body).
- Expiratory stridor or mixed inspiratory/expiratory stridor suggests obstruction below the vocal cords (i.e., croup, bacterial tracheitis, tumor, foreign body).
- Diminished breath sounds can be caused by anything that prevents air from entering the lungs. Such conditions include atelectasis, severe COPD, severe asthma, pneumothorax, tension pneumothorax, and extrinsic bronchial compression from tumor.
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Voice generated sounds can provide important clues about respiratory abnormalities. Normal lungs are filled with air, and air does not transmit sound readily. Normally, transmitted voice sounds are difficult to hear – spoken words are muffled and indistinct and whispered words are usually not heard at all. However, when substances such as fluid or solid masses replace air in the lungs, sounds are transmitted more clearly. The sounds that can be assessed are:
- Whispered pectoriloquy: Ask the patient to whisper a sequence of words such as “one-two-three,” and listen with a stethoscope. Normally, only faint sounds are heard. However, over areas of tissue abnormality, the whispered sounds will be clear and distinct.
- Bronchophony: Ask the patient to say "99" in a normal voice. Listen to the chest with a stethoscope. The expected finding is that the words will be indistinct. Bronchophony is present if sounds can be heard clearly.
- Egophony: While listening to the chest with a stethoscope, ask the patient to say the vowel “e”. Over normal lung tissues, the same “e” (as in "beet") will be heard. If the lung tissue is consolidated, the “e” sound will change to a nasal “a” (as in "say").
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Certain non-pulmonary sounds may be heard during auscultation of the chest. It is important to be familiar with non-pulmonary sounds, such as mediastinal crunch and pleural friction rubs.
- Mediastinal crunch is caused by pneumomediastinum. This sound is characterized by precordial crackles that correlate with the heartbeat rather than respiration. The patient can be asked to temporarily cease respiration to appreciate this difference.
- Pleural friction rub results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall. This sound is non-musical, and described as “grating,” “creaky,” or “the sound made by walking on fresh snow.” Inflammation or neoplasia can cause thickening of the pleural surfaces, which then creates more friction when sliding along one another, creating this sound. Any potential cause of pleural effusion, pleuritis, or serositis can result in a pleural friction rub (i.e., inflammation, neoplasm). Patients may be able to describe the localization of the rub based on pain. A pleural friction rub is a manifestation of pleural disease, though its absence does not exclude this pathology.
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
PeriAnesthesia Nurse Awareness Week
February 7-13, 2022
Ambulatory Care Nursing Week
February 7-13, 2022
#AmbCareNurseWeek
Critical Care Transport Nurses Day
February 18, 2022
Healthcare Observances
Here are some of the healthcare observances being recognized in February.
American Heart Month
#OurHearts
World Cancer Day
February 4, 2022
#WorldCancerDay #CloseTheCareGap
National Eating Disorder Awareness Week
February 21-27, 2022
Theme: See the Change, Be the Change
#NEDAwareness
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
Here we are in February, the month where many of us celebrate love on Valentine’s Day. Love for our partner, our children, our families, and I’m going to add one more to the list – love for our profession. Let’s face it, the last 2 years have been the most challenging for our profession and for all of healthcare. If you’re like me, there have been times over the past 2 years you’ve asked,
“Why do I love the nursing profession?”
Caring for others brings peace to my soul and gives me a purpose. It gives me a reason to get up every day and make a positive impact on someone’s life. It's who I am at my core; it’s my calling
. I recognize the past 2 years have been the most challenging in my nursing career but, it’s what I choose to do – care for others.
There is no greater privilege than to be with people at the best and worst times of their lives. I’ve been with people on their best days: births, hearing they are cancer free, or recovering from a catastrophic illness and being able to go home to their families. Lately, I’ve been with people on the worst day of their life, hearing they or their family member has COVID and won’t be coming home. It’s a privilege to experience these intimate situations with my patients and to remember I am there because they trust me to care for them without judgement.
Learning that communicating just by being present is one of the greatest forms of loving another human being. There is a quiet spirit in what we do; it’s sometimes hard to appreciate it because working in a chaotic environment is loud, but it’s there just under the surface. The act of holding someone’s hand, stroking a forehead, smiling with our eyes behind our masks. We speak volumes with our calmness in the most chaotic situation, reassuring our patients we are here for them and they are not alone.
Nursing has given me the strength to fight for what is right. Doing what is right is often the hardest road. I am the voice for my patients, so they receive equitable healthcare in all situations. I am an advocate for the nursing profession, supporting change to ensure safe work environments, adequate staffing, training, education, and competency so every patient receives the highest quality care that is informed by the best available evidence.
Nursing has taught me the value of life. Living is not about the quantity of time we have on this earth; rather it is about the quality of time we have and what we do with it. So often we see patients who die surrounded by machines, monitors, intravenous pumps, and technology being kept alive as a shell of their former self simply because they didn’t have a conversation with their loved ones about how they wanted their life to end. There is a better way; death can be a blessing and that same patient can die peacefully and pain free surrounded by their loved ones with a nurse at their side.
Let’s not forget why we love nursing…
In the face of the pandemic, it’s easy to lose sight of why we went into the nursing profession in the first place. Remember you are the one constant in your patient’s life – you value their life, inspire their trust, care for them in the most challenging of circumstances, and when it’s time, help them to release their spirit. Nursing…the purest form of loving our neighbor.
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
Nursing
Nurse Work Environment Affects Patient Outcome
AACN Advanced Critical Care
Anna Krupp, Ph.D., R.N., from the University of Iowa in Iowa City, and colleagues estimated the association between hospitals’ nurse work environment and patient likelihood of ICU admission and mortality after surgery. This cross-sectional study involved 269,764 adult surgical patients in 453 hospitals.
COVID-19 Proning Teams Benefit from Wound Care Specialist Nurse
American Journal of Critical Care
Connie Johnson, R.N., from Penn Medicine Princeton Health in Plainsboro, NJ, and colleagues evaluated the association between including a certified wound and skin care nurse on a multiprofessional pronation team and the prevention of pressure injuries in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients with acute respiratory distress syndrome. The analysis included 130 patients (40 percent treated by a team that included a certified wound and skin care nurse) hospitalized with COVID-19 between Feb. 1 and Aug. 30, 2020.
Employment of Nurses Decreased Early in COVID-19 Pandemic
Health Affairs
Peter I. Buerhaus, Ph.D., R.N., from Montana State University in Bozeman, and colleagues used national data from federal government surveys to demonstrate the pandemic's impact on employment and earnings across categories of the nurse workforce. Monthly data were obtained from the Current Population Survey between January 2011 to June 2021 to identify employment trends.
Guidelines & Recommendations
ACG Issues Guidelines for Managing Acute-on-Chronic Liver Failure
American Journal of Gastroenterology
The authors note that prognostic markers that predict ACLF outcome should be differentiated from diagnostic markers that confirm the presence of ACLF. With further validation, microbial composition and microbial-origin metabolites can be used as biomarkers for development and prognosis of ACLF. The diagnosis of ACLF is supported by the presence of kidney, lung, circulatory, or brain failure. Albumin is recommended in addition to antibiotics to prevent AKI and subsequent organ failure in patients with cirrhosis and spontaneous bacterial peritonitis. Assessment for infection is recommended in hospitalized decompensated cirrhotic patients because infection is associated with development of ACLF and increased mortality. Management strategies include a recommendation against daily albumin infusion to maintain serum albumin levels in hospitalized patients with cirrhosis as a means to improve mortality or to prevent renal dysfunction or infection.
Recommendations Updated for Recombinant Zoster Vaccine
CDC Morbidity and Mortality Weekly Report.
For adults aged 19 years and older who are or will be immunodeficient or immunosuppressed due to disease or therapy, the ACIP recommended two doses of RZV for prevention of herpes zoster and related complications.
ACP Issues Two Guidelines for Acute Left-Sided Colonic Diverticulitis
Annals of Internal Medicine
American College of Physicians (ACP) suggests the use of abdominal computed tomography imaging in the case of diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis. It is suggested that clinicians manage most patients with acute uncomplicated left-sided colonic diverticulitis in an outpatient setting. Furthermore, the guideline suggests select patients can be managed initially without antibiotics.
ACP suggests that patients who have not undergone recent colonoscopy should be referred for a colonoscopy after an initial episode of complicated left-sided colonic diverticulitis. The guideline recommends against use of mesalamine to prevent recurrent diverticulitis. In addition, ACP suggests clinicians discuss elective surgery for the prevention of recurrent diverticulitis after initial treatment in patients with uncomplicated diverticulitis that is persistent or recurs frequently; this suggestion also applies to patients with complicated diverticulitis.
WHO Living Guideline Updated for Drug Treatment of COVID-19
The BMJ
The Janus kinase (JAK) inhibitor baricitinib is strongly recommended for patients with severe or critical COVID-19, and sotrovimab is conditionally recommended for nonsevere COVID-19, according to the updated World Health Organization living guideline on drugs for COVID-19.
ADA Updates Standards of Medical Care in Diabetes for 2022
Diabetes Care
Updates and additions to the 2022 report include guidance on first-line therapy determined by comorbidities and a recommendation for initiation of screening for prediabetes and diabetes for all people at age 35 years. Changes were made to gestational diabetes mellitus recommendations, including when and who to test. In addition, recommendations were updated on technology selection, based on individual and caregiver considerations, ongoing education relating to device use, continued access to devices across payers, support of student use of devices in schools, use of telehealth, and early initiation of technology.
More Highlights
Explore all Nursing News Headlines.
When performing a cardiovascular assessment, the rhythm and character of peripheral pulses are observed. While palpating the radial or femoral pulses, one may note that although the rhythm is regular, the strength of the pulse may alternate between weaker and more forceful impulses. Hence, the term
pulsus alternans.
The beat-to-beat variability of pulsus alternans can be confirmed using a blood pressure cuff and listening closely as the cuff is deflated. Initially, only the stronger Korotkoff sounds are heard, but as the pressure in the cuff continues to deflate, the softer sounds appear, though they will eventually fade away (Bickley et al., 2021).
The presence of pulsus alternans strongly suggests severe left ventricular dysfunction (Bickley et al., 2021; Corlucci & Borlaug, 2021). Pulsus alternans may be noted in those with dilated cardiomyopathy with left ventricular outflow obstruction, severe aortic regurgitation, or cardiac tamponade, but rarely without the presence of associated left ventricular dysfunction (Gersh, 2021).
Remember…
- Asking the patient to sit upright during physical examination may highlight this finding.
- Pulsus alternans is frequently associated with left ventricular failure, and this finding should prompt further diagnostic investigation.
References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Corlucci, W.S. & Borlaug, B.A. (2021, March 4). Heart failure: Clinical manifestations and diagnosis in adults. UpToDate. https://www.uptodate.com/contents/heart-failure-clinical-manifestations-and-diagnosis-in-adults
Gersh, B.J. (2021, November 2). Examination of the arterial pulse. UpToDate. https://www.uptodate.com/contents/examination-of-the-arterial-pulse
More Reading & Resources
Cardiac Assessment [Pocket Card]
Understanding Pulsus Paradoxus
Extra Heart Sounds: Do you hear what I hear?
During your cardiac assessment, you may appreciate extra heart sounds or heart murmurs when auscultating the chest. In general, murmurs can be differentiated from additional sounds, such as an S3 or S4, because of their longer duration, however there is much more to assessing murmurs and understanding their underlying causes. The best way to learn is to take advantage of listening to murmurs whenever possible! Let’s review some of the basics.
Characteristics of Murmurs
Timing
The timing of murmurs is identified by when the murmur is heart in the cardiac cycle. Systolic murmurs are heard between S1 and S2; diastolic murmurs are heard between S2 and S1. They can be further characterized by how long they ‘occupy’ systole or diastole. Continuous murmurs begin in systole and continues to diastole without interruption.
Intensity
Different grading systems are used to describe the intensity, or loudness, of murmurs; a six-point scale is used to grade systolic murmurs and a four-point scale is used to grade diastolic murmurs. In general, the grading is expressed as a fraction, with the numerator representing the intensity at its loudest and the denominator being 4 or 6, depending on the scale used.
The intensity of murmurs can be decreased due to obesity, emphysema, and pericardial effusion.
Shape
The shape or configuration of a murmur refers to its intensity over time.
Crescendo is used to describe murmurs that increase or grow louder.
Decrescendo refers to those that soften or decrease in intensity.
Crescendo-decrescendo means the murmur increases and then decreases.
Plateau means unchanged in intensity.
Location & Radiation
When describing the location of a murmur, it’s important to identify where the murmur is best heard, which is typically the site where it originates. When thinking about radiation of the murmur, ask “Where else is the murmur heard?” In some instances, it can be heard over the left scapula or in the axilla.
Pitch & Quality
Murmurs can be described as high-pitched, medium-pitched or low-pitched. The quality can be described as blowing, harsh, scratching, rumbling or musical.
References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Meyer, T. (2020, February 4). Auscultation of cardiac murmurs in adults. UpToDate. https://www.uptodate.com/contents/auscultation-of-cardiac-murmurs-in-adults
When performing a cardiovascular assessment, auscultation of heart tones is an important component of the examination. Each sound has different characteristics, including timing and intensity. Read on to find out more!
The Cardiac Cycle
The cardiac cycle starts with the beginning of one heartbeat to the beginning of the next heartbeat. Systole is the contraction that pushes blood from the ventricles. Blood from the right ventricle travels through the pulmonic valve to the lungs, whereas blood from the left ventricle travels through the aortic valve to the body. During systole, the tricuspid valve is closed preventing regurgitation of blood from the right ventricle into the right atrium. Likewise, the mitral valve is closed preventing regurgitation of blood from the left ventricle into the left atrium. It is the closure of the mitral and tricuspid valves that create the S1 heart sound.
As blood leaves the ventricles, the pressure drops within the chamber. During diastole, the tricuspid and mitral valves open to allow blood flow into the ventricles as the pulmonic and aortic valves are closed to prevent regurgitation from the pulmonary vein and the aorta, respectively. It is the closing of the pulmonic and aortic valves that create the S2 heart sound.
Splits (S1 split, S2 split)
An S1 split occurs when the earlier mitral and later tricuspid closure sounds separate. This can be a normal finding. During expiration, the aortic and pulmonic valves close nearly simultaneously creating a single sound of S2. An S2 split occurs occasionally on inspiration where the pulmonic valve slightly delays its closing. An S2 split can also be a normal finding.
Gallops (S3, S4)
An S3 gallop is sometimes heard after S2 due to deceleration of blood against the ventricular wall. This may be a normal finding in children, younger adults, and athletes. In older adults, however, this is considered pathological and may indicate heart failure.
The S4 heart sound would be heard immediately before S1 of the next beat. If present, this could be suggestive of ventricular stiffness and may be seen in those with hypertension or acute MI. In athletes, this may be a normal finding.
Opening Snaps
An opening snap may be heard as the mitral valve opens if there is restriction of the valve leaflets. This is heard just after S2 and could indicate mitral stenosis.
Systolic Clicks
A clicking sound heard during systole may be indicative of mitral valve prolapse.
Remember
- When documenting S1 and S2 split sounds it is important to identify at what point during the respiratory cycle the sound is heard.
- In older adults, S3 and S4 heart sounds should be reported to the responsible provider.
- Systolic clicks are the most common extra heart sound.
Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
When performing a cardiovascular assessment, auscultation and palpation are used to examine the character of the vasculature. Bruits may be felt over arteries and sometimes thrills are palpated. Why are these significant?
Bruits
The presence of a bruit suggests stenosis or disruption of normal blood flow, such as through a tortuous vessel (Bickley et al., 2021). It is often described as a “whooshing” sound. The diaphragm of the stethoscope is used first to better hear the higher frequency of arterial bruits. In cases where the patient has high-grade stenosis, the frequency is lower (and sometimes absent) which can be better heard with the bell (Bickley, et al., 2021). A bruit may be heard in two phases.
When assessing for carotid bruits, ask the patient to hold their breath for no more than 10 seconds while auscultating to better distinguish bruits from sounds transmitted from the trachea. Other areas to assess for bruits includes the abdominal aorta, as well as the renal and iliac arteries.
Thrills
A thrill is a vibration felt upon palpation of a blood vessel or over the precordium. The examiner may perceive a systolic and diastolic component to the vibration (Bickley et al., 2021). The presence of a thrill suggests stenosis, either of the underlying vessel or it may be transmitted from another source. The grading of systolic murmurs is influenced by the presence of a palpable thrill.
Remember…
- A bruit is the auscultated equivalent of the thrill and has the same significance.
- A thrill felt at the carotid artery may signify aortic stenosis, as the vibration is transmitted through the tissue from the second intercostal space. (Bickley et al., 2021).
- A thrill and a bruit at the site of an arteriovenous (AV) fistula, commonly used for hemodialysis, is a normal finding (Beathard, 2021).
References:
Beathard, G.A. (2022, January 3). Physical examination of the arteriovenous graft. UpToDate. https://www.uptodate.com/contents/physical-examination-of-the-arteriovenous-graft
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Estimating jugular venous pressure (JVP) is a noninvasive method for assessing a patient’s volume status. It is used to estimate whether right atrial pressure (RAP) is high or normal and to assess trends in RAP, including response to treatment.
During your cardiac assessment, you’ll focus on the internal jugular venous pulsations on the patient’s right side to perform the measurement. (Learn the technique for measuring JVP in our
Cardiac Assessment Pocket Card.) The normal venous pressure is 1 to 8 mmHg, so while a low value may be consistent with volume depletion, it is not diagnostic since it may also be a normal finding.
Elevated JVP
JVP measured at greater than 3 cm above the sternal angle, or more than 8 cm in total distance above the right atrium, is considered
elevated above normal (Bickley et al., 2021).
Heart failure (HF) is a major cause of elevated right heart pressures, so estimating JVP can help diagnose HF or detect exacerbations. Elevation of JVP can also be an important factor in diagnosing or managing other disorders, such as superior vena cava obstruction, tricuspid valve disease, pericardial disease, chronic pulmonary hypertension and cardiac tamponade (Bickley et al., 2021; Meyer, 2021).
Remember…
- The JVP is an estimate of the RAP and is not a direct measure of the left ventricular filling pressures. Interpret abnormal results in conjunction with other findings.
- In obstructive lung disease, the JVP may be elevated on expiration, but the veins collapse on inspiration. This is not indicative of heart failure.
References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Meyer, T. (2021, December 3). Examination of the jugular venous pulse. UpToDate. https://www.uptodate.com/contents/examination-of-the-jugular-venous-pulse
Sepsis and septic shock impact millions of patients worldwide (Evans et al., 2021). Sepsis is defined as life threatening end-organ dysfunction caused by a dysregulated host response to infection. Sepsis is the leading cause of death in critically ill patients; early identification and appropriate management markedly improves morbidity and mortality. Management includes prompt recognition, timely administration of appropriate antibiotics, fluid resuscitation, hemodynamic support, and control of the source of infection (Forrester, 2021).
Source control is defined as surgical and non-surgical interventions used to treat an infection (Marshall, 2010). Rapid identification and establishment of source control is an essential component in the workup and treatment of sepsis. It involves investigation with history and physical examination, laboratory studies, and appropriate imaging (Marshall, 2010).
On initial presentation, the process to identify the source of infection can be difficult as the source may not be readily apparent. While a chest radiograph, urinalysis and blood cultures are standard orders in the identification of potential sources of infection, many times further investigation and computed tomography (CT) imaging is warranted to rule out a surgical source of the underlying infection (Kim & Park, 2019).
Four Components of Source Control
The core elements of source control consist of four components: drainage, debridement, device removal, and definitive measures (Lagunes et al., 2016; Marshall, 2010).
1. Drainage refers to the evacuation of infected fluid through the opening of an infected abscess. This is performed through incision and drainage or by in the insertion of a drain. The process of drainage converts a closed, infected abscess into a controlled sinus or fistula to promote drainage (Marshall, 2010). Examples include incision and drainage of an infected Bartholin cyst with insertion of packing, or insertion of a percutaneous cholecystectomy tube in the case of cholecystitis.
2. Debridement involves the removal of necrotic or devitalized or infected tissue through surgical or non-surgical interventions. Local wound care is an example of non-surgical debridement. Surgical debridement involves the excision of gangrenous soft tissue such as necrotizing fasciitis, or debridement of infected intestine.
3. Device removal involves removal of a prosthetic device that has become colonized by organisms. This could include the removal of a central line or urinary catheter, excision of an infected vascular graft, or removal of infected orthopedic hardware.
4. Definitive measures are other interventions, usually surgical, that are performed to remove a focus of infection and restore optimal function and quality of life. This can include surgical excision of diverticular disease and restoration of intestinal continuity, decortication of lung following the drainage of an empyema, or repair of an abnormal wall hernia following treatment of peritonitis.
Sepsis and septic shock carry high mortality rates. Early identification, resuscitation, initiation of antibiotics and prompt identification and management of the underlying source and cause of sepsis is imperative in improving patient outcomes.
References:
Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., Belley-Cote, E., … Levy, M. (2021). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive care medicine, 47(11), 1181–1247. https://doi.org/10.1007/s00134-021-06506-y
Forrester, J. (2021, September). Sepsis and septic shock. Merck manual: professional version. https://www.merckmanuals.com/professional/critical-care-medicine/sepsis-and-septic-shock/sepsis-and-septic-shock
Kim, H. & Park, S. (2019). Sepsis: Early Recognition and Optimized Treatment. Tuberculosis and respiratory diseases, 82(1), 6–14. https://doi.org/10.4046/trd.2018.0041
Lagunes, L., Encina, B., & Ramirez-Estrada, S. (2016). Current understanding in source control management in septic shock patients: a review. Annals of translational medicine, 4(17), 330. https://doi.org/10.21037/atm.2016.09.02
Marshall J. C. (2010). Principles of source control in the early management of sepsis. Current infectious disease reports, 12(5), 345–353. https://doi.org/10.1007/s11908-010-0126-z
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Certified Nurses Day
March 19, 2022
GI Nurses & Associates Week
March 20-26, 2022
#Proud2BGI
Healthcare Observances
Here are some of the healthcare observances being recognized in March.
National Colorectal Cancer Awareness Month
#ColorectalCancerAwarenessMonth
National Endometriosis Awareness Month
#EndometriosisAwarenessMonth
National Kidney Month
#KidneyMonth
National Nutrition Month
#NNMchat, #NationalNutritionMonth
Brain Injury Awareness Month
#MoreThanMyBrainInjury
Multiple Sclerosis Awareness Week
March 13-22,2022
Patient Safety Awareness Week
March 13-19, 2022
World Sleep Day
March 18, 2022
World Tuberculosis Day
March 24, 2022
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
I recently responded to a rapid response team (RRT) call for a patient in acute respiratory distress. Despite interventions, the patient was transferred to the critical care unit, intubated, and placed on a ventilator. The nurses on the floor had done an excellent job recognizing the patient was in trouble and called for help. The team worked like a well-oiled machine, no drama, no chaos; everyone in attendance knew exactly what to do. That’s what competency looks like – a team knowing how to assess a situation, use their critical thinking and judgement skills, intervene, reassure the patient, get the job done and, in this case, have a good patient outcome.
Competency is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgments (ANA, 2014). Competency is a key component of the new American Association of Colleges of Nursing Essentials and it’s how undergraduate and graduate nursing students are taught – with the goal of producing competent, practice-ready nurses after they complete an orientation or nurse residency program. Novice nurses are not the only ones who need additional education and training to be competent. Nurses who are expert in some areas of practice may be novice and not competent in others. Competency needs to be routinely measured and documented and this information needs to be readily available for surveyors and nursing leadership.
The pandemic has revealed the disconnect with staffing based on hours per patient day, beds alone, or average census without considering the acuity of the patient and the competency of workforce. A nurse is not a nurse. You can’t take a nurse who is competent in med/surg and expect them to care for critically ill, high acuity patients in the critical care unit. Staffing must take into consideration the acuity of the patients and the competency of the nurses caring for the patients. The reason the RRT went well in the case illustrated above is because there was an adequate number of staff who were competent to care for the patient.
Competency-based staffing that considers patient acuity/severity of illness is not a new concept; nurses have been advocating for it for years. In a recent nurse leader survey by UKG and Wolters Kluwer (2022), up to 81% of respondents indicated that having competency inform their nurse staffing/scheduling patterns during the next 18 months will be important/very important and up to 79% believe they will need to implement competency-informed shift coverage.
What does competency-informed staffing mean for nurses?
For staff on the front lines, it means having adequate numbers of staff working with you who are competent to care for the type of patients on your unit. We talk about the concept of our colleagues having our back when we work; it means others pitch in and cover your patient while you are dealing with an emergency. You can feel it right away when you walk onto your unit; the culture and who you are working with for that shift set the tone for how your shift is going to be no matter how busy you are. Working beside someone who you know has the knowledge, critical thinking, and skills to step up and handle any situation using clinical judgement makes all the difference.
What does competency-informed staffing mean for healthcare organizations?
For nurse leaders who are responsible for insuring quality patient care, competency-informed staffing will help ensure quality outcomes and greater staff satisfaction because this change supports a safe work environment. Inevitably, changing how we staff will need investment. Healthcare organizations need to collaborate with workforce management industry partners to create the business case that illustrates the return on investment.
Here’s the bottom line, healthcare organizations, nurses and other members of the healthcare workforce want to deliver high quality patient care. Innovative staffing based on patient acuity and care-giver competency has the potential to be the catalyst for optimum quality care and a safer work environment.
UKG and Wolters Kluwer will present the Nursing Workforce Survey results in our webinar,
Nursing’s Wake-up Call: Change is Now Non-negotiable.
Register here!
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
COVID-19
Survival High with Lung Transplant for COVID-19-Associated ARDS
Journal of the American Medical Association
Chitaru Kurihara, M.D., from Northwestern University in Chicago, and colleagues conducted a retrospective case series of 102 patients who underwent a lung transplant between Jan. 21, 2020, and Sept. 30, 2021, including 30 patients with COVID-19-associated ARDS. The researchers found that the median lung allocation scores were 85.8 versus 46.7 for lung transplant recipients with versus those without COVID-19; median time on the lung transplant waitlist was 11.5 versus 15 days, and 56.7 and 1.4 percent, respectively, used preoperative venovenous extracorporeal membrane oxygenation (ECMO).
ACP Issues Final Practice Points for Remdesivir Use in COVID-19
Annals of Internal Medicine
Anjum S. Kaka, M.D., from the University of Minnesota School of Medicine in Minneapolis, and colleagues updated the living review of remdesivir for adults hospitalized with COVID-19. Based on the evidence from five RCTs, the researchers found that the updated results confirm a 10-day course of remdesivir probably results in little to no reduction in mortality compared with control.
Amir Qaseem, M.D., Ph.D., from the American College of Physicians in Philadelphia, and colleagues updated the living, rapid practice points for the use of remdesivir as a COVID-19 treatment. The authors note that five days of remdesivir should be considered for hospitalized patients with COVID-19 who do not require invasive ventilation or extracorporeal membrane oxygenation (ECMO). Extending remdesivir to 10 days should be considered for patients who develop the need for invasive ventilation or ECMO within a five-day course. Initiation of remdesivir should be avoided for hospitalized patients with COVID-19 who are already on invasive ventilation or ECMO.
Guidelines & Recommendations
Guidelines Issued for Managing Critically Ill Pediatric Patients
Pediatric Critical Care Medicine
Heidi A.B. Smith, M.D., from the Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues developed clinical practice guidelines for critically ill infants and children, focusing on seven domains of care, including analgesia, sedation, delirium, and optimizing the environment. The task force issued 44 recommendations (14 strong and 30 conditional) and five good practice statements.
ACSM Updates Guidance for Exercise in Type 2 Diabetes
Medicine & Science in Sports & Exercise
Jill A. Kanaley, Ph.D., from the University of Missouri in Columbia, and colleagues summarized the current evidence and extended and updated the 2010 recommendations on exercise and type 2 diabetes. The authors note that for adults with type 2 diabetes, regular aerobic exercise training improves glycemic management, with less daily time in hyperglycemia and reductions in overall glycemia. In terms of overall glucose management and attenuation of insulin levels, high-intensity resistance exercise training has greater beneficial effects than low- to moderate-intensity resistance training.
Recommended Adult Immunization Schedule Updated for 2022
Annals of Internal Medicine
According to the guidelines, there are no changes to recommendations for the
Haemophilus influenzae type b and hepatitis A vaccines, while notes were added to other vaccines, including human papillomavirus vaccination. For hepatitis B, universal vaccination is recommended for all adults aged 19 through 59 years and for adults aged 60 years or older at high risk for hepatitis B virus infection. Recommendations for influenza vaccine for the 2021 to 2022 season include routine annual vaccination for all persons aged 6 months and older who do not have contraindications, with no preferential recommendation for one influenza vaccine product over another. Routine vaccination is recommended against pneumococcal infection for all adults aged 65 years or older with one dose of pneumococcal conjugate vaccine (PCV)15 or PCV20; if PCV15 is used, it should be followed by a dose of pneumococcal polysaccharide vaccine-23. Those aged 19 through 64 years with certain underlying medical conditions or other risk factors should also be vaccinated.
Child Developmental Milestone Checklists Updated by CDC, AAP
Pediatrics
The checklists, revised for the first time since their release in 2004, outline developmental milestones for infants and young children, to help identify delays earlier and are part of regular checkups by pediatricians. The checklists previously used 50th percentile milestones, meaning only half of children were expected to achieve the milestone at a given age. The updated checklists ask about milestones 75 percent or more of children can be expected to achieve by a certain age.
More Highlights
Explore all Nursing News Headlines.
Each year, on March 8
th, we celebrate
International Women’s Day (IWD). Why is this important?
About IWD
March 8
th is a day to celebrate women, increase our visibility, and forge ahead on achieving gender parity. This is a day when groups come together – worldwide – to celebrate achievements, challenge stereotypes, and emphasize positivity.
2022
In 2022, the focus is on establishing a gender equal world – celebrating the successes of women and calling out inequalities. Wolters Kluwer and Lippincott NursingCenter are proud to celebrate International Women’s Day. How will you elevate women and #breakthebias?
There are times when it is helpful to measure the spleen on assessment. The disease processes that can cause splenomegaly include mononucleosis, idiopathic thrombocytopenia, hemolytic anemia, HIV infection, parasitic infection, connective tissue disorders, cirrhosis, portal hypertension, and splenic infarction, to name a few. Methods for measurement include palpation and percussion (Castell’s sign).
Percussion
Percussion should be performed prior to palpation. Percuss the left anterior midaxillary line at the lowest intercostal space. This sound should be tympanic. Ask the patient to take a deep breath and percuss at peak inspiration. The sound should remain tympanic; dullness is a positive sign but is not completely reliable to assess splenomegaly.
Palpation
Palpation is performed by standing on the patient’s right side and reaching over with the left hand to support the rib cage. Place your right hand just below the costal margin, leaving enough room to detect an enlarged spleen, and depressing the hand inward and upward to locate the splenic edge. Once located, ask the patient to take a deep breath and note the contour of the splenic edge as the spleen descends to meet your fingertips. This procedure may be repeated with the patient positioned on the right side to facilitate locating the spleen by use of gravity.
Report splenomegaly to the provider for further evaluation and treatment.
Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
When doing an abdominal assessment, one might find several different signs that could indicate appendicitis. We will be discussing some of these assessment findings, and how they relate to acute appendicitis.
The
McBurney point is point tenderness located in the center of the right lower quadrant, approximately 3-4cm towards the midline from the iliac spine.
Rovsing sign is a referred (indirect) tenderness in the right lower quadrant associated with rebound; it’s located in the middle of the left lower quadrant when deep palpation is applied. Pain in this location tends to escalate when pressure is released from the area.
Psoas sign is assessed by having the patient lie supine and placing your hand just above the knee. Ask the patient to lift the right leg against resistance of your hand. This motion causes friction of the psoas muscle over the inflamed appendix, causing pain.
To assess for the
obturator sign, position the patient supine with their right knee bent and leg bent at the hip. Rotate the leg internally at the hip, causing the internal obturator muscle to stretch providing indirect pressure over the appendix.
How do these relate?
Appendicitis is highly suspected if there is tenderness at McBurney’s point, along with a secondary positive finding. The assessments above either directly or indirectly cause pressure or friction against the appendix, causing pain due to the already-present inflammation. Communicate any of these positive findings to the provider.
Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Occupational Health Nurses Week
April 3-9, 2022
#OHNWeek
Wound, Ostomy and Continence (WOC) Nurse Week
April 17-23, 2022
#WOCNurseWeek2022
Transplant Nurses Week
April 25 – May 2, 2022
Healthcare Observances
Here are some of the healthcare observances being recognized in April.
Alcohol Awareness Month
Irritable Bowel Syndrome Awareness Month
#IBSAwarenessMonth #LifeWithIBS
Autism Acceptance Month
#CelebrateDifferences
National Child Abuse Prevention Month
National Donate Life Month
#DonateLife #BeeADonor
Sexual Assault Awareness Month
#SAAM2022
STD Awareness Week
April 10-16
#STDWeek
World Immunization Week
April 24-30
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
By now, most nurses have heard about the case of RaDonda Vaught, a nurse found guilty of criminal charges – neglect and negligent homicide – after a 2017 fatal medication error.
Details of the Incident
On December 26, 2017, Vaught was caring for a 75-year-old patient at Vanderbilt University Medical Center in the Neuro Intensive Care Unit. According to
reports, Vaught was the Help-all nurse and had an orientee working with her during the shift. Several red flags are documented that led to the administration of vecuronium, a paralytic, rather than Versed (generic name, midazolam), a sedative that had been ordered to be given prior to a swallow study:
- The medication was not in the patient’s profile in the medication dispensing machine.
- Five warnings appeared during the machine override process. (During a testimony before the nursing board in 2020, Vaught testified that at the time of the incident, technical problems with the medication cabinet and hospital’s electronic health records system prompted Vanderbilt to instruct nurses to use overrides, so it was not unusual to have to use that functionality.)
- The withdrawn medication (vecuronium) was a powder form that needed to be reconstituted; Versed comes in a liquid form.
- In addition to the different drug name than what was ordered, “Warning: Paralyzing Agent” was written on the bottle.
- Vaught administered the medication and then left the patient in the waiting room for the test.
- Upon realizing the error, Vaught followed steps for reporting the incident.
- On January 3, 2018, Vaught was terminated for not following the five rights of medication administration and was reported to the Tennessee Board of Nursing.
There are more details in the timeline related to investigations and legal proceedings that can be found
here.
What are the Issues?
We all know that medication errors happen; in fact, there are whole policies and procedures in place at most institutions to both minimize their occurrence and for reporting when they do occur. But we also know that when we are in a remote area of a hospital, there are less checks and balances, less monitoring, and more distractions.
The criminalization of nonintentional errors is concerning. Licensing boards and civil courts, not criminal courts, are the appropriate outlets to investigate and handle errors when they occur. The outcome of Vaught’s case sets a dangerous precedent. Will nurses, who are now working in the most trying of times during a nursing shortage and a pandemic, report errors and follow steps so that we can learn from them and improve systems to prevent errors?
When it comes to safety, we can liken our work as nurses to a goalie in a soccer game. When someone scores, the goalie is that last line of defense, however, the opposition got past all the other players before approaching the goal. As nurses, we are that goalie, but we are only one line – albeit the final line – of defense. Yes, we have a responsibility to prioritize safety, but without the proper support and safeguards in place, it can be really challenging to stop that ball every time. And when it gets by us, we must be prepared to discuss it and learn from it with our coworkers and leaders, safety experts, product and medication manufacturers, and administrators.
April, the month when nursing students are finishing up their classes, studying for NCLEX and getting ready to start their journey as a new nurse. I remember those days, the feeling of anticipation, worrying about passing NCLEX, and excitement about starting a new job. These feelings haven’t changed for graduate nurses; what has changed over the past 2 years is how new nurses are transitioning to active practice. The nursing shortage exacerbated by the pandemic has increased the number of nurses who are retiring or are shifting from the acute care bedside to other areas in healthcare. This shift has resulted in a loss of wisdom and expertise.
New nurse orientation was greatly affected by the pandemic. Prior to the pandemic, orientation included didactic lessons and clinical time with a preceptor and lasted up to three months. During the pandemic, healthcare organizations needed to get novice nurses up on the floor as quickly as possible and as a result, decreased orientation time and shifted to more self-directed learning paired with clinical experience. The available number preceptors also declined. This approach resulted in many novice nurses being ill-prepared to practice safely. Prior to the pandemic, research revealed that up to 30% of new nurses leave their jobs within the first few years; it will be interesting to see if this trend continues.
Academia and practice settings need to start a dialogue on what it really means to be a practice-ready nurse. What is needed by all graduating nurses and how can academia evolve their curriculum to ensure graduate nurses are adequately prepared to not only pass NCLEX but start practicing using clinical judgement? Academic/practice partnerships are an opportunity to start the discussion and make this change happen.
We need to reimagine orientation and ensure novice nurses are not released to practice independently before they are ready. Orientation must be a combination of didactic lessons, self-directed learning and training in clinical practice. Investment in nurse residency programs can improve retention of novice nurses. They typically last six months to a year and focus on developing clinical skills and clinical judgement in addition to training the novice nurses in evidence-based practice and quality improvement activities. Healthcare organizations must invest in their preceptor programs since many preceptors have only a few years of nursing experience. It’s important preceptors clearly understand their roles, know where to find support resources, and feel confident and competent to train novice nurses.
Experienced nurses need to support novice nurses. Many of us may have experienced “nurses eating their young.” We need to remember our own excitement interlaced with anxiety in our first year of practice. Novice nurses are the future of our nursing profession. We must be invested in shepherding novice nurses through the novice to expert journey and be patient and tolerant as they learn.
Let’s remember the importance of being tolerant and patient with novice learners by remembering this quote from an unknown source, “You want to know the difference between a master and a beginner? The master has failed more time than the beginner has ever tried.”
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
Systematic Reviews
Outcomes Examined for Advanced CKD Patients Who Forgo Dialysis
JAMA Network Open
In a systematic review of 41 cohort studies with 5,102 patients, Susan P. Y. Wong, M.D., from the Veterans Affairs Puget Sound Health Care System in Seattle, and colleagues examined survival, health care resource use, changes in quality of life, and end-of-life care among patients with advanced kidney disease who forgo dialysis.
GLP-1 RA Use May Up Risk for Gallbladder, Biliary Diseases
JAMA Internal Medicine
Use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is associated with increased risks for gallbladder or biliary diseases, with a higher risk for GLP-1 RA use in weight loss. Liyun He, from the Peking Union Medical College Hospital in China, and colleagues conducted a systematic review of randomized controlled trials (RCTs) comparing the use of GLP-1 RA drugs with placebo or with non-GLP-1 RA drugs in adults to examine the association with gallbladder and biliary diseases. Data from 76 RCTs with 103,371 patients were included in the meta-analysis.
USPSTF: Evidence Lacking for OSA Screening in Asymptomatic Adults
The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to recommend screening for obstructive sleep apnea (OSA) in asymptomatic adults. Cynthia Feltner, M.D., M.P.H., from the University of North Carolina at Chapel Hill Evidence-based Practice Center in Research Triangle Park, and colleagues conducted a systematic review of the evidence on screening and treating asymptomatic adults with OSA or those with unrecognized symptoms of OSA. The researchers found that none of the randomized controlled trials that were reviewed directly compared screening with no screening. The accuracy and clinical utility of potential tools that could be used to screen for OSA in the primary care setting currently are uncertain. Trials of positive airway pressure have not established whether treatment of OSA reduces mortality.
Guidelines & Recommendations
Management of Antithrombotics in GI Bleed, Endoscopy Addressed
Journal of Gastroenterology
In a clinical practice guideline issued jointly by the American College of Gastroenterology and the Canadian Association of Gastroenterology, updated recommendations are presented for the periendoscopic management of anticoagulants and antiplatelets during acute gastrointestinal (GI) bleeding and in the elective endoscopy setting.
For patients presenting with acute GI bleeding, the authors suggest against giving fresh frozen plasma or vitamin D for patients on warfarin; prothrombin complex concentrate (PCC) is suggested if needed, rather than fresh frozen plasma administration. The authors suggest against PCC administration for patients on direct oral anticoagulants. For patients on antiplatelet agents, the authors suggest against platelet transfusions. For patients in the elective endoscopy setting, continuation of warfarin is suggested as opposed to temporary interruption; however, for procedures with a high risk for GI bleeding in whom it is held, the guideline suggests against bridging anticoagulation, unless the patient has a mechanical heart valve.
Universal HepB Vaccination Recommended for Adults Age 19 to 59
U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report
Hepatitis B (HepB) vaccination should be administered to adults aged 19 to 59 years and to those aged 60 years or older with risk factors for HepB
. Mark K. Weng, M.D., from the CDC in Atlanta, and colleagues updated recommendations for HepB vaccination for adults based on a review and discussion of the relevant scientific evidence. The review was informed by 263 studies deemed eligible.
Molnupiravir for Nonsevere COVID-19 Added to Living Guideline
The BMJ
Molnupiravir is recommended for patients with nonsevere COVID-19 who are at the highest risk for hospitalization, according to the updated World Health Organization living guideline on drugs for COVID-19. Based on data from six randomized controlled trials with 4,796 patients, the researchers added a new recommendation for molnupiravir in patients with nonsevere illness. Molnupiravir is recommended for those at highest risk for hospitalization and should be combined with implementation of mitigation strategies to reduce potential harms.
ACR Updates Guidelines for Juvenile Idiopathic Arthritis
Arthritis & Rheumatology
Karen B. Onel, M.D., from the Hospital for Special Surgery in New York City, and colleagues conducted a systematic literature review and updated the guidelines for pharmacologic management of JIA The authors provide recommendations for initial and subsequent treatment of JIA with oligoarthritis, temporomandibular joint arthritis, and systemic JIA. None of the recommendations were supported by moderate- or high-quality evidence.
In a second set of recommendations, Onel and colleagues focused on nonpharmacologic therapies, medication monitoring, immunizations, and imaging, regardless of JIA phenotype. The authors recommended use of physical therapy and occupational therapy interventions; an age-appropriate, well-balanced diet; laboratory monitoring for medications; and widespread immunization us. They also emphasized the importance of shared decision making with patients/caregivers. The low quality of evidence supporting most of these recommendations underscores the importance of clinical judgment and emphasizes the need for more high-quality evidence to support current practice and improve disease management
More Highlights
Wherever there are person-person interactions, there is potential conflict. Conflict in the boardroom may be a result of rivalry, misunderstanding, or the need for resources to get the work done. Two types of conflict may occur on a board, task conflict or relationship conflict.
Task conflict is a perception of disagreement between group members or individuals about the content of their decisions, differences in viewpoints, and opinions.
Relationship conflict is a perception of interpersonal incompatibility and may include annoyance and animosity among individuals.
If conflict occurs openly in the boardroom, it could be perceived as healthy since it may contribute to effective performance. If it continues after the board meeting, it may be perceived as unhealthy and can have destructive effects such as restrictive communication and decreased cohesiveness, and may hinder performance. Constructive conflict often improves decision making, stimulates creativity, encourages interest, provides a forum to release tension, and fosters change. Regardless of the conflict, it is important to always strive to create and maintain good relationships. Trust is essential for board members to engage in unfiltered, and constructive debate of ideas.
“To build this critical trust, prioritize communication, teamwork and transparency,” notes Melissa A. Fitzpatrick, MSN, RN, FAAN, president of Kirby Bates Associates and the first-ever nurse to serve on the Board of UNC Rex Healthcare and its Quality, Patient Safety, and HR Committee. “When facing conflict, live your values, role model grace and the attitude you hope to see in others, communicate honestly and surround yourself with the best and the brightest so that you can find the path forward together.”
5 ways to proactively manage conflict while on a board
- Ask about formal procedures to resolve conflict or grievances issues.
- Keep comments and discussions aligned with the board’s purpose, objectives, and plans.
- Encourage and model active listening to prevent misunderstandings that may impact decision-making.
- Participate in educational offerings to build your collaborative skills and trust with others.
- Use the appropriate conflict management style based on the situation. This may include accommodating, avoiding, collaborating, competing, and compromising.
References:
Friend, M. L. (2021). Power and Conflict. In D. L. Huber and M/L. Joseph (Ed.), Leadership & nursing care management (7th ed., pp.175-208). Elsevier.
Thakore, D. (2013). Conflict and conflict management. IOSR Journal of Business and Management (IOSR-JBM), 8(6), 07-16.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Nurses Month
#NursesMonth
Oncology Nursing Month
#OncologyNursingMonth
National Student Nurses Day
May 8, 2022
National Skilled Nursing Care Week (NSNCW)
May 8-14, 2022
Theme: Creating and Nurturing Connections
#NSNCW
National School Nurse Day
May 11, 2022
#SND2022
International Nurses Day
May 12, 2022
Theme: Nurses: A Voice to Lead - Invest in Nursing and respect rights to secure global health
Neuroscience Nurses Week
May 15-21, 2022
#NNW22
Healthcare Observances
Here are some of the healthcare observances being recognized in May.
Arthritis Awareness Month
Hepatitis Awareness Month
#HepAware2022, #HepatitisAwarenessMonth, #Hepatitis
Skin Cancer Awareness Month
#SharetheFacts, #SkinCheckChallenge, #ThisIsSkinCancer
Mental Health Month
#MHAM, #Together4MH
National Asthma and Allergy Awareness Month
National Celiac Disease Awareness Month
#CeliacAwarenessMonth, #ShineaLightonCeliac
National Osteoporosis Awareness and Prevention Month
#NationalOsteoporosisMonth
National Stroke Awareness Month
#StrokeMonth
Preeclampsia Awareness Month
World Preeclampsia Day
May 22, 2022
#WorldPreeclampsiaDay2022
National Trauma Awareness Month
Critical Care Awareness Month
#NCCARM, #BlueICU
National Women's Health Week
May 8-14, 2022
Theme: Forward Focus: Achieving Healthier Futures Together
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
The last few years have been especially challenging for the nursing profession. We have faced fighting a virus that has wreaked havoc on patients, families, and on ourselves. We have struggled with equity, diversity, and inclusivity issues and healthcare inequity has become more evident than ever. Schools of nursing have adapted to new ways of providing education to those who wish to join our profession although they were facing the reality of inadequate numbers of faculty, low salaries, and a lack of resources and clinical sites. Yet, our profession continues doing what it does best, making a difference each and every day and that’s what we celebrate this Nurses Month.
Every day I marvel at the dedication and resiliency I see in my colleagues – direct-caregivers; faculty and professional development practitioners; those developing evidence-based content for professional development and clinical decision support; and those working in industry to develop workforce resources to improve labor/productivity/and care models. The depth and breadth of those working in the nursing profession is vast and their efforts to consistently move the profession forward with the goal of optimizing patient outcomes is awe-inspiring.
How can we as profession continue making these efforts? We must invest in ourselves by making sure we address our own selfcare. We need to recognize when fatigue and exhaustion are moving to moral distress and burnout, and we must intervene before that happens. We need to gaze into our own mirror, assess our reflection, and initiate interventions that support our own wellbeing.
We need to recognize each other for the work we are doing each and every day and offer gratitude for those efforts. Gratitude is defined as the quality of being thankful and being ready to show appreciation for and to return kindness. It’s time to show some gratitude by saying thank you and doing random acts of kindness for our colleagues. Some may say our organizations and leaders should be showing gratitude and I can’t disagree. However, gratitude starts within each of us; we need to model the behaviors we want demonstrated to us.
We need to continue investing in professional development, so we are ready to lead the future of healthcare.Learning new skills, investing in new knowledge and education, and challenging ourselves to think differently about situations and being mindful will help propel our nursing journey. Our profession was built on nurses who were willing to take risks, learn, and challenge the status quo. The future of our profession will be secured if enough of us have the courage to keep moving forward.
Nursing is about caring for people. Our impact goes far beyond an individual person, it extends to our communities locally, nationally, and internationally. We need to be advocates for those in need and foster care equity, diversity, and inclusivity for those we serve. The nursing profession will insure every person’s life has value, and everyone has a right to health.
This Nurses Month, let’s remember to invest in our own wellbeing and professional development, engage in our communities, and demonstrate gratitude for those who travel with us on this wonderful journey we call nursing. Thank you for your investment in our profession!
It’s been 6 years since we created
My Nursing Care Plan! At that time, we focused on meeting professional requirements, being a lifelong learner in nursing, and work-life
balance. While the first two goals still make sense, I’ve struggled with the third for quite some time. Do we really ever balance everything in our lives? I can’t think of a time when everything in my life was equally balanced, when my energy and time was equally divided among work, family, and all the other responsibilities that compete for my attention.
So, I decided it was time to revise that section of My Nursing Care Plan. Take a closer look at what you need to do to achieve harmony – physically, mentally, and spiritually.
Assessment
Ask yourself these questions:
- Am I up to date on medical care & screenings?
- Am I getting enough rest?
- What is the quality of my rest?
- How’s my nutrition?
- How is my stress level?
- Am I seeing my family and friends?
- Am I spending time doing things that bring me joy?
Diagnosis
*Readiness for enhanced self-health management related to identifying my own health care needs.
*Readiness for enhanced self-care related to maintaining personal relationships and managing stress.
Planning
- Check your medical records and make a list of what screenings and immunizations are recommended based on your age and medical and family history.
- Update your calendar with your work schedule and upcoming social events; include downtime and time for activities that bring you joy.
- Think about how you best deal with stress. Is it a yoga class? Reading? Being outdoors?
- Set short-term and long-term goals.
Implementation
Physical Health Strategies
- Schedule appointments and screenings.
- Get moving. Physical exercise benefits your physical and mental health; it increases alertness and energy.
- Eat healthy, nutritionally balanced meals.
- Practice yoga.
- Get adequate sleep.
- Stay hydrated.
- Practice deep breathing.
- For those working in an office or home office…
- Take a drive to break routine.
- Take stretch breaks.
- Use tinted glasses to help with eye strain and prevent headaches.
Mental Health Strategies
- Sign up for a class, gym, or other activities that help you manage stress. Remain committed to these endeavors.
- Consider simple changes to your schedule – would grocery shopping after work save you time on the weekend?
- Schedule time with family and friends.
- Take time off.
- Try and keep interactions with negative people to a minimum.
- Take a break from TV and social media.
- Embrace joy.
- Relax/unwind.
- Take a walk.
- Read a book.
- Find a hobby.
- Create a bedtime routine.
- Utilize aromatherapy.
- Explore music therapy.
- Enjoy the outdoors.
- Set small goals and reward yourself.
Spiritual Health Strategies
- Start each day by being grateful.
- Self-awareness is key. Discover who you are and what you want.
- Try meditation.
- Make time for your faith and prayers.
- Incorporate relaxation techniques throughout your workday.
- Practice meditation and mindfulness.
- Identify three positives at the end of the day.
Evaluation
Revisit this care plan throughout the year and fill this in. Ongoing evaluation and revisions are key components to meeting your goals.
You are the gatekeeper of your own time. Find what's important to you in your life and remember you don't have to do it all. Find what fills you up and try to avoid those things that deplete your resources. Embrace joy because it's a choice not just a feeling. Start small and go from there!
Gratitude is defined as the quality of being thankful and being ready to show appreciation for and to return kindness. Over my many years of being a nurse and nurse practitioner, one thing I recognize is being thankful for those who work along side of me. Knowing that the person beside me has my back no matter what the situation, has gotten me through some very tough situations. Whether it’s been in my practice, my work as adjunct faculty, or in my role as an evidence-based content developer and provider, just knowing that I have colleagues working with me who have the same dedication and drive to do the best they can in any situation makes all the difference.
Gratitude can be shown in many ways. How many times have you said to your colleague, “Thank you for working with me today, thanks for all you do and having my back.” Something so simple as just saying thank you can make the difference in someone’s day. It’s easy in our busy days to forget to say these two words. Little, random acts of kindness such as buying someone a coffee or tea when we see their energy fading can also make a big difference.
I know many of you will be thinking our organizations need to show more gratitude for all we do, and I can’t disagree. Now is the time for organizations to say thank you and demonstrate gratitude to their workforce. However, let’s not forget that gratitude starts within each of us. We need to model the behaviors we want demonstrated to us.
Nursing is a caring profession, and we demonstrate this everyday by the care we deliver to our patients. Now it’s time to show some gratitude and kindness by caring for ourselves and our colleagues. I want to personally thank each of you for the dedication to your patients, your colleagues, and our profession. I am forever grateful to each of you for efforts and kindness you deliver each day.
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
Nursing
Rotating Night Shifts May Hamper Healthy Aging
JAMA Network Open
Rotating night shift work is associated with a decreased probability of healthy aging among U.S. female nurses. Researchers found that compared with women who never worked rotating night shifts, the odds of achieving healthy aging decreased significantly with increasing duration of night shift work.
Medication Errors Reported Frequently by Home Care Service Nurses
Pharmacology Research & Perspectives
More than 40 percent of fully trained nurses from home care services reported medication errors within a 12-month period. The odds ratio of not making medication-related errors was 1.79 for nurses who had attended medication training within the last two years as opposed to a longer period (frequently versus rarely applied double-check principle [DCP]). No significant associations were seen for years of professional experience, amount of patients per shift, or type of work contract (full versus part-time) with reported medication errors.
Potential Moral Injury Seen in Health Care Workers Similar to Vets
Journal of General Internal Medicine
The potential for moral injury is high among combat veterans and COVID-19 health care workers (HCWs) and is associated with negative mental health outcomes.
Guidelines & Recommendations
Preventing Surgical Site Infection (SSI) After Major Extremity Trauma
In an evidence-based clinical practice guideline published by the American Academy of Orthopaedic Surgeons, recommendations are presented for the prevention of surgical site infection (SSI) after major extremity trauma. Fourteen strong and moderate-strength recommendations were developed.
Diagnosis and Management of Barrett Esophagus
In a new American College of Gastroenterology guideline, screening methods have been broadened and guidance has been updated on intervals and techniques of surveillance for patients with Barrett esophagus (BE).
Health Supervision for Children and Adolescents with Down Syndrome
All families should receive formal counseling by a clinical geneticist or genetic counselor. At every health supervision visit, and at least annually, several areas should be reviewed, including personal support available to the family; participation in a family-centered medical home; age-specific Down syndrome-related medical and developmental conditions; financial and medical support programs for which the child and family may be eligible; injury and abuse prevention; and nutrition and activity for maintenance of appropriate weight. Guidance is provided for pregnant women who have been given a prenatal diagnosis, as well as age-specific guidance for care of the individual with Down syndrome from birth through infancy, childhood, and adolescence.
More Highlights
I’ve been a nurse coming up on 30 years, with over a decade of experience as a critical care nurse practitioner. In that time, I’ve come to know some things about myself. One of the habits I have that goes back many years is explaining my orders. I realized to my horror that despite the care I take with the tone of my statements, perhaps I was participating in something similar to another social phenomenon with quite a negative reference. Was I “nurse-splaining?”
Allow me to explain…
As a nurse, I would receive orders that sometimes I didn’t quite understand. Why was I doing this? Why wasn’t I doing that? Often times, I would be met with defensive explanations when I would ask the ordering provider. I vowed that I would never do that. There are some orders that require no explanation: vital signs, neuro checks, acetaminophen… But how do I choose one pressor over another? Why are we doing this CAT scan? As a critical care nurse practitioner, I have found myself explaining some of my orders to the nurses not for justification, but to involve them in the process. I feel it’s important for them to know why I’m asking them to do certain things, or why we shouldn’t do certain things. What are we looking for on that CAT scan? Why is it important that we go now? I like to close the loop on the communication so we’re all on the same page.
Here’s a good example.
A patient with liver failure comes in with cirrhosis and hepatic encephalopathy. His ammonia level is elevated and he needs lactulose. We all know what happens next. Many times, I will be asked for an order for a fecal management system. Many times, I am not able to order it because the patient has severe portal hypertension and known esophageal varices. But instead of just saying no, I explain why, “There is a high likelihood that the patient will also have rectal varices which could rupture if we placed a large balloon in the rectum.” Sometimes I’ll recommend a rectal pouch that is non-invasive.
Is this nurse-splaining? Am I offending someone by doing so? Or am I merely providing the rationale for the orders? I posed this question to the nurses that I work with.
Feedback from Nurse Colleagues
Most nurses felt that they were a part of the decision, and actually were able to learn something from what I was explaining. There have been times when I have learned something from them or been the grateful recipient of more information that might change the plan of care. I have not yet been advised that I have offended anyone, but I can’t say that it hasn’t happened. I truly feel that we were all a team and we’re in this together, and the last thing I want to do is offend anyone.
One of the benefits to having this exchange, is that sometimes the nurses have a different perspective. I feel that open dialogue between all providers is important. This can only improve patient care and achieve better outcomes. What are your thoughts?
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Pride Month
#PrideMonth
Alzheimer's & Brain Awareness Month
#ENDALZ #EndAlzheimers
Men's Health Month
National Safety Month
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
Care without judgement and best care everywhere. That’s what the nursing profession is about; we care for everyone and advocate for health equity, diversity, and inclusion for all people. The past several years have brought attention to the fact that as a country, we are still facing a divide where race, ethnicity, gender, sexual orientation, and health equity are concerned. Weekly, and sometimes daily, we see the division in the news, or we witness it firsthand. Where is our humanity? According to the dictionary, humanity speaks to those attributes that make us human such as the ability to have compassion, love, and care for one another. From where I sit, humanity is lacking right now. We must do better.
Every day as nurses we care for people of all colors, genders, sexual orientations, and socioeconomic classes, and with different beliefs or morals than our own. Our mission is to provide care regardless if the person thinks, looks, or believes as we do. We combine the art and science of nursing and healthcare and our own humanity to improve the patient’s outcome, ease their burden and demonstrate that we are ready and willing to care. We are the patient’s advocate when they are struggling to let their desires be known and when their voice is silent because they cannot speak. As a profession we are bound to do no harm and we readily step up to protect our patient’s when no one else will.
June is
Pride Month. As a profession, it’s our obligation to support and care for our LGBTQ+ patients and ensure they receive care without judgement and best care everywhere. Everyday we need to fight for inclusivity, diversity, and health equity in our communities. The people in our communities become our patients and they need to know nurses will be supporting them throughout their life journey. We are all different; we need to respect and support those differences and realize they make humanity stronger.
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
Nursing
Greater Nurse Staffing Tied to Better Sepsis Outcomes
JAMA Health Forum
Jeannie P. Cimiotti, Ph.D., from Emory University in Atlanta, and colleagues assessed whether registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis. An increase in registered nurse hours per patient day was associated with a 3 percent decrease in 60-day mortality.
Guidelines & Recommendations
Updates Issued for Standards of Medical Care in Diabetes
In a supplemental issue of
Diabetes Care, the American Diabetes Association has published updates to the new
Standards of Medical Care in Diabetes - 2022. Updates include changes to section 10, which addresses cardiovascular disease and risk management, and section 11, which addresses chronic kidney disease and risk management. The recent updates offer information regarding the effects of finerenone on cardiovascular outcomes for people with type 2 diabetes and chronic kidney disease and the effects of sodium glucose cotransporter 2 inhibitors on heart failure and renal outcomes among people with type 2 diabetes. New information was also included on calculating estimated glomerular filtration rates and the inclusion of race in the diagnosis of kidney disease.
Using New Guidelines Would Increase Diabetes Screening Eligibility
Implementing the new changes in U.S. Preventive Services Task Force (USPSTF) and American Diabetes Association (ADA) diabetes screening guidelines would increase screening eligibility among U.S. adults, according to a research letter published in the
Journal of the American Medical Association.
Guideline Updated for Use of Radiation for Brain Metastases
In a clinical practice guideline issued by the American Society for Radiation Oncology and published 6 in
Practical Radiation Oncology, updated recommendations are presented regarding the use of radiation for treating brain metastases. The updated guideline discusses advanced radiation therapy techniques and places emphasis on multidisciplinary care.
Focus on Artificial Intelligence (AI)
AI May Help Detect Breast Cancer in Mammography Screening Program
An artificial intelligence (AI) system can help detect breast cancer in a population-based mammography screening program, according to a study published in
Radiology.
AI Aids Assessment of Indeterminate Pulmonary Nodules on CT
Use of computer-aided diagnosis (CAD) improves estimation of malignancy risk for indeterminate pulmonary nodules (IPNs) on chest computed tomography (CT) scans, according to a study published in Radiology.
Most Patients Have Positive Views About AI in Medicine
Most patients have positive views about the ability of artificial intelligence (AI) to improve care but have concerns about unintended consequences, according to a research letter published in JAMA Network Open.
More Highlights
This past May was our third
Nurses Month during the COVID-19 pandemic and our appreciation and support of nurses is stronger than ever – and not just on any certain day, week, or month. We strive to demonstrate our gratitude and pride for you, nurses, no matter your role or setting, each and every day.
Since there is a dedicated recognition month, though, we did put together some special content! Here are the highlights!
Our NCPD collection supporting the weekly themes of Nurses Month was offered FREE and so many of you took advantage! We are thrilled to support your professional development and even more thrilled that your participation in our
CE for Charity campaign resulted in a donation of $4100 to
National Alliance on Mental Illness (NAMI) Frontline Wellness Initiative, which supports caring for health care professionals on the frontline.
Throughout the month, we focused on
Celebrating Nurses Making a Difference in People’s Lives and our Profession, remembering that “Our impact goes far beyond an individual person, it extends to our communities locally, nationally, and internationally. We need to be advocates for those in need and foster care equity, diversity, and inclusivity for those we serve. The nursing profession will insure every person’s life has value, and everyone has a right to health.”
We also prioritized
A New Goal: Work-Life Integration, because do we really ever balance everything in our lives? This infographic includes strategies to help you achieve harmony – physically, mentally, and spiritually.
Recognizing Others by Sharing Gratitude and Kindness was another important theme that we focused on. It’s important we remember the value of a “thank you” in any form. It can make someone’s day, and as we pay it forward, the feeling of being appreciated can spill over beyond that moment.
Lastly, please allow me to highlight some of our new multimedia content…
- Webinars – now available on demand, with free contact hours available!
- Podcasts
Thank you, nurses, for all you do!
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Here are some of the healthcare observances being recognized in July.
Medical Malpractice Month
Juvenile Arthritis Awareness Month
National Cleft & Craniofacial Awareness & Prevention Month
World Hepatitis Day
July 28, 2022
Theme: I Can’t Wait
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
The cervix is examined during a
female genitourinary assessment. During internal visual examination, its color and position, as well as any lesions or discharge, can be assessed, and cervical specimens can be obtained.
Assessment of cervical motion tenderness (CMT) is part of the bimanual examination. To assess for CMT, insert the index finger and middle finger into the vagina until they are at the posterior fornix of the vagina. Then use the other hand to place pressure on the abdominal wall, over the suprapubic region. Each hand applies pressure towards the opposite hand, allowing for complete examination of the size, position, shape, and mobility of the cervix, and to assess if there is any tenderness or palpable masses. Bimanual examination should continue to assess the uterus and ovaries, to distinguish the location of any acute tenderness, or identify if there is isolated CMT.
CMT is a significant clinical finding that often indicates peritoneal irritation. CMT, uterine and/or adnexal tenderness are defining characteristics of acute symptomatic pelvic inflammatory disease (PID) (Ross & Chacko, 2022). CMT is also a hallmark sign of ectopic pregnancy and appendicitis (Bickley et al., 2021) but can also add to the differential diagnosis of any process with peritoneal involvement, such as diverticulitis, inflammatory bowel disease, hernia, perforated abdominal viscus, abdominal wall hematoma, ureteral lithiasis, interstitial cystitis, endometriosis, endometritis, tubo-ovarian abscess, ovarian or adnexal torsion, chronic pelvic cellulitis, vaginitis, cervicitis, or pelvic thrombophlebitis (Cortes & Adamski, 2021).
References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Cortes, E.G., Adamski, J.J. Chandelier Sign. [Updated 2021 Jul 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545286/
Ross, J. & Chacko, M. (2022, April 20). Pelvic inflammatory disease: Clinical manifestations and diagnosis. UpToDate. https://www.uptodate.com/contents/pelvic-inflammatory-disease-clinical-manifestations-and-diagnosis
On July 23, 2022, the global mpox outbreak was designated a public health emergency of international concern. As the virus spreads across countries, including the U.S., here are 10 things for nurses to know to help you in clinical practice and public health education.
Mpox is a close relative of smallpox; the smallpox vaccine also prevents mpox infection.
Two vaccines are currently available in the U.S.
Transmission occurs from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials, such as bedding.
The incubation period of mpox can range from five to 21 days. It is usually a self-limited disease with the symptoms typically lasting from 2 to 4 weeks.
Mpox presents with fever, a
characteristic rash and usually swollen lymph nodes. The lymphadenopathy of mpox distinguishes it from smallpox; it may be generalized or localized to several areas, such as the neck and axillae.
Clinicians should be alert for patients who have rash illnesses consistent with mpox. The
clinical course includes the development of lesions, which often appear simultaneously and evolve through the
enanthem through the scab stage together, on any given part of the body.
The preferred laboratory test for mpox is detection of viral DNA by polymerase chain reaction (PCR). Specimens should include two swabs from two different lesions, preferably from different locations on the body or from lesions which differ in appearance.
Standard, contact, and droplet precautions are recommended when caring for a patient with mpox; an airborne infection isolation room should be used for procedures that may aerosolize secretions, such an intubation and extubation.
For inpatients, discontinuation of isolation precautions should be made in consultation with the local or state health department. For outpatients, isolation precautions should be maintained until all lesions have crusted and fallen off, and a fresh layer of healthy skin has formed.
Severe cases occur more commonly among children and are related to the extent of exposure, and the patient’s underlying health status. Immune deficiencies may lead to worse outcomes.
Complications can include secondary infections, bronchopneumonia, sepsis, encephalitis, and infection of the cornea which may cause vision loss.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Here are some of the healthcare observances being recognized in August.
Children's Eye Health and Safety Month
#ChildrensEyeHealthAndSafetyMonth
National Breastfeeding Month and
World Breastfeeding Week August 1-7, 2022
Theme: Together We Do Great Things!
#NBM22, #WBW2022
National Immunization Awareness Month
#ivax2protect
Psoriasis Action Month
National Health Center Week
August 7-13
#NHCW2022
International Overdose Awareness Day
August 31
#iOAD2022
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
August, the month when nursing students go back to school to start their fall semester and faculty worry about having enough resources to meet the needs of their students. The nursing shortage has placed an enormous burden on academia and that burden worsened with the impact of COVID. Today there is real concern the profession will not graduate enough new nurses to fill the gaps of baby-boomer nurses retiring or younger nurses leaving the bedside to work in other areas. In academia, we are witnessing a similar situation, baby-boomer faculty are retiring and there are not enough faculty to replace the gaps. Resources are stretched thin and finding clinical sites for undergraduate and graduate nursing students is challenging.
Someone asked me recently should they be worried about what is happening in academia and the answer is yes; we should all be worried, because the day will come when we need a nurse to care for us and there won’t be one.
It’s time practicing nurses work with academia...
Think about being a preceptor for nursing students. Don’t underestimate the impact you have by precepting our next generation of nurses. Yes, it is additional work but, the return on investment will be paid back in dividends. You can provide knowledge and expertise, facilitate clinical judgement, and teach students how to develop trusting relationships with those we care for.
Think about furthering your education by becoming faculty. Further education requires an investment in your time as well as a financially. Look for scholarships to help cover the cost of the higher degree and leverage tuition reimbursement from your practice location. If being full-time faculty is not something you desire, consider becoming adjunct faculty. Being an experienced nurse does not equate to being a successful nurse educator; one needs to be taught to facilitate learning in an academic setting and many healthcare organizations are now partnering with academia to develop adjunct faculty who teach for academic partner institutions while continuing to practice in the healthcare organization. This type of academic/practice partnership helps fill the needs of both organizations.
Academic centers are constantly looking for places where students can gain clinical experience. We need to remember that care is 24/7 not just 7am to 7pm, Monday through Friday. Offer more opportunities for students to fulfill their clinical requirements by opening alternative shifts and weekends to students. Let’s not forget that nursing students need experiences outside of acute care. Schedule students in clinics, home care, hospice, and health system run community centers.
It’s time to give back to our profession to get back our profession...
I’m fortunate to have the opportunity to not only continue practicing, but I’m also adjunct faculty for two graduate nursing programs. I’m not unique; I’m one of many nurses who feel the need to give back to the profession to get back our profession. Sharing knowledge, experience, and wisdom by facilitating learning, supports the next generation of nurses and advanced practice nurses and helps insure when you need a nurse, someone will be at your side.
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
Nursing
Impact of COVID-19 Pandemic on Infection Prevention Professionals Explored
The likelihood of reporting negative COVID-19 impacts is lower for infection prevention professionals (IPs) with organized wellness support, according to a study published online in the
American Journal of Infection Control.
Bernadette Mazurek Melnyk, Ph.D., from The Ohio State University in Columbus, and colleagues surveyed a random sample of Association for Professionals in Infection Control and Epidemiology members regarding mental and physical well-being, lifestyle behaviors, and perceived worksite wellness support during the pandemic; 926 IPs responded (15 percent response rate). The researchers found that few of the respondents met the guidelines for sleep, physical activity, and fruit and vegetable consumption (34.1, 18.8, and 7.3 percent, respectively). The rate of depression was 21.5 percent; anxiety, 29.8 percent; and burnout, 65 percent.
Guidelines & Recommendations
Recommendations Issued for Medical Response to Mass Shootings
In an article published online in the
Journal of the American College of Surgeons, recommendations are presented for the medical and surgical management of mass shooting incidents. These recommendations addressed regular readiness training; public education; a staged and iterative triage process; effective communication between prehospital personnel and hospitals; a patient tracking system; documentation and medical records; reunification of families; and mental health services for responders. An additional 11 recommendations were created by two subgroups each. These recommendations included trauma and/or other response training for clinicians; Stop the Bleed education; mass shooting triage protocol for prioritizing patient care; surgeon participation in emergency department triage; regionwide, coordinated hospital communications; and immediate systems to reach and recall staff.
Guidance Issued for Managing Visual Disorders After Pediatric Concussion
In a policy statement issued by the American Academy of Pediatrics and published online in
Pediatrics, guidance is presented for the management of visual disorders following a concussion among children.
Christina L. Master, M.D., from the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues developed recommendations for screening, identifying, and initiating clinical management of visual symptoms in pediatric patients after concussion. The authors note that most children and adolescents with visual symptoms after concussion will recover by four weeks; however, a subset does not have spontaneous recovery and should be referred to a specialist with experience in comprehensive concussion management for assessment and treatment.
Recommendations Developed for Treating Preinvasive Vulvar Lesions
In consensus statements published in the July issue of the
Journal of Lower Genital Tract Disease, recommendations are presented for the management of patients with preinvasive vulvar lesions.
Mario Preti, M.D., from the University of Torino in Italy, and colleagues from the European Society of Gynaecological Oncology, International Society for the Study of Vulvovaginal Disease, European College for the Study of Vulval Disease, and European Federation for Colposcopy developed consensus statements on preinvasive vulvar lesions to improve the quality of care for patients with vulvar squamous intraepithelial neoplasia, vulvar Paget disease in situ, and melanoma in situ.
More Highlights
Early Warning System Can Identify Sepsis Patients
An early warning system has the potential to identify sepsis patients early and improve patient outcomes, according to a study published online in
Nature Medicine.
Roy Adams, Ph.D., from Johns Hopkins University in Baltimore, and colleagues conducted a prospective, multisite cohort study to examine the association between patient outcomes and provider interaction with a deployed sepsis alert system, the Targeted Real-time Early Warning System (TREWS). The researchers found that patients in this group whose alert was confirmed by a provider within three hours had a reduced in-hospital mortality rate (adjusted absolute reduction, 3.3 percent; adjusted relative reduction, 18.7 percent), organ failure, and length of stay compared with those whose alert was not confirmed by a provider within three hours after adjustment for patient presentation and severity. Patients who were additionally flagged as high risk had larger improvements in mortality rate (adjusted absolute reduction, 4.5 percent).
Updated Meta-Analysis Links NAFLD to Increased Risk for Heart Failure
Nonalcoholic fatty liver disease (NAFLD) is associated with an increased long-term risk for new-onset heart failure, according to research published online in
Gut.
The researchers identified 11 longitudinal cohort studies, which included data on 11,242,231 middle-aged individuals and 97,716 cases of incident heart failure during a median of 10 years. There was an association for NAFLD with a moderately higher risk for new-onset heart failure (pooled random-effects hazard ratio, 1.50), independent of age, sex, ethnicity, adiposity measures, diabetes, hypertension, and other common cardiovascular risk factors.
Whether you work in a state where cannabis is fully legal for adult use or one where medical cannabis can be recommended, as a nurse, you will frequently encounter patients who use cannabis. One of the issues healthcare professionals have now is that patients often view cannabis use as either harmless and not worth mentioning
or as a substance that is stigmatized, and so they become fearful around mentioning their cannabis use. As the U.S. heads toward the likelihood of cannabis being made federally legal, nurses need to be comfortable and confident with their ability to assess patients’ cannabis ingestion and support, educate, and coach them around safe and effective cannabis use.
Here are 3 common questions I hear frequently from nurses and nursing students who are interested in cannabis care nursing and supporting patients’ safe and effective use of cannabis:
1. How does cannabis work for so many different disease issues?
Our bodies have a master regulator system called the endocannabinoid system (ECS). We make and then degrade our own endocannabinoids (cannabis-like substances) that interact with this system to ensure our bodies remain in homeostasis, and endocannabinoids help the immune system to function properly so that we stay well. When the ECS does not have what it needs to function properly due to stress, illness, dietary, or lifestyle issues, we may not make adequate endocannabinoids to meet the system’s needs. People with a variety of illnesses may find that they have a clinical endocannabinoid deficiency, and they will need to supplement cannabinoids to feel healthy and well (Russo, 2016). We now know that when patients are guided toward proper self-titration of cannabis, they can safely and effectively use the medicine to support their healing process and palliative needs without getting high or becoming addicted to the medicine (Clark, 2021).
2. If cannabis is federally illegal, how can I talk about it in the healthcare workplace?
The federal legality issue has never been an issue in any healthcare setting; no facility has ever lost funding for patients using cannabinoids or healthcare practitioners talking about cannabis. We can always remain in our scope of practice by educating and coaching patients. In fact, in an issue of the
Journal of Nursing Regulation, the National Council of State Boards of Nursing (NCSBN) (2018) identified the 6 essential areas that all nurses must be educated around when providing care for cannabis patients You can view and download
The NCBSN National Nursing Guidelines for Medical Marijuana free and share it with others in your workplace.
3. How do I convince my workplace that we should be assessing patients for cannabis use and educating them around using it effectively?
The first step is educating yourself and gaining confidence around how cannabis works in the body; why and how prohibition of cannabis has created a stigma for patients and vulnerable populations; proper dosing of cannabis; access to safe cannabinoid therapeutics; and our ethical obligation to address these issues in the workplace. Use your professional communication tools and published literature when speaking with colleagues and administrators. In addition to sharing the NCSBN (2018) guidelines, the American Cannabis Nurses Association (2019) created
The Scope and Standards of Practice for Cannabis Nurses (Clark et al., 2019). The
first textbook for nurses that provides you with a depth of information about cannabis care nursing is also now available.
Cannabis has long been used to stigmatize vulnerable populations and people of color during the prohibition era. As nurses, we can help to end the stigma around this plant entheogen and begin to usher in a post-prohibition era where patients can safely use cannabis to help manage their palliative and healing needs, including symptoms of pain, appetite issues, sleep, anxiety, spiritual healing, and quality of life concerns.
References:
Clark, C.S. (2021). Cannabis: A handbook for nurses. Wolters Kluwer.
Clark, C.S., Bernhard, C.E., Quigley, N., Smith, K., Theisen, E., & Smith, L.D. (2019). Scope and standards of practice for cannabis nurses. American Cannabis Nurses Association. https://www.cannabisnurses.org/scope-and-standards-of-practice-for-cannabis-nurses
National Council of State Boards of Nursing. (2018). The NCSBN national nursing guidelines for medical marijuana. Journal of Nursing Regulation, 9(2), supplement. https://www.ncsbn.org/The_NCSBN_National_Nursing_Guidelines_for_Medical_Marijuana_JNR_July_2018.pdf
Russo, E. (2016). Clinical endocannabinoid deficiency: Current research supports the theory in migraine, fibromyalgia, irritable bowel, and other treatment-resistant syndromes. Cannabis and Cannabinoid Research, 1(1). https://www.doi.org/10.1089/can.2016.0009
About the Author
Carey S. Clark, PhD, RN, AHN-BC, FAAN serves as Professor of Medical Cannabis at Pacific College of Health Sciences. She is the Past President of the American Cannabis Nurses Association, and has been a nurse since 1994, with a wide practice background including experience within the acute care setting, pediatrics, hospice care, and parish nursing. Dr. Clark has over 40 publications in journals such as Advances in Nursing Science, International Journal for Human Caring, Holistic Nursing Practice, Clinical Journal of Oncology Nursing, and Creative Nursing.
Dr. Clark has presented at many national and local conferences, particularly with oncology and holistic nurses, where she focuses on bringing basic knowledge about the endocannabinoid system, medicinal use of cannabis, and the nurse’s role. She is the editor of the textbook Cannabis: A Handbook for Nurses (2021, Wolters-Kluwer).
When assessing the skin, it’s important to document your findings using the correct terminology to describe skin lesions. Here’s a quick A-to-Z guide to describing skin lesions.
Bullae – Raised; fluid-filled; greater than 1 cm
Burrow – Small linear or serpiginous pathways in the epidermis
Carbuncle – multiple inflamed hair follicles (furuncles)
Furuncles – Inflamed hair follicle
Macules – Flat; smaller than 1 cm
Nodule – Raised, larger and deeper than a papule
Papules – Raised; smaller than 1 cm
Patches – Flat; greater than 1 cm
Plaques – Raised; greater than 1 cm
Pustules – Small; palpable; appear white
Subcutaneous mass/cyst – encapsulated collections of fluid or semisolid; may be mobile or fixed
Vesicles – Raised; fluid-filled; less than 1 cm
Wheals – Localized edema; evanesces (comes and goes) within 1-2 days
Reference:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
Skin cancer screening and patient education are important factors for recognizing potential skin cancers and intervening early. The American Academy of Dermatology also recommends that patients perform regular skin self-examinations. Teach patients the ABCED-EFG method for assessing moles as outlined below.
The ABCDEs
Clinicians and patients can apply the ABCDE method when screening for melanoma. A mole exhibiting any of the following signs should be referred for further examination and/or biopsy (Swetter & Geller, 2021):
- Asymmetry: if a lesion is cut in half, one side is not identical to the other; may be higher on one side, a different texture, or color
- Border irregularity and bleeding: jagged edges, tails, bleeding or ulceration are signs of melanoma
- Color variegation: 2 or 3 colors present or distributed unevenly
- Diameter: greater than or equal to 6 mm
- Evolving: any change in mole over weeks to months in size, shape or color
EFG
The addition of EFG has been included to help detect aggressive nodular melanomas.
- Elevated
- Firm to palpation
- Growing progressively over several weeks
References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
García-Lozano, J. A., Salerni, G., Cuellar-Barboza, A., la Garza, J., & Ocampo-Candiani, J. (2019). Rapid Dermoscopic Changes in Nodular Melanoma. Dermatology practical & conceptual, 10(1), e2020016. https://doi.org/10.5826/dpc.1001a16
Swetter, S. & Geller, A. (2021, February 22). Melanoma: Clinical features and diagnosis. UpToDate. https://www.uptodate.com/contents/melanoma-clinical-features-and-diagnosis
Benzodiazepines are a class of drugs used to treat generalized anxiety disorder, tension, insomnia, seizure disorders, procedural/surgical sedation or amnesia, skeletal muscle spasm, tremor, and delirium (Comerford & Durkin, 2022). The precise action of benzodiazepines is not fully understood but they have been found to work selectively on polysynaptic neuronal pathways throughout the central nervous system (CNS). Let’s take a closer look at the mechanism of action for benzodiazepines.
Mechanism of Action
Benzodiazepines enhance or facilitate the action of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the CNS that suppresses the activity of nerves. The drugs appear to act at the limbic, thalamic, and hypothalamic levels of the CNS to produce anxiolytic, sedative, hypnotic, skeletal muscle relaxant, and anticonvulsant effects (Comerford & Durkin, 2022).
At the cellular level, the speed of impulses from a presynaptic neuron across a synapse is influenced by the number of chloride ions in the postsynaptic neuron. The passage of chloride ions into the postsynaptic neuron depends on the inhibitory neurotransmitter GABA. When GABA is released from the presynaptic neuron, it travels across the synapse and binds to GABA receptors on the postsynaptic neuron. This binding opens the chloride channels, allowing chloride ions to flow into the postsynaptic neuron, resulting in a slowing of the nerve impulses. The result is a different type of depression. Benzodiazepines bind to receptors on or near the GABA receptor, enhancing the effect of GABA and allowing more chloride ions to flow into the post-synaptic neuron. This depresses the nerve impulses, causing them to slow down or stop.
Drugs and Indications
Benzodiazepine Drugs and Indications (Facts and Comparisons, 2021; Comerford & Durkin, 2022) |
Generic Name |
Brand Name |
FDA-Approved Indications |
Alprazolam |
Xanax® |
Anxiety, panic disorder |
Chlordiazepoxide |
Librium® |
Anxiety, alcohol withdrawal |
Clobazam |
Onfi®, Sympazan® |
Seizure disorder |
Clonazepam |
Klonopin® |
Anxiety, panic disorder, seizure disorder |
Clorazepate |
Tranxene® |
Anxiety, seizure disorder |
Diazepam |
Valium® |
Anxiety, muscle relaxant, procedural anxiety/surgical sedation, seizure disorder |
Estazolam |
N/A |
Insomnia |
Flurazepam |
N/A |
Insomnia |
Lorazepam |
Ativan® |
Anxiety, procedural anxiety/surgical sedation, seizure disorder |
Midazolam |
Versed® |
Procedural anxiety/surgical sedation, seizure disorder |
Oxazepam |
Serax® |
Anxiety |
Quazepam |
Doral® |
Insomnia |
Remimazolam |
Byfavo® |
Sedation |
Temazepam |
Restoril® |
Anxiety, insomnia |
Triazolam |
Halcion® |
Anxiety, insomnia |
Contraindications (Facts and Comparisons, 2021)
Benzodiazepine use is contraindicated in patients with a known hypersensitivity to any component of the drug; severe hypersensitivity to dextran or products containing dextran; pregnancy; acute narrow-angle glaucoma; untreated open-angle glaucoma; significant liver disease; infants younger than 6 months; myasthenia gravis; coadministration with CYP3A inhibitors; sleep apnea; and severe respiratory impairment.
Side Effects & Monitoring (Comerford & Durkin, 2022)
Major sides effects of benzodiazepines include drowsiness, impaired motor function, visual disturbances, and cardiovascular irregularities. Toxic doses may cause issues with short-term memory, confusion, severe depression, vertigo, slurred speech, bradycardia, respiratory depression, respiratory arrest, or severe weakness. Prolonged or frequent use may lead to the development of addiction and withdrawal symptoms with a decrease in dose or termination of therapy. The antidote for benzodiazepine overdose is intravenous flumazenil.
For complete information, please consult the drug’s specific package insert or the
Nursing2022 Drug Handbook® + Drug Updates.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
September Nursing Recognition Dates
National Clinical Nurse Specialist Recognition Week
September 1-7, 2022
Theme: Unstoppable Advocacy
#CNSWeek
National Pediatric Hematology/Oncology Nurses Day
September 8, 2022
Vascular Nurses Week
September 4-10, 2022
Nephrology Nurses Week
September 11-17, 2022
#NNW22, #NephNurseStrong
Nursing Professional Development Week
September 11-17, 2022
#NPDWeek
Neonatal Nurses Week
September 12-18, 2022
#neonatalnursesweek
September Healthcare Observances
Here are some of the healthcare observances being recognized in September.
Sepsis Awareness Month
World Sepsis Day – September 13, 2022
#SAM2022, #SepsisAwarenessMonth
World Alzheimer's Month
World Alzheimer’s Day - September 21, 2022
Theme: Know Dementia, Know Alzheimer’s
#KnowDementia, #KnowAlzheimers, #WorldAlzMonth
More Healthcare Observances in September
September Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
Recently I had the opportunity to talk with nurses about their mental health and well-being. The results were concerning; several nurses I spoke with felt they were burned out, exhausted, and had minimal, or nothing left to give of themselves to their patients or even to their own families. The nurses described they didn’t feel valued by their organization, the leaders, or even their patients anymore. Their healthcare institutions were not having the patient surges they experienced during the pandemic, yet many of their institutions continued to have staffing issues due to nurses resigning, retiring, or due to staffing cuts. The nurses spoke about incivility in the workplace and feeling they were not practicing in a healthy work environment.
Recent studies reveal that up to 45% to 60% of nurses and healthcare professionals are experiencing burnout (Dzau, Kirch, & Nasca, 2020). In one recent research study, up to 66% of nurses under the age of 35 reported feelings of anxiety and 47% experienced feelings of depression (ANA, 2021). In another study, 5.5% of nurses experienced suicidal ideation which is 1% higher than other healthcare workers (Kelsey, West, & Cipriano, 2021). In a recent study on nurse practitioners, 60% of the respondents were feeling burned out; 30% had experienced it for over a year and 20% experienced it for 2 years in a row (Robbins, 2022).
The Pandemic Amplified the Nursing Shortage
Those of us in healthcare have had enough! We know that the work of nursing is challenging because we are caring and advocating for people and their families during the best and worst times of their lives. We expect the work to be intellectually stimulating and at times tiring. We knew that during the pandemic we would be stretched to our full capacity, and we rose to the challenge. We expected our work/life balance would be impacted for a short time. What we did not expect was continued staffing issues, burn out, mental and physical exhaustion, and continued work/life imbalance. The nursing shortage was amplified due to the pandemic which in turn, has worsened the situation for nurses who are still practicing or thinking of entering the profession.
Healthcare Organizations Need to Provide a Healthy Work Environment
We simply need to do better! Healthcare organizations need to adopt a healthy work environment culture, staff their patient units by integrating nurse competency and patient acuity with their staffing systems, and demonstrate they value their workforce by focusing on retention of their staff by addressing compensation and benefit issues. In addition, they need to revamp their recruitment and orientation programs and develop nurse residency programs to ensure new graduates stay at their organization for longer than two years. There needs to be renewed interest in developing career pathways for those who want to move laterally into adjacent positions or move into leadership roles such as management or advanced practice.
Health care systems need to enhance their mental health coverage for their workers; this includes having adequate mental health providers who can recognize when staff are in trouble and getting help quickly to those who need it. This means working to remove the stigma of mental health care and ensuring it is easily accessible when and where the workforce needs it (Rushton & Boston-Leary, 2022). We need to engage the workforce at all levels, listen to concerns, and develop innovative solutions that make a real difference by improving workforce well-being.
Nurses know how wonderful our profession truly is when we have the means, energy, and staffing to provide the quality nursing care our patients deserve. We need to find our passion for our profession, and imagine the possibilities when well-being is at the center of who we are and what we do.
Wolters Kluwer is dedicated to providing evidence-based, information to healthcare professionals when and where they need it. Workforce well-being is crucially important to achieve the best patient outcomes; therefore, we are investing in making sure nurses and other healthcare professionals have information they need to improve their own well-being. It’s not just about Building Resilience as a Nurse; our institutions must focus on Fostering Workforce Well-Being. It’s critical to ensure healthcare professionals have the resources they need to improve their mental health and well-being, find their passion, and imagine future possibilities.
References
Dzau, V. J., Kirch, D., & Nasca, T. (2020). Preventing a Parallel Pandemic - A National Strategy to Protect Clinicians' Well-Being. The New England journal of medicine, 383(6), 513–515. https://doi.org/10.1056/NEJMp2011027
American Nurses Foundation. (2021, October 13). Pulse of the Nation’s Nurses Survey Series: Mental Health and Wellness. Taking The Pulse on Emotional Health, Post-Traumatic Stress, Resiliency, And Activities for Strengthening Wellbeing. https://www.nursingworld.org/~4a22b6/globalassets/docs/ancc/magnet/anf-mh3-written-report-final-foundation-edits-2.pdf
Kelsey, E. A., West, C. P., Cipriano, P. F., Peterson, C., Satele, D., Shanafelt, T., & Dyrbye, L. N. (2021). Original Research: Suicidal Ideation and Attitudes Toward Help Seeking in U.S. Nurses Relative to the General Working Population. The American journal of nursing, 121(11), 24–36. https://doi.org/10.1097/01.NAJ.0000798056.73563.fa
Rushton, C. H., & Boston-Leary, K. (2022). Nurses Suffering in Silence: Addressing the Stigma of Mental Health in Nursing and Healthcare. Nursing management, 53(8), 7–11. https://doi.org/10.1097/01.NUMA.0000853148.17873.77
Robbins, R. (2022, August 17). Medscape Nurse Practitioner Burnout and Depression Report 2022. Medscape Nurses. https://www.medscape.com/slideshow/2022-np-burnout-rpt-6015568#1
Nursing Research
Nurse-Led Interventions May Cut Children's Fear of Needles
Two new nurse-led interventions to reduce negative impacts of vaccinations in children -- divided attention (DA) and positive memory reframing (PMR) -- were feasible and may reduce needle-related fear, according to a study published in
European Journal of Pain.
Obstacles, Helpful Behaviors Explored at Critical Access Hospitals
Obstacles and helpful behavior items unique to critical access hospitals, created to bring health care to rural populations, rank below the top 10 items for nurses, according to a study published in the
American Journal of Critical Care. The researchers found that seven of the top 10 obstacles were directly related to behaviors and attitudes of family, including lack of understanding about what lifesaving measures entail and internal disagreement relating to life support. Interventions that were controlled by nurses and items that affected the nurses having adequate time to deliver end-of-life care were included as helpful behaviors ranked in the top 10.
Smart Socks May Cut Hospital Fall Rates in At-Risk Patients
Use of the Smart Sock system may reduce hospital fall rates among fall-risk patients, according to a study published in the
Journal of Nursing Care Quality. Smart Socks consist of socks with built-in pressure sensors that detect when a patient is trying to stand, in combination with interrelated devices with sensors and a notification device worn by nurses. The researchers found that patients wearing Smart Socks had a lower fall rate compared with the historical rate (zero versus four per 1,000 patient-days).
Multidisciplinary Effort Key in Hip Fracture Care for Elders
A collaborative care initiative may expedite care for hip fractures among elderly patients, according to research published in
Geriatric Nursing. The Returning Seniors to Orthopedic Excellence (RESTORE) service focused on prioritizing early pain management and reducing time to surgery for geriatric patients with hip fractures, which was integrated with the Nurses Improving Care for Healthsystem Elders (NICHE) program. The NICHE program standardizes early ambulation, delirium assessment and management, and hospital room protocols for better orientation and healing and improves follow-up visit adherence.
Protocol Helps Increase Direct Breastfeeding for Preemies in NICU
Standardizing direct breastfeeding (DBF) practices increases DBF during hospitalization for infants less than 37 weeks of gestation at birth, according to a study published in
Advances in Neonatal Care. The Encourage, Assess, Transition (EAT) protocol was developed and implemented for infants less than 37 weeks of gestation at birth using quality improvement methods.
Guidelines & Recommendations
Consensus Developed on Managing Hypertension in Children
In a consensus document published in the
European Heart Journal, recommendations are presented for the management of hypertension among children aged 6 to 16 years. The authors recommend implementing the development of appropriate multiethnic normative tables for office blood pressure, ambulatory blood pressure, and home blood pressure measurements through the organization of longitudinal registries, with the potential to link to adult cardiovascular risk. They also recommend the development of randomized clinical trials to document the specific benefits and potential harms of blood pressure-lowering agents and behavioral lifestyle strategies. Hypertension management should include a stepped approach for management, starting with lifestyle modifications, followed by a low-dose single drug, full-dose single drug or low-dose combination, and full-dose combination, as appropriate.
USPSTF Continues to Recommend Against Genital Herpes Screening
The U.S. Preventive Services Task Force (USPSTF) did not find new evidence that could result in a change to the 2016 recommendation on screening for genital herpes and consequently continues to recommend against routine serologic screening.
More Research Highlights
Blood Biomarker Linked to Incident VTE in COVID-19 Patients
Higher levels of soluble urokinase plasminogen activator receptor (suPAR) are associated with incident venous thromboembolism (VTE) among patients hospitalized for COVID-19, regardless of D-dimer levels, according to a study published in the
Journal of the American Heart Association.
EHR-Based Food Insecurity Screening Process Feasible
An electronic health record (EHR)-based food insecurity screening process can be implemented and increases screening and identification of food-insecure patients, according to a study published in the
Journal for Healthcare Quality.
Early recognition and intervention are improving short-term survival of sepsis, however there are many who suffer complications, long after resolution of the primary infection and discharge from the hospital. Post-sepsis syndrome (PSS) occurs in about one-sixth of sepsis survivors and includes both physical and psychological long-term effects (Prescott & Costa, 2018).
What are the Signs and Symptoms of Post-Sepsis Syndrome?
Sepsis survivors have higher readmission rates and an increased risk of myocardial infarction, stroke, and fatal coronary heart disease (Shankar-Hari & Rubenfeld, 2016). The
Sepsis Alliance (2021) identifies the following physical and psychological effects of PSS lasting months to years:
Physical Effects
- Difficulty sleeping; fatigue; lethargy
- Shortness of breath; dyspnea
- Muscle or joint pain; swelling in the limbs
- Repeat infections
- Poor appetite
- Organ dysfunction
- Hair loss; rash
Psychological Effects
- Hallucinations
- Panic attacks
- Flashbacks
- Nightmares
- Decreased cognitive functioning
- Depression; loss of self-esteem
- Mood swings
- Difficulty concentrating; memory loss
- Post-traumatic stress disorder (PTSD)
Who’s at Risk for Post-Sepsis Syndrome?
All patients diagnosed with sepsis are at risk for PSS and the incidence increases with sepsis severity. Older adults and patients with preexisting medical conditions are also at increased risk for PSS. Other conditions associated with poor long-term outcomes include immobility, vision or hearing impairment, frailty, residing in a nursing home, single marital status, and development of delirium during hospitalization (Prescott & Costa, 2018).
How Can the Occurrence of Post-Sepsis Syndrome Be Minimized?
While the most effective method to treat PSS is to prevent sepsis (using primary prevention techniques such as handwashing, vaccinations, and nutrition), managing chronic conditions is also key to decreasing sepsis and PSS risk (Leviner, 2021).
When a patient develops sepsis, treatment with antibiotics is indicated. Stewardship programs are recommended to improve antibiotic use and decrease the risk of future infections. Procalcitonin levels can be used to help providers make decisions on titrating or stopping antibiotics (Prescott & Costa, 2018).
When stress ulcer prevention is indicated, H2-receptor agonists are preferred over proton pump inhibitors (PPI) to minimize the risk of subsequent infections, as PPI have been associated with increased risk for
clostridium difficile infection and pneumonia (Prescott & Costa, 2018).
Other recommendations, especially for the highest risk patients in the ICU, include using medications for pain and agitation at the lowest possible doses for the shortest durations. Strategies such as treating pain first in conjunction with routine pain assessments using a validated pain assessment scale; using intermittent rather than continuous medications; using a sedation scale (i.e., Richmond Agitation Sedation Scale, or RASS) to target light levels of continuous sedation; and performing daily awakening trials are suggested. Also, benzodiazepines have been associated with increased risk for delirium, which is associated with worse long-term outcomes. Propofol and dexmedetomidine, both short-acting continuous sedative medications, are preferred over benzodiazepines when continuous sedation is required. (Prescott & Costa, 2018).
Nonpharmacological strategies mirror those that prevent delirium and include:
- Promoting progressive activity and early mobility, including while the patient is in the ICU
- Vision and hearing aids if the patient normally uses them
- Use of adaptive equipment to facilitate independence
- Promote sleep at night and activity during the day
Rehabilitation is associated with decreased 10-year mortality, as well as improved physical functioning and quality of life (Leviner, 2021), so physical and occupational therapy referral and follow-up are key.
These recommendations make it clear that clinicians in most settings play a role in lessening the effects of PSS. In outpatient settings, educating patients on infection prevention and chronic disease management, and recognizing signs and symptoms of PSS, are critical. In the acute care setting, working collaboratively to optimize treatment while minimizing risks and complications is vital as well. PSS awareness and strategies for PSS prevention are key to optimize long-term outcomes after sepsis.
References:
Annane, D., & Sharshar, T. (2015). Cognitive decline after sepsis. The Lancet. Respiratory medicine, 3(1), 61–69. https://doi.org/10.1016/S2213-2600(14)70246-2
Leviner S. (2021). Post-Sepsis Syndrome. Critical care nursing quarterly, 44(2), 182–186. https://doi.org/10.1097/CNQ.0000000000000352
Prescott, H. C., & Costa, D. K. (2018). Improving Long-Term Outcomes After Sepsis. Critical care clinics, 34(1), 175–188. https://doi.org/10.1016/j.ccc.2017.08.013
Sepsis Alliance (2021, January 21). Post-Sepsis Syndrome. https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/
Shankar-Hari, M., & Rubenfeld, G. D. (2016). Understanding Long-Term Outcomes Following Sepsis: Implications and Challenges. Current infectious disease reports, 18(11), 37. https://doi.org/10.1007/s11908-016-0544-7
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Midwifery Week
October 2-8
Theme: Midwives for Justice
#MidwiferyWeek2022, #MidwivesforJustice
National Pediatric Nursing Week
October 3-7
#ProudPediatricNurse
Emergency Nurses Week
October 9-15, Emergency Nurses Day: October 12
#ENWeek
National Case Management Week
October 9-15
#NCMW
International Orthopaedic Nurses Week
October 24-30
#OrthoNursesWeek2022, #IAmAnOrthoNurse
Healthcare Observances
Here are some of the healthcare observances being recognized in October.
Domestic Violence Awareness Month
#WeAreResilient, #DVAM2022
Mental Illness Awareness Week
October 3-7, 2022
Theme: What I Wish I Had Known
National Healthcare Quality Week
October 16-22, 2022
More Observances in October
Nursing Events
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
We’ve all heard the news about nursing workforce issues: lack of faculty, resources, and clinical sites to educate nursing students; burnout; staffing issues; nurses being dismayed with the work of nursing; and nurses leaving the profession. I want to share with you some good news – the nursing students coming into the profession and those pursuing graduate degrees are really excited about their future.
Light-Bulb Moments in Nursing Education
I have the privilege to teach for two graduate nursing programs as adjunct faculty and speak with nursing students in undergraduate programs. I experience a sense of joy when facilitating learning for these students because they are eager to acquire new knowledge and skills and to learn how to critically think. To see the “light bulb” moments when concepts come together and they understand how everything related to our bio-psycho-social being is intertwined and impacts health, truly gives me a sense of joy and hope for our profession. These students are not afraid to ask the hard questions, they want to know the why and how and offer suggestions for doing things differently.
Working with Students or New Graduates is Mutually Beneficial
In clinical practice, we know that precepting a student or a new graduate is challenging. It adds to our work, but it also makes us stop and think about why we do the things we do in clinical practice. Students and new graduates force us to relook at the research and make sure our actions are supported by the latest evidence and best practice. They also look to us to be a role model of professional practice.
Students and New Graduates are Our Next Generation of Nurse Leaders
Often, we think of those in leadership roles as those in managerial or administrative roles, but it’s much broader. Demonstrating leadership means having the ability and knowledge to guide or influence decision making; this is something all nurses do every day at the bedside and it’s what we do in our professional practice. Experienced nurses have an obligation to teach students and new nurses how to be nurse leaders who are authentic. Authentic leaders lead with their heart, have integrity, are active listeners, are transparent and develop trust. When we look at our relationships with our patients, they are based on these same characteristics. In meetings where decisions are being made, it’s the authentic leader who garners the most respect and can facilitate change.
As nurses we recognize there are times when we may not be enamored with our jobs, yet at the heart of it all, we still love being nurses. As we precept nursing students and new nurse graduates, we need to remember we are preparing our next generation of nurse leaders. We are charting our profession’s future now and these new nurses will navigate the profession into the future. Let’s make sure we invest in our future by supporting students and graduates as they embark on their career journey.
Awareness of current research is a big component of staying up to date in nursing and healthcare and providing evidence-based care. Here’s a look at a selection of the latest studies and practice-changing recommendations.
The Impact of the Pandemic on Healthcare Professionals
COVID-19 Pandemic Tied to Burnout in Health Care Professionals
The COVID-19 pandemic is associated with higher burnout among health care professionals (HCPs), particularly patient-facing HCPs, according to a study published in
The British Journal of Psychiatry (BJPsych) Open. The researchers found generally higher rates of various probable mental health issues among HCPs versus non-HCPs at each phase (baseline, six weeks after baseline, and four months after baseline), but no differences were significant, except that HCPs had a 2.5-fold increased risk for burnout after six weeks.
Pandemic Heightened Emotional Exhaustion in Health Care Workers
Emotional exhaustion among health care workers (HCWs) worsened during the COVID-19 pandemic, according to a study published online in
JAMA Network Open. Researchers conducted three waves of a survey of hospital-based HCWs in clinical and nonclinical roles at 76 community hospitals within two large U.S. health care systems. The researchers found that the overall percentage of respondents reporting emotional exhaustion (percent EE) increased from 31.8 to 40.4 percent, with a proportional increase of 26.9 percent. Nurses had consistent increases in percent EE from 40.6 percent in 2019 to 46.5 percent in 2020 to 49.2 percent in 2021.
Guidelines & Recommendations
Guideline Developed for Assessing Penicillin Allergies
AAP Issues Guidance for Assessing Bleeding Disorders When Child Abuse Suspected
ACR Updating Guideline for Glucocorticoid-Induced Osteoporosis
CDC Says Universal Masking Can Be Dropped in Some Nursing Homes, Hospitals
Recommendations Issued for Perioperative Antithrombotic Management
USPSTF Recommends Depression Screening for All Adults
Twelfth Version of Living Guideline Issued for Drugs for COVID-19
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Medical-Surgical Nurses Week
November 1-7, 2022
#MSNW22
Urology Nurses and Associates Week
November 1-7, 2022
Forensic Nurses Week
November 6-12, 2022
Perioperative Nurses Week
November 13-19, 2022
#PeriopProud
National Nurse Practitioner Week
November 13-19, 2022
Theme: NPs: Rising to Meet the Needs of Patients
#NPweek
Healthcare Observances
Here are some of the healthcare observances being recognized in November.
American Diabetes Month
Theme: Today's Diabetes Hits Different!
National COPD Awareness Month
#BreatheBetter
National Family Caregivers Month
#CaregivingHappens
National Healthy Skin Month
#YourHealthiestSkin
National Hospice Palliative Care Month
Theme: It’s About How You Live
International Survivors of Suicide Day
November 19, 2022
Nursing Event
See all events for 2022 here!
Anything missing? Please let us know in the comments!
Have a good month!
Let’s face it, everyone wants to live, work, and be cared for in a safe environment. Safety is defined as the condition of being protected from an experience likely to cause danger, risk, or injury (Oxford Languages, 2022). Unfortunately, safety continues to be an issue in healthcare. Too often we hear about healthcare workers or patients being harmed; the causes are different but, the results are similar – someone is affected.
Healthcare Workplace Violence is Increasing
According to the lasted research, workplace violence is increasing, and healthcare workers are five times more likely to experience workplace violence than other professions (Ramzi, Fatah, & Davandi, 2022). Workplace violence is often related to unexpected acute illness, fear of unpredictability, or severe stress experienced by a patient or family member (Stene et al., 2015). The COVID surges and civic unrest have certainly increased all these factors for many people. Healthcare workers in high stress areas such as the emergency department and critical care are the most vulnerable due to the nature of the specialties. Healthcare worker violence is associated with decreased job satisfaction, decreased productivity, and lower quality of life, in addition to increased stress, burnout, and sleep disorders (Ramzi, Fatah, & Davandi, 2022). These are some of the same factors that contribute to patient safety issues.
Patient Safety Remains a Prominent Issue
Patient safety costs the world $42 billion annually with one out of every 10 patients worldwide experiencing an adverse event (Skelly, Cassagnol, & Munakomi, 2022). In the U.S. alone, 250,000 patients experience an adverse medical event annually and 50% of those events are preventable. The majority of patient safety issues are centered around surgical issues, medication, and healthcare associated infections (Skelly, Cassagnol, & Munakomi, 2022). Patient falls also continue to be problematic. These numbers aren’t surprising. We knew there was a problem prior to the pandemic; during the pandemic we were just trying to keep people alive.
It’s Time to Focus on Safety for All
Healthcare workers have the right to be safe at their jobs and patients have the right to be safe in healthcare environments. In January of 2022, the Joint Commission put in place the
Workplace Violence Prevention Standards (2022) to keep the workforce safe. That translates into a renewed investment in managing safety concerns, monitoring data, and educating and training the workforce on how to keep themselves safe, decrease risk, and respond if they are in jeopardy.
All healthcare institutions are evaluating quality care and patient safety scores and implementing programs to optimize patient care and safety. As part of this initiative, one cannot forget the importance of having an adequate number of competent staff in addition to ensuring emotional and psychological safety of healthcare workers, so they feel unencumbered to voice concerns over unsafe situations.
The bottom line is safety is everyone’s right. When people enter our healthcare domains as either workers or patients, they have a right to be safe, feel safe, and be treated safely. It’s time to focus on safety for all!
References:
Ramzi, Z. S., Fatah, P. W., & Dalvandi, A. (2022). Prevalence of Workplace Violence Against Healthcare Workers During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis. Frontiers in psychology, 13, 896156. https://doi.org/10.3389/fpsyg.2022.896156
Skelly, C. L., Cassagnol, M., & Munakomi, S. (2022). Adverse Events. In StatPearls. StatPearls Publishing.
Stene, J., Larson, E., Levy, M., & Dohlman, M. (2015). Workplace violence in the emergency department: giving staff the tools and support to report. The Permanente journal, 19(2), e113–e117. https://doi.org/10.7812/TPP/14-187
While many eyes are on current levels of influenza and COVID-19 activity across the U.S., another virus is on the rise, impacting both
adults and children. Pediatric cases of respiratory syncytial virus, or RSV, are causing an influx of hospitalizations. RSV is a virus that causes the common cold and while illness is typically mild, it can lead to bronchiolitis and pneumonia and even be life-threatening for infants and children.
Quarantine over the past three years helped protect children from COVID-19, but it also limited exposure to other viruses. In general, children have their first exposure to RSV by the time they are two years old (CDC, 2022). However, many children are having their first exposure to RSV now and their immune systems are not prepared. Pediatric hospitals are feeling the impact, and many are at or over capacity. Some pediatric hospitals are even experiencing a shortage of ICU beds (Advisory Board, 2022).
As clinicians, we need to be aware of this surge in cases and hospitalizations, brush up our knowledge, and contribute to efforts to curb transmission.
Distinguishing RSV from other Respiratory Illnesses
How important is it to recognize RSV and distinguish it from other viral infections, such as COVID-19 and influenza? Symptoms among these three viruses are often quite similar, but it’s important to recognize those children at high risk of complications as well as the subtle differences in the presentation of RSV.
The pediatric groups at high risk include premature infants, infants 6 months and younger, children younger than 2 years old with chronic lung disease or congenital heart disease, children with suppressed immune systems, and children who have neuromuscular disorders, including those with difficulty swallowing or clearing mucus secretions (CDC, 2022).
Infants and young children with RSV may have rhinorrhea and decreased appetite as their initial symptoms. Cough usually develops one to three days later, sometimes followed by sneezing, fever, and wheezing. In very young infants, irritability, decreased activity, and/or apnea may be the only symptoms (CDC, 2022).
Laboratory testing is key to diagnosis. Both real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) and antigen testing can confirm RSV infection.
Preventing Severe Illness and Hospitalization due to RSV
As adults, we can help prevent the spread of RSV ourselves and educate others, including parents and caregivers of children at high risk for severe RSV infection, on infection control practices, such as hand hygiene, covering coughs and sneezes, cleaning frequently touched surfaces, and avoiding close contact with anyone who is sick.
For those with RSV, treatment is supportive and includes fever reducers and pain relievers, such as acetaminophen or ibuprofen, and fluids to prevent dehydration. Palivizumab is a monoclonal antibody available to help prevent serious lower respiratory tract disease caused by RSV in certain infants and children at high risk for severe disease (Lexicomp, 2022).
As we get deeper into the fall and winter, it’s important that we stay informed on the status of seasonal viral illnesses. Though they are being referred to as the ‘triple threat’ or ‘triple-demic’ in many headlines, RSV, influenza, and COVID-19 are only three of the many viruses that spread during the colder months. Together we can take steps to minimize the spread of all infectious diseases, keep patients safe, and support our healthcare workers.
References:
Advisory Board. (November 8, 2022). 'Crisis mode': RSV surge overwhelming pediatric hospitals. https://www.advisory.com/daily-briefing/2022/11/08/rsv-surge
Centers for Disease Control and Prevention (CDC). (October 28, 2022). Respiratory Syncytial Virus (RSV). https://www.cdc.gov/rsv/clinical/index.html
Do your loved ones quickly turn to you when medical questions arise? Do you find yourself putting on your 'nurse hat' even when gathered around the holiday table?
Many of us will soon be sitting around the table with different generations of friends and family celebrating the holidays. For some, it may be the first time in a while that you will gather and there will be a lot to catch up on. The holidays are a good time to assess everyone’s well-being, particularly if there are members in your circle with chronic health conditions. I know, as the only nurse in my family, the questions often come at rapid-fire speed!
I am also in that sandwich generation – launching my own children off into the world while supporting aging family members. I am seeing firsthand the physical and emotional impact on family caregivers. It is certainly overwhelming for the whole family, but I am especially concerned for the health and well-being of those providing regular care. I feel lucky as a nurse to be armed with the knowledge and skills to be a strong advocate and source of support.
National Family Caregivers Month
November is
National Family Caregivers Month and the theme this year is #CaregivingHappens. About 14% of American adults serve as caregivers for someone age 50 years or older. When that person is of a certain age or has health problems themselves, it is more challenging, and caring for someone with dementia places caregivers at an even higher risk of stress and illness (Health in Aging, 2022).
Signs of Caregiver Stress
We know that the care we provide as nurses is not solely for an individual patient; our care extends to families and communities. It is important that we are aware of signs of caregiver stress in the families we care for, as well as our own families. These include burnout, self-neglect, alcohol or drug overuse, depression, sleep problems, and financial concerns (Health in Aging, 2022).
How Nurses can Support Family Caregivers
Providing strategies and resources will benefit both the family caregivers and the patient. Ensuring that referrals to appropriate disciplines such as nursing, home health, physical and occupational therapy, social work, etc., is key. It is also important to prioritize patient independence in the plan of care, for example, implementing safety measures, structuring the daily routine, and assessing that medications are correct and appropriate (Hale & Marshall, 2022).
The
American Journal of Nursing maintains a
Family Caregivers series to help nurses provide family caregivers with tools to manage their loved one’s health care at home. Produced in cooperation with the AARP Public Policy Institute, each article includes an informational sheet and links to educational videos for caregivers. They are all free and I encourage you to use these in your practice and share them this holiday season.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
Here are some of the healthcare observances being recognized in December.
World AIDS Day
December 1
#RockTheRibbon
National Influenza Vaccination Week
December 5-9
#FightFlu
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
Every month, I write a blog post that addresses issues we are seeing in our profession or healthcare. Usually, I have no problem deciding what to write, but this month has been different. It’s different because I feel like 2022 has been more of the same: another challenging year for many dealing with violence; issues with diversity, equity, and inclusion; a higher cost of living; RSV ramping up; staffing issues; and nurses leaving their positions and even the profession.
Where is the Joy?
Joy is defined by the Oxford dictionary as a feeling of great pleasure and happiness. Talking to people this year I have heard time and time again:
“I can’t find joy. I can’t find joy in my life or my work.”
How Can We Find Joy?
- Joy is found within you. Stop looking for someone or something else to bring it to you. Many people look for joy outside of themselves. They look for someone or something to bring them happiness in their life. These people spend endless hours searching, often moving from job to job, hoping the grass is greener and finding it’s not. Pick up a mirror and take a look at yourself; joy and happiness from within changes your entire perspective.
- Work on yourself first; it’s not your job to fix others. The FAA gets this right, “Put on your own oxygen mask before helping others.” It’s so easy to point the finger at others in our families or at our jobs. We need to be accountable for who we are, what we do, and how we treat others. Many of us are feeling down or anxious; if it’s more than occasional ups and downs, seek help from a professional.
- Just say no! Many of us are overextended working multiple jobs, picking up extra shifts at work, and assuming multiple roles. We need to stop saying yes to everything and set our own limits. Personal time is one of our most valuable assets and once it’s gone you can never get it back.
- Decide on your most important and impactful roles and focus on those. I am a wife and mother and when my children were young, I sometimes placed work above my family. I regret it now because I missed some of the key events that were important to them. While we may cringe at attending those elementary school concerts, being there means the world to our children and it is important to them. We can’t be the best at everything, so choose your priorities wisely.
- Show gratitude. Giving of ourselves produces more joy than receiving gifts. Taking the time to say thank you and giving without expecting anything in return can often make a difference in someone else’s life and make them feel valued. This is why we went into nursing – because we care and want to make a difference.
It’s Time to Find your Joy and Share It
So here we are at the end of 2022, taking stock of the things that went well and not so well and deciding how to make 2023 even better. There are things we can’t control in our lives, but there are many things that are within our control. As you look to celebrate the holidays with your friends and loved ones, don’t forget to find your joy, share it with others and let your light shine bright.
Almost half of the world’s population uses social media in one form or another, which has led to an increase in those who produce personal content providing one’s own point of view (Vukušić Rukavina et al., 2021). Nurses are becoming more active in the social media world as influencers; some are looked at as trusted professionals who can provide antidotes to medical misinformation, whereas others are seen as purely entertaining. Truthfully, nurses can be both informative and entertaining, however, we must remember that nurses are one of the most trusted professions in the world and we need to remain professional in this relatively new role.
The Benefits of Nurses as Social Media Influencers
There are many benefits to having an audience of social media followers, but there some cautions as well. Our professionalism can be demonstrated by integrity, education, and dissemination of knowledge as well as correction of misinformation. Influencers can be viewed as a source of accurate information for the public and other nurses. Social media can bridge some gaps, evade some conventional barriers that are present in healthcare information and reach colleagues that may not have the strongest network (Gentry& Prince-Paul, 2020; Bautista, Zhang & Gwizdka, 2021).
The role of nurses as social influencers can also combat medical disinformation with evidence-based education that can be targeted to other nurses or the public. Social media moves information at a fast pace, with images and data becoming viral in hours. This can work to our advantage as nurses, but also has disadvantages (Bautista, Zhang & Gwizdka, 2021).
The Cautions of Nurses as Social Media Influencers
The high visibility associated with social media also means that nurse influencers must understand that their audience is likely not limited to healthcare providers, but also lay persons who may misunderstand things like satire – which can be a form of misinformation. Other unprofessional behaviors, such as bullying and blurring professional boundaries in presentation can detract from the positive benefits of nurses as influencers. These behaviors can result in loss of credibility and even legal/disciplinary consequences. Also, there is a certain ethical (and legal) responsibility to ensure one is providing accurate medical information to the public.
One example of this is a complaint filed in October 2022 regarding a California nurse practitioner with a Doctor of Nursing Practice degree (DNP) who referred to herself as “Dr. Sarah” on social media but was not always clear that she was an advanced practice registered nurse and not a physician. She has been fined $19,750 for the ambiguity and violation of the California State Business and Professions Code (Book, 2022).
Follow Your Institution’s Social Media Policy
Many health systems have strict social media policies to protect their interests and the privacy of patients. Some common restriction examples include excluding the name of the facility where the nurse works, obscuring/removing ID badges with familiar trademarks, prohibiting pictures within facilities, and identifying the nurses’ employers within profiles. Obviously, discussion of confidential incidents or protected health information consistent with Health Insurance Portability and Accountability Act (HIPAA) would likely be met with civil as well as legal consequences. Protected health information (PHI) is any information that is specific enough to a case that the patient could potentially be identified, such as a case where a pediatric ICU/ER nurse at Texas Children’s Hospital who posted several comments about a rare case of measles. Through information on her profile identifying her, her employer, and her position at the hospital combined with the rarity of the illness made this patient potentially identifiable. Texas Children’s Hospital suspended and terminated the nurse for a HIPAA violation four days later (Alder, 2018).
Discretion and Digital Professionalism
Discretion is paramount in any case where a nurse would present themselves in their nursing role. Practical jokes which might be entertaining to some nurses may be ill-received by others and can lead to a generalized perception of nursing as unprofessional, uncaring, or immature. They may even do irreparable harm to the individuals involved or the facility where it took place if it is able to be identified.
Social media has benefits, but also must be used with caution to preserve the integrity of the healthcare professions, including nursing. Unfortunately, the inappropriate actions of a few have eroded professional identities of many. Now enters the concept of digital professionalism, which is becoming more important in the ever-expanding world of social media. Social media influencers, particularly those in healthcare, must remain mindful of their exposure to a variable audience who see them as professionals. Reputations can easily be damaged with misinformation or unprofessional behaviors. Nursing has taken many decades to achieve being one of the most trusted and respected professions, and a careless post could unravel this progress in a single viral video (Guraya, Guraya & Yusoff, 2021).
Tips to Maintain Your Professional Identity on Social Media
Should you wish to post on social media as a representative of nursing, the following may be helpful in maintaining your professional identity:
- Maintain a professional demeanor. The internet is forever. Ensure your content is how you wish to be portrayed.
- Avoid work stories. There are often details that could identify the facility or the patient. Even leaving out a name does not protect the identity of someone with a rare condition or circumstance.
- Always present evidence-based information. This is important if your opinion or judgement comes into question.
- Follow your facility’s social media policies. Failure to follow these policies can lead to discipline or legal issues.
- HIPAA, HIPAA, HIPAA. If in doubt, don’t post!
References:
Alder, S. (2018, September 13). Texas Nurse Fired for Social Media HIPAA Violation. HIPAA Journal. https://www.hipaajournal.com/texas-nurse-fired-for-social-media-hipaa-violation/
Bautista, J. R., Zhang, Y., & Gwizdka, J. (2021). US Physicians' and Nurses' Motivations, Barriers, and Recommendations for Correcting Health Misinformation on Social Media: Qualitative Interview Study. JMIR public health and surveillance, 7(9), e27715. https://doi.org/10.2196/27715
Book, C. (2022, November 23). Nurse Practitioner (DNP) Fined $19K for Calling Self “Doctor Sarah.” Nurse.org. https://nurse.org/articles/nurse-practitioner-fined-for-calling-self-doctor/
Gentry, H., & Prince-Paul, M. (2021). The nurse influencer: A concept synthesis and analysis. Nursing forum, 56(1), 181–187. https://doi.org/10.1111/nuf.12516
Guraya, S. S., Guraya, S. Y., & Yusoff, M. S. B. (2021). Preserving professional identities, behaviors, and values in digital professionalism using social networking sites; a systematic review. BMC medical education, 21(1), 381. https://doi.org/10.1186/s12909-021-02802-9
Vukušić Rukavina, T., Viskić, J., Machala Poplašen, L., Relić, D., Marelić, M., Jokic, D., & Sedak, K. (2021). Dangers and Benefits of Social Media on E-Professionalism of Health Care Professionals: Scoping Review. Journal of medical Internet research, 23(11), e25770. https://doi.org/10.2196/25770
As we near the end of 2022, we are happy to share our top 10 list of blog posts. It brings us great joy to cover topics that resonate with our readers and we are grateful that you found this information valuable to read and share! Here’s a look at our most-read blog posts of 2022.
Top 10 NursingCenter Blog Posts of 2022
We are looking forward to staying connected in the coming year and we wish you a safe, healthy, and happy 2023!
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National CRNA Week
January 22-28, 2023
Theme: CRNAs: The Original Anesthesia Experts
#crnaweek #stepforward
IV Nurse Day
January 25, 2023
Theme: INS Strong
Healthcare Observances
Here are some of the healthcare observances being recognized in January.
Thyroid Awareness Month
#thyroidawareness
National Slavery and Human Trafficking Prevention Month
Cervical Health Awareness Month
#CervicalHealthMonth
More Observances in January
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
Most of us remember the first time we performed cardiopulmonary resuscitation (CPR). For me, it was in the Medical Intensive Care Unit where I was working as a staff nurse. I was a new graduate, and it was emotional, traumatic and exhausting. Unfortunately, the patient did not survive. Immediately after his death, I had to change gears and care for my other patient who was weaning from the ventilator and whose family had just arrived to visit. After a brief update for them, I performed postmortem care on the deceased patient and prepared for his family’s arrival. The shift was a busy one and there was no time to debrief, let alone acknowledge what had just happened.
On Monday, January 2, 2023,
Damar Hamlin, safety for the Buffalo Bills, suffered a cardiac arrest after making a tackle during a football game against the Cincinnati Bengals. He was resuscitated on the field for several minutes, and fortunately, he is now in stable condition and showing neurological improvement.
Immediately following his collapse and resuscitation, the game was suspended, and it has since been decided that it
will not be resumed. In the following days, the
mental health of Hamlin’s teammates, Bengals players, and other witnesses – both on and off the field – has been a focus.
In other recent news, during a New Year’s Day Philadelphia Eagles game,
a medical resident and nurse performed CPR on a fan in the stands after his collapse. The fan survived and was transported to the hospital.
Lessons Learned about CPR and Mental Health
We know that cardiac arrest occurs both in clinical and nonclinical settings more than nonmedical persons may realize. In the two instances above, CPR was lifesaving and there were many witnesses to the traumatic events. What can we learn from this?
- Learning CPR is important. In school and on the job, we learn how to intervene in an emergency. CPR certification is required for nurses and other healthcare professionals, and we must maintain that certification throughout our careers. But what about when a professional is not present when CPR is necessary? There are opportunities for others to become certified through the American Red Cross and local healthcare facilities and emergency service organizations. Share this CPR Certification Tool and encourage others to learn how to respond to emergencies and become certified.
- Addressing mental health is essential. We know that mental health issues are prevalent among healthcare providers and suicide rates are higher than in the general population. Recognizing warning signs in ourselves and our colleagues and taking the time to debrief or seeking professional help must be prioritized. Please review and share these resources:
As nurses, we realize the importance of being prepared and we are familiar with the trauma of administering and witnessing CPR. We also tend to put the needs of others ahead of our own – it’s what we’ve been trained to do. However, we can’t continue to ask so much of ourselves and our colleagues; it’s not sustainable. Let’s take a lesson from these recent events and prioritize self-care and look to our leaders and institutions to help foster well-being.
The Monro-Kellie doctrine was first described over two-hundred years ago by Dr. Alexander Monro and Dr. George Kellie. It describes the direct relationship between the contents of the cranium and intracranial pressure (Mokri, 2001). According to the Monro-Kellie doctrine, the contents of the cranium – which are the brain parenchyma, blood, and cerebrospinal fluid (CSF) – are constant/fixed (Amin-Hanjani & Smith, 2022). In adults, the intracranial compartment is protected by the skull, a rigid structure with a fixed internal volume of 1400-1700 mL (Amin-Hanjani & Smith, 2022). The brain parenchyma makes up 80% of that volume, the CSF makes up 10%, and the blood volume makes up 10%.
According to the Monro-Kellie doctrine, any increase in the volume of one component necessitates a decrease of the other components through compensatory mechanisms, an increase in intracranial pressure (ICP), or both (Amin-Hanjani & Smith, 2022). The normal value for ICP is 5-15 mmHg; a value above 20 mmHg requires prompt recognition and treatment (Benson, Carr, Cutsforth-Gregory, Johnson & Madhavan, 2022). Major causes of increased intracranial pressure include intracranial mass, cerebral edema, increased CSF production, decreased CSF absorption, obstructive hydrocephalus, obstruction of venous outflow, and idiopathic intracranial hypertension (pseudo tumor cerebri) (Amin-Hanjani & Smith, 2022).
The Monro-Kellie doctrine has been a fundamental principle for over two-hundred years in neurology/neurosurgery. It is a well-accepted principal that describes the relationship between intracranial contents and intracranial pressure.
References:
Benson, J. C., Madhavan, A. A., Cutsforth-Gregory, J. K., Johnson, D. R., & Carr, C. M. (2022). The Monro-Kellie Doctrine: A Review and Call for Revision. AJNR. American journal of neuroradiology, 10.3174/ajnr.A7721. Advance online publication. https://doi.org/10.3174/ajnr.A7721
Edward, S., Amin-Hanjani, S. (2022). Evaluation of management of elevated of intracranial pressure in adults. https://www.uptodate.com/contents/evaluation-and-management-of-elevated-intracranial-pressure-in-adults
Mokri B. (2001). The Monro-Kellie hypothesis: applications in CSF volume depletion. Neurology, 56(12), 1746–1748. https://doi.org/10.1212/wnl.56.12.1746
Social media platforms have become a go-to information source for the public, and a soap box for healthcare providers of all types. While this may seem to be a positive influence, the information may not be completely correct or may even be outright false. With so much data being presented in a persuasive manner, how are laypersons or even professionals able to decipher fact from opinion? What is a nurse’s role in fighting false information? Moreso, what is the nurse’s responsibility to ensure that the information they are presenting is evidence-based and factual, rather than opinion or incorrect?
Misinformation and disinformation: What’s the difference?
Let’s first talk about two concepts that are related, but different in one important aspect: misinformation and disinformation. Misinformation is defined simply as inaccurate information, whereas disinformation is a deliberate spread of inaccurate information with the
intent to spread fear or invoke harm. This is an important distinction, however both types can cause impressions, opinions, and thought processes that are hard to correct and have been identified as a public health threat by the World Health Organization (WHO) and the United Nations (Bautista et al., 2021).
Disinformation directly conflicts with the nurses’ tenet of “do no harm” (American Nurses’ Association [ANA], 2015). This is unethical and can result in action against one’s license in some instances. Per the National Council of State Boards of Nursing (NCSBN), “When nurses identify themselves by their profession, they are professionally accountable for the information they provide to the public” (NCSBN, 2021). Distortion of information, false truths, and purposeful omissions are examples of disinformation.
Misinformation is a little harder to discern. There may be unintentional omissions of information, rumors, or misinterpretations of data that lead to inaccurate information. For instance, a data point in a study that was not adequately investigated may lead to misinformation. Providing sources of evidence can help in preventing misinformation.
How can nurses combat misinformation and disinformation?
In all of these cases, evidence-based investigation can help to alleviate some of the issues. Nurses are in a unique position of trust and clinical knowledge that can help with correcting this information. Many healthcare professionals are personally and professionally motivated to correct this information, however, there have been barriers identified as well. Some include lack of positive outcome when corrections are made, time, harassment, and lack of institutional support (Bautista et al., 2021).
Nurses can help by directing the public to trustworthy online sources of information, such as the Centers for Disease Control and Prevention and Departments of Health. Some nurses feel more comfortable leading others to the source, whereas others may engage in conversation regarding the science and the data. Regardless of the conversation, the information should be supported by evidence. Many nurses consider themselves social media influencers, who can disseminate factual information and education and debunk false information, regardless of intent. There are outlier healthcare professionals and websites providing opinions or information
not based on evidence; efforts should be made to correct any misinformation or disinformation to prevent community harm.
Some healthcare providers feel that the correction of misinformation or disinformation is not within their scope. As nurses, we have a social and professional responsibility to provide accurate information supported by evidence to ensure a healthy population. This is championed by nursing leadership organizations such as the ANA and NCSBN, as well as international healthcare interests, such as the World Health Organization (WHO) and United Nations. As nurses, we do have the power to change the way the world sees us and views modern healthcare despite outside (and sometimes) inaccurate influences.
References:
American Nurses Association. (2015). Code of Ethics for Nurses. Retrieved from https://www.nursingworld.org/ practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/
Bautista, J. R., Zhang, Y., & Gwizdka, J. (2021). US Physicians' and Nurses' Motivations, Barriers, and Recommendations for Correcting Health Misinformation on Social Media: Qualitative Interview Study. JMIR public health and surveillance, 7(9), e27715. https://doi.org/10.2196/27715
NCSBN. (2021). Policy Statement: Dissemination of Non-scientific and Misleading COVID-19 Information by Nurses. Retrieved from https://www.ncsbn.org/public-files/PolicyBriefDisseminationofCOVID19Info.pdf
More Reading and Resources
Communication is the expression of a message between a sender and a recipient. Sounds simple but, it’s much more complicated than we realize. We communicate in different ways. Some prefer verbal communication, some prefer the written word in email or text, and others prefer to post on social media. There are so many ways to express ideas, yet so many opportunities for our messages to be misunderstood. Healthy work environments foster healthy communication; healthy communication allows involved parties to feel valued and respected and leads to flourishing relationships. In relationships where communication is poor or one-sided, trust and respect erode.
Improve communication with these 4 steps
Try taking these steps towards effective communication to build relationships and connection in your work environment.
1. Think first. Before you speak, text, email, or post, ask yourself: “Where is this message coming from?” Are you communicating from a place of anger, frustration, fear, desperation, or exhaustion? Communicating from a place of emotion is more likely to lead to misinterpretation. Consider the root of an issue and take time to think about the most effective way to communicate without being perceived as combative, accusatory, apathetic, or insensitive.
2. Body language and tone matter. Most of us have been on the receiving end of a finger being thrust in our face, a text or email in all capital letters, or an angry stare. When we are angry or frustrated our voice tends to become louder, our body posture becomes more dominant and imposing, and sometimes we enter someone’s personal space. Think about how your body language and tone can alter how your message is being received.
3. Is the recipient ready to listen? Are you? Listening is the ability to be quiet, hear and understand what a person is trying to say. Listening is hard; especially if you don’t agree with, respect, or trust the person speaking with you. It’s also hard if you’re involved with something else, such as your own emotions or a task in front of you. If you’re trying to communicate with someone and they have their arms crossed, they continue working while you speak, or they are texting and scrolling, they’re too distracted to really hear what you’re saying. Make sure you have the person’s undivided attention before you start communicating with them and that you give your undivided attention to others.
If someone you are trying to speak to is busy, delay the conversation until later. However, if it’s an emergency – say it! Assertively state, “I need two minutes of your time because my patient is doing poorly, and I don’t want them to code,” or, “It’s an emergency and I need to speak to you right away.”
4. Be open to feedback. Be aware of your posture and tone when someone is responding to you. Think about how you have felt when someone walked away before you had a chance to speak. Communication is a two-way street; to receive open, honest, respectful communication, we need to also offer it.
Communication, like nursing, is both an art and a science.
Communication should take into consideration the way human beings process and respond. It will always contain both a message and emotions, it needs to be centered on respect and trust, and it should be reciprocal and intentional. Prioritize being an effective communicator to improve relationships and outcomes. It is the foundation for all our interactions with our colleagues, our patients, and beyond.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
PeriAnesthesia Nurse Awareness Week
February 6-12, 2023
Theme: Strong, United, Resilient
#aspan #PANAW
Ambulatory Care Nursing Week
February 6-12, 2023
Theme: Pediatrics, women's health, clinics, schools...We're Everywhere!
#AMBCARENURSE2023
Critical Care Transport Nurses Day
February 18, 2023
Healthcare Observances
Here are some of the healthcare observances being recognized in January.
American Heart Month
#OurHearts
World Cancer Day
February 4, 2022
#WorldCancerDay #ClosetheGap
More Observances in February
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
Sympathy and empathy are closely related terms that are both important traits of emotional intelligence. Emotional intelligence (EQ) is believed to be more important to success in career, and potentially patient relationships, than intellectual intelligence (IQ) (Cherry, 2022). In healthcare, sympathy and empathy are often used interchangeably, however there are differentiating qualities of each that set them apart from each other.
Defining Sympathy and Empathy
Sympathy is defined as an emotional reaction of pity toward the misfortune of another. It is the appreciation of what a person is going through from your own perspective. An example of a sympathetic statement is, “I am sorry you are suffering with chronic pain.” Sympathy is often motivated by pity, ego, and obligation.
In contrast, empathy is defined as the ability to understand and accurately acknowledge another’s feelings. Another way to define empathy is the ability to emotionally understand what someone is going through from the other person’s perspective. It is putting yourself in someone else’s shoes to better understand that person’s situation; it is the ability to ‘feel with someone.’ An example of an empathetic statement is, “I see your chronic pain is causing a lot of stress in your life; help me understand more about your situation.” Motivators of empathy include affective understanding of the other person and relatedness to that person (Sinclair et al., 2017).
How do Sympathy and Empathy Relate to Patient Care?
How do our patients perceive sympathetic and empathetic statements? Which ones will most benefit our patient relationships? Research reports that patients feel sympathy is superficial and a misguided reaction to suffering. It promotes the well-being of the observers, i.e., a flood of get-well cards or phone calls/texts, that are often short-lived and overwhelming to the sufferer. Sympathy is not effective in meeting patient needs and is an emotionally distant, depersonalized response.
Conversely, empathy has a much more positive patient response. The patient feels the observer is emotionally engaged and the patient feels the personal connection. Empathy is welcomed and valued by patients. It is a superior emotional response to help alleviate the suffering of our patients and enhance relationship bonds (Sinclair et al., 2017).
Developing the Skill of Empathy
Emotional skills and reactions come naturally to us all, but self-awareness is imperative to assess the integrity and effectiveness of your current personal EQ qualities. No matter your EQ starting point, emotional skills such as empathy can be developed and improved.
- Start by truly and actively listening to your patients through both their verbal and non-verbal language. Asks open ended questions.
- Next, practice empathizing with what the patient is communicating to you by asking yourself how you would feel in their situation.
- Finally, take time to reflect on how your emotions play a part in your interactions with the patients. Take time to conjure thoughtful and meaningful responses to situations that will provide comfort and direction to the conversation or relationship (Cherry, 2022).
Practicing these steps will lead to skills that can enhance not only your professional relationships with patients and colleagues, but also personal bonds with family and friends too.
References
Cherry, K. (2022, November 7). What is emotional intelligence. Very Well Mind. https://www.verywellmind.com/what-is-emotional-intelligence-2795423
Sinclair, S., Beamer, K., Hack, T., McClement, S., Bouchal, S., Chochinov, H., & Hagen, N. (2017). Sympathy, empathy, and compassion: A ground theory of palliative care patients’ understandings, experiences, and preferences. Palliative Medicine, 31(5), 437-447. https://doi.org/10.1177/0269216316663499
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Certified Nurses Day
March 19, 2023
GI Nurses and Associates Week
March 19-25, 2023
#Proud2BGI
Healthcare Observances
Here are some of the healthcare observances being recognized in March.
National Kidney Month
#KidneyMonth
National Nutrition Month
#NationalNutritionMonth
Theme: Fuel for the Future
Patient Safety Awareness Week
March 12-18, 2023
Multiple Sclerosis Awareness Week
March 12-19, 2023
More Observances in March
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
I was recently asked the question, “Does nursing certification really matter?” “Matter to whom?” is the question. We know patients expect to receive the best quality care when they come to a healthcare organization. As nurses, we expect the nurse practicing next to us to be competent – and even better – expert. And healthcare organizations are required to measure patient outcomes to receive reimbursement from Centers for Medicare and Medicaid and other third-party payers. So, yes, certification does matter – to patients, to colleagues, and to the institutions where we work.
What does it mean to be a certified nurse?
Certification is the recognition of specialized knowledge, skills, and experience by passing a national standardized specialty nursing exam and enables nurses to demonstrate their specialty expertise and validate their knowledge to employers and patients, according to the American Nurses Credentialling Center. We recognize that healthcare is evolving quickly and as such, nurses must invest in life-long learning to ensure they remain knowledgeable and are delivering the latest, evidence-based care.
Certification is an indicator of professionalism; professionalism is defined as the competence of skill expected of a professional, conducting oneself with responsibility, integrity, accountability, and excellence, according to the U.S. Department of Labor. When you invite a contractor into your home to do work, you expect them to be certified and expert in their specialty and conduct themselves accordingly.
The correlation between certified nurses and improved quality care is clear.
The research is clear, in healthcare, certification matters. There is a direct relationship between certified nurses and clinical patient outcomes.
- Healthcare systems that employ BSN prepared nurses who are board certified in their specialty see a lower percentage of falls and healthcare-associated infections.
- Certified nurses have more professional opportunities and tend to earn higher pay than their non-certified colleagues.
- Healthcare systems that support certification in their nurses have improved retention rates because they are investing in their workforce.
- Certified nurses have fewer medical errors thus improving the organization’s bottom line (Boyle, 2022; Coelho, 2020; Halm, 2021).
As a professional, certification matters to me.
I have been a certified nurse for many years; years before I knew what it really meant. As I’ve grown in my years of experience, I can now clearly see the difference that certification makes in my practice. I am a more knowledgeable nurse and nurse practitioner because of the requirements to maintain my certification. Attending professional conferences, taking journal continuing professional development courses, and adding to the professional literature through making presentations and writing articles for peer reviewed publications, brings the concept of life-long learning to reality for me. Without a doubt, experience is important; however, being knowledgeable in your profession and being able to continually reinforce this through certification, demonstrates dedication to the profession and to patients.
If you were ever unsure whether certification is something you should consider, don’t hesitate. It’s the professional responsibility of certified nurses to encourage their colleagues to pursue it. Nurses provide the highest quality care to their patients. Certification is a vital step in the process to make this a reality.
References
Boyle, D. 2017. Nursing Specialty certification and patient outcomes: What we know in acute care hospitals and future directions. Journal of the Association for Vascular Access, 22(3), 137-142. https://doi.org/10.1016/j.java.2017.06.002
Coelho P. (2020). Relationship Between Nurse Certification and Clinical Patient Outcomes: A Systematic Literature Review. Journal of nursing care quality, 35(1), E1–E5. https://doi.org/10.1097/NCQ.0000000000000397
Halm M. A. (2021). Specialty Certification: A Path To Improving Outcomes. American journal of critical care: an official publication, American Association of Critical-Care Nurses, 30(2), 156–160. https://doi.org/10.4037/ajcc2021569
U.S. Department of Labor. (n.d.) Professionalism. Retrieved February 13, 2023. https://www.dol.gov/sites/dolgov/files/odep/topics/youth/softskills/professionalism.pdf
As I add wood to the fire on a quiet evening, my phone rings. It’s a colleague I worked with a few years ago. I think, “Probably needs another lecturer,” and I decide I’ll answer the phone once I’m finished getting the fire going. A few moments later I realize that there is no voicemail. Maybe it was a misdial. Almost immediately, my phone rings again. A longtime friend who I haven’t spoken to in quite a while is calling. My heart sinks as I begin to realize something is wrong, and reluctantly answer the phone. He asks me if I’m home, and I quickly realize that this is not going to be a catchup phone call. In a fashion that we both have used in practice fairly frequently and almost rote, he informs me of a mutual colleague’s death. Only, he follows it with, “It was suicide, Beth.” At a loss for words, my mind races to process what I heard. No. Not him. There must be a mistake. He was the kindest and one of the smartest colleagues I’ve ever worked with. Are we sure? Maybe there was a congenital heart anomaly, or maybe he succumbed to substance abuse, and this was a horrible accident. He advises me that the manner of death could be no other.
I immediately think of his wife and children. If I’m having this much trouble processing this, I can’t imagine what they are going through. Well-liked by everyone he met, how could he feel so alone? He was always there for everyone, to explain a hard concept without making you feel dumb or to put a hand on your shoulder when you had a particularly rough day. He was just that kind of human. And now we’ve lost this wonderful person to a darkness we will never know or understand.
Suicide among healthcare professionals is a silent epidemic that nobody wants to talk about. As I think about this epidemic, I wonder if perhaps it’s because we don’t want to appear weak and ask for help. Perhaps we don’t realize we’re slipping down into an abyss. Maybe we have conditioned ourselves to behave normally in the most abnormal of circumstances to such a degree that no one knows when we’re falling in. We have to be strong for others, but have we somehow forgotten about ourselves? We give so much of ourselves, that we deplete our own stores. In the last few years, I have lost several friends and colleagues to this silent killer. It must stop. Between 2007 and 2018, nurses were 18% more likely to die from suicide than the general public (Davis et al., 2021). Healthcare workers (including nurses, physicians, advanced practitioners, and others) are particularly vulnerable to suicide for several reasons, including high-stress environments, poor work-life balance, repeated psychological trauma, difficult working conditions, and extensive knowledge and access to lethal means such as medications (Tiesman et al., 2021).
As the hours go by my phone continues to ring, as so many people are coming to the realization of what and who we have lost. Perhaps it’s our own mortality that we see. If he felt there was no way out, how do we know that we won’t feel the same at some point? Everyone’s situation is different, but we bear a similar thread as our conditioned responses to trauma as healthcare professionals makes it difficult to know when some of our friends are in trouble. By virtue of how we handle ourselves in crisis, it becomes particularly difficult to identify someone who is struggling. We have to stop asking the superficial question, “Are you OK?,” because of course we are. How else could we be? Perhaps we need to do periodic gut checks to make sure that one of us isn’t slipping through the cracks in plain sight. We have to be comfortable asking each other the hard questions that we ask our patients all the time. We have to lose the stigma that we have to be strong, no matter what is happening. We have to learn to accept help the same way that we help others. We have to do better for ourselves.
If you or someone you know, maybe contemplating suicide, please intervene. Here are some resources to help:
References
Davis, M. A., Cher, B. A. Y., Friese, C. R., & Bynum, J. P. W. (2021). Association of US Nurse and Physician Occupation With Risk of Suicide. JAMA psychiatry, 78(6), 1–8. Advance online publication. https://doi.org/10.1001/jamapsychiatry.2021.0154
Tiesman, H., Weissman, D., Stone, D., Quinlan, K., & Chosewood, L.C. (2021, September 17). Suicide Prevention for Healthcare Workers. NIOSH Science Blog. Centers for Disease Control and Prevention. https://blogs.cdc.gov/niosh-science-blog/2021/09/17/suicide-prevention-hcw/
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Occupational Health Nurses Week
April 9-15, 2023
#OHNWeek
Wound, Ostomy and Continence (WOC) Nurse Week
April 16-22, 2023
#WOCNurseWeek
Transplant Nurses Week
April 24-May 1
#transplantnursesweek
Healthcare Observances
Here are some of the healthcare observances being recognized in April.
Alcohol Awareness Month
Irritable Bowel Syndrome Awareness Month
#IBSAwarenessMonth, #LifeWithIBS
Autism Acceptance Month
#CelebrateDifferences
STI Awareness week
April 9-15, 2023
More Observances in April
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
Year over year, we hear that new nursing graduates are not ready for practice. The numbers are clear; over the past 3 years the NCLEX pass rate for RNs has declined from 88.2% in 2019 to 79.9% in 2022 (NCSBN, 2022). In addition, only 23% of graduate nurses demonstrated entry level competence and readiness to practice (Kavanaugh & Szweda, 2017). The NCSBN has recognized that the current NCLEX exam did not adequately measure clinical judgement. Clinical judgement is defined as the process by which nurses make decisions based on nursing knowledge, evidence, theories, other disciplinary knowledge, critical thinking, and clinical reasoning (AACN, 2023). Starting in April 2023, the NCSBN will release the Next Generation NCLEX exam that improves testing of clinical judgement.
Clinical judgement: a necessary component of competency
Practicing nurses expect the nurse working beside them to be competent, confident and have their back if an emergency arises — essentially practice ready. The truth of the matter is that new graduate nurses are not practice ready because they are not fully competent; they are beginners. Being competent in nursing means being able to fully care for a patient in each situation by integrating knowledge, clinical judgement, skills, values, and attitudes to perform activities defined by their scope of practice (ANA, 2018). Clinical judgement is a component of competency; it does not mean one is competent. Based on Benner’s Novice to Expert Model, student nurses start at a novice level, meaning they have no professional experience and progress to a proficient level where they can recognize patient issues, are starting to utilize clinical judgement and learning to prioritize what has to be addressed first in patient care situations (Benner, 2020). It’s not until a nurse has 2 to 3 years of experience that they reach true competency. Today, healthcare organizations are facing an experience gap due to many of their most experienced nurses retiring or moving away from the bedside.
Healthcare organizations need to facilitate competency
Once a graduate nurse passes NCLEX and begins their transition to practice, that’s where the work begins to facilitate competency. Those in practice need to accept that graduate nurses will not be competent; it is the healthcare organizations responsibility to get them there through comprehensive orientation programs, nurse residency programs, mentorship, coaching, and monitor experiences. Healthcare organizations must provide a robust preceptor program and offer new graduates structure, resource support, and training as they progress through their orientation. While there is a push to get new graduate nurses independent and competent as quickly as possible, the results from pushing too quickly can be disastrous. The turn-over rate for graduate nurses at one year is 18% to 33% and increases by the second year (Blegan et al., 2017; Flinkman, Isopahkala-Bouret, & Salanterä, 2013). New graduate nurses leave when they do not feel they are being supported through their transition from beginner to competent nurse. Health care organizations that offer nurse residency programs have a much lower attrition rate than those who offer standard orientation programs (Knighten, 2022).
It's a partnership between academia and practice that ensures graduate nurse success
It’s obvious that academia or practice alone cannot insure nurse competency; it must be a partnership. Healthcare organizations that partner with academia through formal academic/practice partnerships where the students spend more clinical time within a healthcare organization and have oversight by preceptors and faculty with dual academic/practice appointments have demonstrated success in better preparing graduates and preventing attrition (Kennedy, 2020). Our healthcare organizations often struggle with the cost of longer, more comprehensive graduate nurse orientation programs or nurse residency programs. One needs to consider the return on investment on initiating and maintaining these programs. The average cost to fill a nurse vacancy is $46,100; if the organization can retain a new graduate and facilitate their professional growth from beginner to competent and finally expert clinician, the cost savings are substantial (NSI, 2022).
Investing in graduate nurses matters to our future
The Next Generation NCLEX examination is a first step to ensuring new graduate nurses are on their way to competency. However, experienced nurses and healthcare organizations need to change their perspective on how they think about nurse graduates. Recognize new nurse graduates are learning to use clinical judgement but it’s the organization’s and fellow nursing colleague’s role to facilitate their growth from beginner to competent nurse. We need to understand that the investment in new nurse graduates will build our ranks of competent nurses and the next time you’re faced with an emergency, you’ll know the nurse working beside you is competent, confident, and has your back.
References
American Association of Colleges of Nursing (AACN). (2023). The Essentials: Clinical judgement concepts. https://www.aacnnursing.org/Essentials/Concepts/Clinical-Judgement
American Nurses Association (ANA). (2018). ANA leadership: Competency Model. https://www.nursingworld.org/~4a0a2e/globalassets/docs/ce/177626-ana-leadership-booklet-new-final.pdf
Benner, P. (2020, August 1). From novice to expert. Nursology. https://nursology.net/nurse-theories/from-novice-to-expert/
Blegen, M. A., Spector, N., Lynn, M. R., Barnsteiner, J., & Ulrich, B. T. (2017). Newly Licensed RN Retention: Hospital and Nurse Characteristics. The Journal of nursing administration, 47(10), 508–514. https://doi.org/10.1097/NNA.0000000000000523
Flinkman, M., Isopahkala-Bouret, U., & Salanterä, S. (2013). Young registered nurses' intention to leave the profession and professional turnover in early career: a qualitative case study. ISRN nursing, 2013, 916061. https://doi.org/10.1155/2013/916061
Kavanagh, J. M., & Szweda, C. (2017). A Crisis in Competency: The Strategic and Ethical Imperative to Assessing New Graduate Nurses' Clinical Reasoning. Nursing education perspectives, 38(2), 57–62. https://doi.org/10.1097/01.NEP.0000000000000112
Kennedy, S. (Facilitator). (2020, November 5). Practice/Academic Partnerships in the Age of COVID: You Can Do This! (in partnership with the National Council of State Boards of Nursing) [Webinar]. American Journal of Nursing. https://journals.lww.com/ajnonline/Pages/video.aspx?autoPlay=false&v=156
Knighten M. L. (2022). New Nurse Residency Programs: Benefits and Return on Investment. Nursing administration quarterly, 46(2), 185–190. https://doi.org/10.1097/NAQ.0000000000000522
Nursing Solutions, Inc. (NSI). (2022). 2022 National healthcare retention and RN staffing report. https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
How many times have you heard – or even said – “If it’s not documented, it wasn’t done”? Consider that statement related to your own experiences. We know that reflection and
debriefing are important for nursing students, but what about us “more experienced” nurses? What are the benefits for our well-being and growth? Can we consider journaling our personal “documentation” that reinforces what happened and how we felt about an experience?
Why journal?
Journaling involves writing down experiences and thoughts, as well as any related insights. It’s a private conversation, a safe place to express oneself without disapproval or judgement. The health benefits are numerous and include reduced stress and anxiety, lowered blood pressure, and improved immune function.
Getting started and sticking with it
Like any self-care regimen, getting started is often the hardest step. Here are some tips to help:
- Write every day. Add journaling to your daily to-do list.
- Keep it simple. A few minutes is all it takes. The time commitment and costs are low.
- Journal at the right time for you. It doesn’t have to be long or at the same time each day, though it may be easier to write and reflect at set times, such as with your morning coffee or as you wind down in the evening.
- Write about whatever makes sense to you. Is it something that happened to you today? Or perhaps how someone or something made you feel? A letter to someone? Something you are grateful for?
- Choose a journal prompt when you are unsure what to write about. Some examples include, “I want to be…,” “Remember when…,” or “I can’t believe….”
Gratitude journals
Gratitude is the quality of being thankful, the readiness to show appreciation, and to then return that kindness (Cumella, 2022). A grateful disposition can turn even the most negative situations into more positive experiences as it forces us to shift our thinking and consider a different perspective. Writing down two to three things each week for which you are grateful is an easy way to start. It’s a realistic intervention that is often therapeutic and is a step in the right direction toward focusing on positivity, especially when times are tough.
Consider sharing your stories
As you become more experienced and comfortable with your writing, consider sharing your nursing stories with others! In this
interview with Linda Honan from Yale University School of Nursing, she explains the development and importance of the creative writing ward at Yale University School of Nursing, and at the University of Pennsylvania School of Nursing, the annual
Nursing Story Slam is an event where nurse storytellers can share their “true, personal stories that explore the breadth, depth, and diversity of nursing.” Writing for publication and speaking at nursing and public events are ways to share your experiences and educate those around us about the important work we do as nurses.
Do you journal? Please share your ideas and advice!
I can’t think of a single nurse that hasn’t had at least one unanticipated twist or turn in their career journey! We are constantly learning and being exposed to different patient populations, experiences, and technologies. It makes sense that opportunities arise regularly for us to shift our career trajectory and explore new options.
However, it is also not uncommon for a point to come in our careers when we feel stagnant or yearn for something different. Here’s some advice for when you are looking to advance your nursing career.
1. Network and connect.
Attend conferences and take advantage of the chance to grow your network; connect with both attendees and the presenters too! Introduce yourself, ask questions, and exchange contact information if you are interested in keeping touch to learn more about this person, their role, and potential opportunities. If you have a business card, be sure to share it! Also, both local and larger scale conferences, virtual or in person, offer many opportunities to network.
You can also connect with others online through social media. LinkedIn is a great platform to develop professional connections and explore career opportunities. Use caution, of course, because
misinformation and disinformation can be present anywhere. Take steps to protect yourself and be sure to always remain professional.
Do you have a
mentor? Someone to guide and advise you, while supporting you and being an advocate and ally, is truly a gift. You may want to ask a trusted colleague or role model who has achieved a level of expertise to which you aspire to become your mentor. This is a relationship that requires nurturing and active participation by both the mentor and the mentee; it is well-worth it.
2. Join a committee or board.
In 2014, the
Nurses on Boards Coalition (NOBC) first convened with a goal of achieving 10,000 board seats filled by nurses by the year 2020. This milestone was achieved, and the NOBC continues to inspire with the guiding principle that “building healthier communities in America requires the involvement of more nurses on corporate, health-related, and other boards, panels, and commissions.”
Nurses have a unique perspective and need to be at the table where decisions are being made. We make up the largest segment of health care providers in the United States and are with patients, providing care, education, and support, 24 hours each day. Consider joining a working group, committee, board, council, or government to ensure the voice of nurses is heard. Here is a
series of blog posts and podcasts with experts who have great advice from finding the right group to being an actively involved board member.
3. Get certified.
Nurses who are certified demonstrate a personal responsibility to their education, and in turn, patient care and outcomes, and specialty certification sends a message of commitment to a current or potential employer. The personal benefits include feeling a sense of accomplishment and empowerment, plus validation of knowledge that can improve your confidence. For some, certification may also impact your salary and career advancement.
To learn more about certification, explore our
Guide to Certification. This handy table of specialty certification boards and contact information along with the associated credential and requirements is a good place to start your journey!
4. Go back to school.
Deciding to go back to school can be a difficult decision. Whether you are looking at
RN-to-BSN programs, or considering an
advanced nursing degree, there are many factors to consider, including timing, money, availability, and program options. When you are ready to take this next step, know that not only will you benefit yourself professionally, but you also will be elevating the nursing community.
5. Pursue new opportunities.
Finally, don’t be afraid to put yourself out there and take risks. Seek out learning opportunities, whether it’s caring for a complex patient or a learning a new technology. As nurses, we must be
lifelong learners; healthcare is an everchanging field and staying on stop of the latest
evidence is essential.
Consider taking on new roles if you haven’t already – become a preceptor to a student, new nurse, or new-to-your-unit nurse; accept the charge nurse role; join or lead a working group or committee (see #2); and take advantage of opportunities to advance on the clinical ladder, if that is an option. You can start small by talking with or shadowing someone in a different role.
What other advice do you have for nurses looking to advance their careers?
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Nurses Month
Theme: You Make a Difference
#NursesMonth, #YouMakeADifference
Oncology Nursing Month
National Student Nurses Day
May 8, 2023
National School Nurse Day
May 10, 2023
#SND2023, #schoolnurses
International Nurses Day
Theme: Our Nurses. Our Future.
#IND2023
National Skilled Nursing Care Week (NSNCW)
May 14-20, 2023
Theme: Cultivating Kindness
#NSNCW
Neuroscience Nurses Week
May 14-20, 2023
#NNW23
Healthcare Observances
Here are some of the healthcare observances being recognized in May.
Critical Care Awareness Month
#CritCareMonth
National Trauma Awareness Month
Skin Cancer Awareness Month
#ThisIsSkinCancer, #SharetheFacts, #SkinCheckChallenge
American Stroke Month
#AHAstrokemonth
More Observances in May
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
May is the month we celebrate Florence Nightingale’s birthday and the nursing profession. What was once a week-long recognition has grown over the past few years to an entire month. I give thanks every day for having the opportunity to be a nurse. From the time I was a child, playing nurse with my dolls, I knew what I wanted to be. I wanted to care for people, and I wanted to teach others how to become a nurse. Even during the pandemic with death all around me, I knew I was doing what I was meant to do. My story is not unique; it is the same story I hear time and time again; nurses are called to do what we do.
Nursing at its best
This past weekend while I was working at the hospital, I had the opportunity to witness nursing at its best. One patient was not going to live past the weekend because their disease had finally ravaged their body to the point where failure was imminent. The nurses caring for the patient contacted the family and welcomed them and their friends to come and have a celebration of life while the patient was still able to share stories, laugh, cry, tap their feet to the music, and taste their favorite foods. What a glorious celebration it was!
The next day the patient, unable to speak anymore, wrote they were ready to go to sleep forever. They were ushered into the great beyond, unafraid because they were surrounded by their immediate family and the nurses by their side. The family said to the nurses, “Thank you for all you do, you really make a difference.” This story is not unique; it happens every day in healthcare. I was lucky enough to be one of those nurses, just doing what we do best; making a difference when it matters the most.
The beauty of being a nurse
When I talk to people about their profession, some struggle to identify what they do and the difference they make. In nursing, we don’t have that problem. We are with people when they enter the world, when they are faced with healthcare challenges, and ultimately when they leave this earth. We calm their troubled minds and spirit, we rejoice with them when they receive good news, and we weep with them when they face devastation. We are trusted to tell people the truth, speak the language of evidence, and use our hands and heart to illustrate and practice the art of caring. We make a difference in people’s lives every day and for that, we are grateful. During this month and every day, thank you for making a difference!
As a former ICU nurse, working in community health never crossed my mind. I was used to patients paralyzed and sedated, mechanically ventilated, and requiring titration of multiple IV drugs to support them. How would I transition to a community health setting?
Fast forward to about five years ago, when a need arose for volunteers to staff a clinic in my community, I said, “Sure, tell me more about that.” I had been away from a clinical setting for many years, working as a
clinical editor. I thought to myself that this could be a good way to dust off my skills. Not only did I dust off some skills, but I learned a whole new set of skills!
While much of the health care world had advanced during my time away from the bedside, our small clinic had not, and it remains like the “old days” of paper charts and actual patient education handouts.
My community is not what I thought it was.
I have learned so much working in community health – about patients, the community where I live, and myself. As a married white woman raising three children in a home with a yard, enough food and resources, and family support around me, I did not know the diversity that is right outside my door. Did I not see it? Was I too focused on my own life?
When I step inside the nurses clinic, my world opens up. Most patients don’t speak English. Some have only been in this country a few days. Some run out of food before they have money to buy more. Some have left family members behind. Some children have travelled long distances alone to be greeted by family or friends in this country that they’ve never met. Everyone has a different story.
The patients need us.
In our clinic, we manage chronic conditions and treat acute illness, perform school and work physicals, and administer some vaccinations. We refer to specialists and provide some medications (and if necessary, find alternatives or pharmacies that can provide what patients need at the lowest cost to them). I have learned that often patients must choose between food and medication because they can’t afford both. Sometimes we need to get creative to help them manage those decisions.
One of the greatest needs is education. One of the first patients I met had come in fearful that they had breast cancer. They didn’t know that the ‘lump’ they were feeling was actually a rib. Another patient had been taking
penicillin purchased from a local grocer for a wound on his foot. Of course, the additional layer to this needed education, is that it is mainly done with the help of our talented interpreters.
In the five years I have been there, we have added a registered dietitian to our staff which has helped greatly with nutrition education. We also have a pantry that we stock with donations and incorporate education about healthy food choices with options for them to take home with them.
On a normal day, we can’t simply tell a patient to follow up with neurology or that they need an x-ray. A lot of what we do is helping them navigate the available services with limited funds or resources. Fortunately, our relationships and network with certain pharmacies and providers is very helpful. And while we don’t charge for any of the care we provide, I am amazed at the generosity and gratitude that we are shown by those we care for. From cash donations to baked goods and flowers, we all feel appreciated for the work we do.
How I have changed.
I understand that there are different perspectives that make up my community and I now truly see all the people in it. Everyone is working hard in various roles – from the restaurants and hotels to landscaping and construction – trying their best to make a life for themselves and their families. It bothers me that I didn’t see this so clearly before, but I am grateful that my eyes – and my world – are now open.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Pride Month
Alzheimer's & Brain Awareness Month
#ENDALZ
National Safety Month
#gogreenforsafety
More Observances in June
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
Health equity and access to care is front and center in the news. People are dying because they don’t have access to healthcare. Patients are voicing concerns they can’t afford their prescriptions and groceries. When did it become necessary to choose between purchasing prescribed medications and food? Healthcare institutions are discontinuing select services or closing all together and healthcare providers are relocating to states where they won’t be prosecuted for providing quality care. What is happening in this country? We spend more on healthcare than any country in the world, yet our health outcomes are some of the worst (Gunja, Gumas & Williams, 2023). It’s time for a change.
It's time to change the narrative from health equality to health equity.
We need to finally agree that all people across the planet have a right to receive healthcare. For years we talked about health
equality, or providing the same interventions for everyone. The truth is health equality doesn’t work. We cannot use a one size fits all approach to healthcare. What we need to focus on is the health outcome and then determine which interventions work best for the individual person so they can achieve a specific outcome and achieve an optimal level of wellness.
Too often people don’t have access to healthcare disease prevention and screening and end up being diagnosed with conditions that could have been caught early enough to be managed more effectively. People will argue that prevention and screening cost money. Yes, that’s certainly true; however, taking the time to educate someone on safe sex, diet modification, exercise, and smoking cessation costs less that treating a myocardial infarction, heart failure, COPD, lung cancer, or HIV.
It's time to bring healthcare to where the people are.
We need to do a better job at providing access to care. Healthcare organizations need to recognize and appreciate the responsibility for addressing the needs of the community it serves. That means bringing healthcare to where the people are. People need to trust that healthcare professionals and organizations want to help them. In the pandemic, trust was established within our communities by standing up clinics and offering vaccines and COVID-19 screening. We need to address access to care and that means addressing transportation to healthcare facilities and appointments. Healthcare organizations can’t do this alone; they need to work with their community governments and social services to make this happen.
Healthcare takes a multidisciplinary approach. It’s time to break down our silos and have physicians, nurses, pharmacists, social workers, mental health professionals, physical and occupational therapists, and dieticians working together to improve and optimize healthcare. All members of the healthcare team need to have a seat at the table where discussions are happening, and decisions are being made.
It’s time for health equity for all.
Not long ago, I took care of a patient with a disease that should have been prevented. They should have received screening and treatment and lived their life. Instead, their life was cut short. I grieve for this person. I grieve because our system could have done better. I am not alone; we see these cases every day. The question is are you willing to take a stand and try to make the system better? Is your healthcare organization ready to change the narrative from
healthcare equality to
health equity for all?
Reference:
Gunja, M., Gumas, E., & Williams, R. (2023, January 31). U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. Commonwealth Fund. https://doi.org/10.26099/8ejy-yc74
We recently lost a very good friend and supporter of the nursing profession, Robert “Bob” Maroldo. Bob was the publisher of Wolters Kluwer, Lippincott NursingCenter for over 20 years. He started working on Lippincott NursingCenter because he truly believed in and wanted to support the mission of nurses to care for people. Bob came by this naturally because his late wife was a nurse, and he witnessed her coming home with stories about making a difference in people’s lives. He also heard these stories from his coworkers many who are nurses. Bob wanted to make the life of nurses a little better by providing them with the latest evidence-based practice information so they could help patients make better informed decisions. When Bob retired in June 2022, he was setting out to travel and see the world – something he thoroughly enjoyed – but he never hesitated to pick up the phone or send an email to check in to see if he could help his work family.
Bob’s guidance, innovation, and “let’s do it” spirit was contagious. He shared his knowledge about running websites, SEO, and providing nurses with the information they need to improve their practice. He was a mentor to many of us. We will always remember his jovial smile, his deep laugh, and his welcoming spirit.
The words of Alfred Delp embody Bob and how he lived his life, “If through one man’s life there is a little more love and kindness, a little more light and truth in the world, then that man’s life has had meaning.”
The Wolters Kluwer, Lippincott NursingCenter family will always remember the impact Bob made on us and his support of the nursing profession. He will be missed.
Heartburn. It’s an unpleasant burning feeling in your throat and chest that occasionally happens for some individuals after eating. Frequent occurrence, two or more days a week, may be a sign of gastroesophageal reflux disease (GERD) which should be treated. There are several medications called histamine (H
2) receptor antagonists (H
2RA) available by prescription or over the counter (OTC) to treat heartburn and other gastronintestinal conditions. Millions of people take these drugs daily, but how do they work?
Pathophysiology
When we eat, gastric acid is secreted to aid in digestion. Certain endogenous substances, primarily histamine, but also acetylcholine and gastrin, attach to receptors on the surface of parietal cells. These substances activate the enzyme adenyl cyclase, which converts adenosine triphosphate (ATP) to the intracellular catalyst cyclic adenosine monophosphate (cAMP). The cAMP ultimately stimulates proton-pump (H/K ATPase) activity. The pump catalyzes the exchange of extracellular potassium (K) ions for intracellular hydrogen (H
+) ions. When the H
+ ions combine with extracellular chloride (Cl) ions excreted by gastric cells at a different site, the result is hydrochloric (HCl), or gastric, acid. The mucous lining of the stomach protects it from the acid. However, when the lower esophageal sphincter at the junction of the esophagus and stomach is weakened or does not close properly, it may allow a backflow or “reflux” of acid into the esophagus, which does not have a protective mucous lining.
How Do H2 Receptor Antagonists Work?
H
2Ras, or H
2-receptor blockers, competitively bind to H
2-receptor sites on the surface of parietal cells and inhibit the common pathway that histamine and other substances must travel to stimulate proton-pump activity and promote gastric acid secretion. This results in reduced gastric acid secretion, gastric volume, and hydrogen ion concentration.
Indications & Formulations (Facts and Comparisons, 2020)
H2 blockers are approved by the U.S. Food and Drug Administration (FDA) for short-term use to treat a variety of gastric disorders outlined in the table below. Three medications are currently approved: cimetidine, famotidine, and nizatidine. Famotidine and cimetidine are available either OTC or by prescription. Nizatidine is available by prescription only. OTC and prescription ranitidine (Zantac) formlations have been removed from the U.S. market due high levels of a contaminant known as N-Nitrosodimethylamine (NDMA), a human carcinogen (FDA, 2020).
Histamine H2 Antagonists Indications (Facts and Comparisons, 2020) |
Indication |
Cimetadine
(Tagamet) |
Famotidine
(Pepcid) |
Nizatidine
(Axid) |
Benign gastric ulcer treatment |
+ |
+ |
+ |
Duodenal ulcer treatment |
+ |
+ |
+ |
Duodenal ulcer maintenance |
+ |
+ |
+ |
GERD |
+ |
+ |
+ |
Heartburn |
+ |
+ |
|
Pathological hypersecretory conditions |
+ |
|
|
Formulations |
|
|
|
Tablet |
+ |
+ |
+ |
Oral powder for suspension |
|
+ |
|
Intravenous solution |
|
+ |
|
Nursing Considerations (Nugent, Falkson & Terrell, 2022; Facts and Comparisons, 2020)
H
2RAs take effect in approximately 60 minutes with a duration of action ranging from 4 to 10 hours. H
2RAs are commonly taken once or twice daily. They may be taken with antacids (i.e., aluminum hydroxide, calcium carbonate, magnesium hydroxide) if faster relief is needed, however they should not be taken with other acid reducing medications (i.e., proton pump inhibitors). When taking H
2 blockers over-the-counter, advise your patients to stop use if they develop trouble or pain when swallowing food, vomiting with blood, or bloody or black stools. Patients should not self-treat with H2RAs for more than two weeks without consulting their primary care provider.
For complete information, please consult the drug’s specific package insert or the
Nursing2024 Drug Handbook® + Drug Updates.
More Reading & Resources
Ethics guide how we should treat one another, how we should act, and what we should do. As nurses, we've all dealt with difficult ethical issues, even
dilemmas, in our practice. They can sometimes be more challenging than the physical care we provide for our patients.
Nursing ethics are the values and principles governing nursing practice, conduct, and relationships between the nurse and patient, patient’s family, other healthcare professionals, and the public. Regardless of practice setting or specialty, nurses face ethical challenges every day. Make sure you are familiar with the ethical principles below.
1. Advocacy
As advocates, nurses help patients navigate the healthcare system and communicate with members of their care team, including when patients cannot speak for themselves. This also involves preserving dignity and ensuring equitable care. Nurses must also advocate for themselves to prioritize a safe work environment.
2. Autonomy
The use of sound clinical judgment to make nursing decisions is the foundation of autonomy. These decisions and nursing care must be within the nurses’ scope of practice as determined by the state and institution where they work.
Autonomy also relates to the right of patients to make decisions for their care, even if their choices are different from the beliefs or recommendations of the providers and caregivers.
3. Beneficence
In nursing, beneficence refers to making sure patients’ best interests are considered, understanding that what is best for one patient may not be best for another. Oftentimes beneficence involves going beyond what is required.
4. Confidentiality
Confidentiality is the right for personal details and health care information to be protected and private unless permission is given to share. The
Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that includes standards to protect sensitive patient health information.
5. Fidelity
Fidelity refers to fulfilling commitments and staying true to professional promises and responsibilities, such as providing high quality, competent and safe patient care. Demonstrating fidelity helps to maintain credibility.
6. Informed consent
With
informed consent, communication between a patient and a health care provider results in the patient’s agreement to undergo a procedure or treatment. It is both a legal and ethical obligation. Nurses are key participants in the informed consent process, in both educating the patient of the potential risks involved in the procedure and verifying understanding.
7. Justice
Nurses – who approach care holistically – are ideal advocates for justice. We are trusted by the public and are the largest group of health care professionals. Justice refers to the fair and equal treatment of all, protection of rights, equitable distribution of resources, and ensuring that decisions are unbiased.
8. Moral distress
Moral distress, or
moral injury, refers to a situation when it is impossible or nearly impossible to do the morally right thing due to institutional, procedural, or social constraints.
9. Nonmaleficence
Avoiding harm is the heart of nonmaleficence. Also, it involves balancing unavoidable harm with benefits of good.
10. Respect
The
Code of Ethics for Nurses differentiates the respect for autonomy and the respect for persons. The first focuses on allowing others to make their own decisions and to act upon those decisions as long as harm to others is not a result. The latter is based on the fact that
all persons have value and should be treated with respect.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Juvenile Arthritis Awareness Month
National Cleft & Craniofacial Awareness & Prevention Month
Medical Malpractice Month
World Hepatitis Day
July 28, 2023
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
If you’ve been watching the news lately, you’ll notice that individual states are considering patient safety by proposing minimum patient/nurse ratios for healthcare systems. The research has been clear; the more patients a nurse has to care for, the worse the patient outcomes and the increased risk of mortality (Levins, 2023). This is not new. Healthcare systems have been wrestling with the patient/nurse ratio question for years. Nurses – especially since the pandemic – have been vocal about the need to address staffing so they are better equipped to provide safe patient care.
Should the state governments regulate safe staffing ratios? Let’s look at the issues.
The nursing workforce has an experience gap.
Today less experienced nurses outnumber nurses with greater experience at the bedside. We knew we would be facing a nursing shortage prior to the COVID pandemic simply because of the aging of the nursing workforce. Older nurses would be leaving the bedside and retiring due to age and the physical challenges of taking care of people. What was not anticipated was that nurses, especially younger nurses between the ages of 25 to 35 years of age, would also be leaving the bedside. Based on the latest data, 100,000 nurses have left the profession due to burnout and stress associated with the pandemic; however, even many more have moved from the bedside to other roles that do not deliver direct patient care (Martin et al., 2023). We’ve also seen nurses move to specialty areas where the patient/nurse ratio is more stable.
We need to address nursing education issues so we can fill the nursing pipeline.
Faculty are aging just as the those in active practice are aging. Nursing schools lack enough full-time and part-time faculty to address the over 78,000 of qualified applicants to undergraduate and graduate nursing programs that are turned away (AACN, 2023). There is a need to hire more adjunct faculty and teach them how to facilitate learning. The way we teach is evolving because our students and healthcare are evolving. There will be more emphasis on simulation to help solve the inadequate numbers of clinical sites. Equally important, simulation will help us facilitate learning and assessment of clinical judgement. Resources in nursing education must improve and that means we need to start paying faculty what they are worth. The last year has shown a decline in the enrollment in nursing programs AACN, 2023). There needs to be a culture change at the bedside so nurses and others will recommend the nursing profession to potential candidates.
New nurse graduates are not practice ready; so let’s stop treating them like they are.
The most recent research into the nursing workforce reveals new nurse graduates are not practice ready and they are not sufficiently supported by healthcare institutions when they graduate and start working. The NCLEX-RN pass rate has declined 10% over the past 3 years, and research involving educators and those in practice reveal that passing the NCLEX-RN exam doesn’t mean they are able to assume the role of a practice ready nurse upon graduation (NCSBN, 2023). According to Benner’s Model, From Novice to Expert, it takes 2 to 3 years for a nurse to be truly competent (Benner, 1982). That means we need to change our expectations of a graduate nurse and support them with training, mentoring, and precepting so they can become competent.
Health systems need to establish a safety net for new nurses by investing in in nurse residency programs and preceptor programs.
The experience gap impacts the number of quality preceptors and resource personnel who are available to support new nurse graduates. The movement of experienced nurses to other roles away from the bedside leaves new graduate nurses without a sufficient safety net, which includes experienced preceptors. The turnover rate for nurses with one year or less of tenure is 32.8% (NSI, 2023). Those institutions who have nurse residency programs tend to have lower turnover rates and improved return on investment because they have a better support system in place for new graduate nurses (Knighten, 2022).
Nurse retention should be a higher priority than nurse recruitment.
So often healthcare systems entice nurses to come work for them with bonuses and other perks. What they don’t realize is that bringing that talent in the door is not enough; they need to prioritize retaining that talent. There are many stories where nurses come to healthcare organizations following large sign-on bonuses just to find out what lies beyond the curtain is not at all what was promised. After a short time, the nurse wants to leave because the promise of being able to practice with adequate staffing, flexible scheduling, and the feeling of being valued just doesn’t exist. Many times, these nurses face paying back large amounts of money to leave their contracts. Investing in retention by providing adequate safe staffing with competent nurses and having flexible scheduling and benefits that people really need, can make all the difference. That means management needs to be up on the units to see what really is happening in patient care today. They need to ask the questions, “What do you need to practice safely? Why do you stay? What can the organization do so you feel valued?”
Nurses want to care for patients, and they want to do it safely.
So often we hear people say, “Nurses must not care about their patients if they go out on strike.” This is far from the truth. Nurses want to care for people; that’s who we are and what we do. However, we need to do it in an environment where we can provide the highest quality care. To provide quality care, we need a sufficient number of nurses who are competent. Strikes in healthcare are seldom about money alone; they are about the need to have sufficient numbers of nurses and resources to provide safe, quality care.
Staffing matters!
The research is clear; having the right number of competent nurses is necessary to deliver safe, quality care and improve patient outcomes. Staffing can no longer be about numbers because the numbers are not equitable. Healthcare institutions need to realize a nurse is not a nurse is not a nurse. Specialty knowledge, training, skills, and competency are different for each specialty unit. Patients are sicker and more complex than ever before. Therefore, while staffing ratios may be a first step, they are not the only step. Staffing needs to be determined by evaluating the number of patients, patient severity of illness, and competency of the nurse.
Quality healthcare costs money; providing unsafe care costs more.
Without a doubt, all the things listed above cost money. However, having insufficient, unsafe staffing levels or staffing with nurses who are not competent and experienced in the specialty area leads to more medical errors, increased patient dissatisfaction and increased staff dissatisfaction. Just look at quality measure scores, Leapfrog scores, and star ratings. Quality care suffers when there is an insufficient number of competent nurses caring for patients. Lower quality care leads to more lawsuits, increased patient bounce-backs, higher complication rates, and lower reimbursement. To be a successful healthcare organization today, one needs to invest in its workforce. The workforce is 50% of a healthcare organization cost and therefore can have the highest impact on whether the organization will be successful or not (Kaufman Hall, 2023). Investing in the workforce leads to a higher return on investment.
Back to the original question…Should the state governments regulate safe nurse staffing ratios?
If healthcare organizations won’t regulate themselves, someone needs to step in to protect the patients. Healthcare is about providing quality care to those in need in a safe manner. Staffing ratios are a first step in restoring quality patient care but it’s not the only step. In a better world, healthcare organizations would invest in their workforce, regulate themselves, and see the benefits to the patients and the community in which they serve. Isn’t it time for a better world?
A new
study that looks at clinician wellbeing as a factor to decrease turnover and improve care was recently published in
JAMA Health Forum. This was a refreshing angle to address the current staffing crisis, focusing on improving the work environment as opposed to resiliency training, which often puts the added burden on individuals themselves – many of whom are suffering from compassion fatigue, burnout and
moral injury.
In summary, the
US Clinician Wellbeing Study was a large, multisite collaborative investigation of the health and well-being of clinicians from 60 Magnet-recognized hospitals. Researchers looked at improving the work environment versus bolstering resiliency of clinicians to impact turnover and patient safety.
Data on wellbeing, turnover, and safety
All of the data of this
original investigation, which looked at responses from both physicians and nurses, can be reviewed in the report; here are some highlights:
- One half of the nurse-respondents reported experiencing high burnout.
- Over 40% of nurses would leave their current hospital if possible.
- Five in 10 nurses report a great deal of stress because of their job.
- Problems with overall health and sleep were more characteristic of nurses than of physicians.
- Approximately 26% of nurses gave their hospital an unfavorable grade on patient safety.
- More than half of nurses reported there were too few nurses.
- Both physician and nurse turnover were significantly associated with nurse burnout, nurse dissatisfaction, and nurses’ intentions to leave their current job.
- For both nurses and physicians, the highest-ranking intervention was improving nurse staffing (87% and 45%, respectively).
Key takeaway: Improve care delivery
Prioritizing organizational improvements is key. For their health and wellbeing, both physicians and nurses reported that interventions that improve care delivery is more important than those directly focused on improving their mental health. Providing safe workloads and better work-life balance should be the priority, and one way to do this is to improve nurse staffing. In a recent blog on nurse staffing, Dr. Anne Dabrow Woods breaks down
staffing ratios and the importance of focusing on competency of new nurses and retaining experienced nurses.
Nurses – our time is now. As the largest group of health care professionals, we can continue to impact the health of patients and the public by advocating for ourselves and our profession. Use your voice to share this data and look to leadership to invest in improving care delivery where you work.
Reference:
Aiken, L. H., Lasater, K. B., Sloane, D. M., Pogue, C. A., Fitzpatrick Rosenbaum, K. E., Muir, K. J., McHugh, M. D., & US Clinician Wellbeing Study Consortium (2023). Physician and Nurse Well-Being and Preferred Interventions to Address Burnout in Hospital Practice: Factors Associated With Turnover, Outcomes, and Patient Safety. JAMA health forum, 4(7), e231809. https://doi.org/10.1001/jamahealthforum.2023.1809
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
National Breastfeeding Month
Theme: This is Our Why
World Breastfeeding Week
August 1-7, 2023
Theme: Enabling Breastfeeding: Making a difference for working parents
#WBW2023
National Immunization Awareness Month
Psoriasis Action Month
#ThisIsPsoriasis
National Health Center Week
August 6-12, 2023
#NHCW23
Children's Eye Health and Safety Month
International Overdose Awareness Day
August 31, 2023
Theme: Recognizing those people who go unseen
#IOAD2023
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
We can no longer turn away from the truth; climate change is having a major health impact on our world. All you need to do is look at the news and step outside. People are dying due to extreme heat, dehydration, flooding, fires, smoke, and pollution exposure. It doesn’t stop there; we’re seeing issues with vector-borne, water, and food related illnesses, and even violence and overall poor mental health (United States Environmental Protection Agency, 2023). Some areas of the world are experiencing the hottest days on record while in other geographic areas they are experiencing torrential downpours, tornadoes, hurricanes, and flooding. Climate change is not a national issue; it’s a global one.
Climate change is the biggest health threat facing humanity.
Climate change has a direct impact on the social determinants of health leaving people with food, economic, housing, and healthcare insecurities. Recently, the World Health Organization (WHO) declared that climate change is the biggest health threat facing humanity (WHO, 2023). The WHO estimates that climate change will cause an additional 250,000 deaths from 2030 to 2050 due to malnutrition, malaria, diarrhea, heat stress and other illnesses and injury (WHO, 2023). The direct impact to healthcare costs is estimated to be two to four billion dollars per year – about 0.044% of the total global expenditure on healthcare (based on an estimated nine trillion-dollar total global expenditure on healthcare) by 2030 (WHO, 2022; WHO, 2023).
Let’s teach people how to stay healthy.
Nurses care for people, and climate change provides the perfect opportunity for nurses to step up and volunteer in their communities. Nurses are known for their ability to educate people and gain trust. This is our chance to educate and prepare others for the impact of climate change. Nurses can support their community climate change initiatives and emergency response network by offering to educate people on how to decrease their carbon footprint and decrease greenhouse gases. Nurses can also assist with setting up shelters and relief centers where people can go to escape extreme heat, cold weather, or flooding. Nurses can identify those who are vulnerable in the community due to exposure, sensitivity, or lack of adaptive capacity in an event and initiate action to assist those individuals.
The economic burden to reduce our carbon footprint should not supersede our duty to protect our planet for future generations to come.
-Myrna Schnur, MSN, RN
It's up to each of us to make a difference.
No matter how hard we may try, we can’t escape it. Global warming is impacting the health of everyone across the globe. Most, if not all, nurses have taken care of patients impacted by a climate change-related issue. The role of nurses will include becoming leaders and climate advocates. Here’s our chance to help prioritize climate change interventions, recognize those most vulnerable, and intervene to keep them safe. Every nurse can decrease their own impact on the environment and motivate others to change.
References:
United States Environmental Protection Agency. (2023, June 30). Climate Change. Environmental Protection Agency. https://www.epa.gov/climate-change
World Health Organization. (2022). Global expenditure on health: Rising to the pandemic’s challenges. https://www.who.int/publications/i/item/9789240064911
World Health Organization. (2023). Climate Change. https://www.who.int/health-topics/climate-change
We know that equal access to care and resources is not the same as
health equity. And while the image below has always caught my eye and served as a nice visual to understand this, recent discussions around justice have made me look a little deeper. How does justice fit into the health equity equation?
Equality, equity and justice
Let’s think about it this way…
- If equality means everyone gets the same resources and care without regard to social determinants of health…
- And equity means providing accommodations to break down barriers and essentially even the playing field…
- Then justice means we eliminate those barriers.
Here’s a new visual to demonstrate this:
Striving for health justice
A one size fits all approach to healthcare will never be effective. While completely removing obstacles is a lofty goal, there are steps that can be taken.
- Ensure honest, effective, nonjudgmental and culturally responsive communication with all patients (Ward, 2023).
- Develop the capacity to reach a broad range of patients (Ward, 2023).
- Consider and employ these 10 The Principles of Trustworthiness to engage and partner with your community (AAMC, 2023)
- Recognize, engage, respect and empower communities that have been disenfranchised by racism, poverty, and other forms of inequality (Wiley et al., 2022).
Final thought: Prioritize communication
We need to do a better job at identifying barriers so we can remove them and provide accessible and appropriate care. It starts with working together as a team with our colleagues and communities.
Communication is the foundation of establishing trust and it’s not always about what you
say. Pay attention to how you say it, who you say it to, and what others say to you.
Listen to their words, their body language, and also what is
not being said.
Wiley, L. F., Yearby, R., Clark, B. R., & Mohapatra, S. (2022). INTRODUCTION: What is Health Justice?. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics, 50(4), 636–640.
https://doi.org/10.1017/jme.2023.2
I am happy to share that I recently achieved CCRN certification. It was a lot of studying, but I am so happy I did it. It had been on my to-do list for years and I must admit, it was more difficult than I anticipated. With a background in critical care nursing and prior CCRN certification, and all the reading and content creation I do for Lippincott NursingCenter, I thought taking the test would just be a formality. I was incorrect.
I quickly realized how much studying was ahead of me after taking a practice exam. This was a great first step because I was able to identify my knowledge gaps, and I realized I was going to need a study plan. Here’s what worked for me!
Certification Exam Plan
- Decide on the appropriate certification for you. What are your professional goals? I planned to take the CCRN exam because though I am not currently in clinical practice, my work impacts critical care nurses.
- Visit the website for the professional organization which offers the certification you seek. Make sure you qualify to take the test. Do you meet the requirements for specialty area and practice hours?
- Explore the exam preparation policy and handbook, if provided and accessible, and any study tools that are available.
- Apply for the exam. It may be cost-effective to become a member of the certifying organization. Take a look at all your options!
- Take a comprehensive test and see how much you do know and what body systems or topic areas you may need to put some extra study time towards.
- Prepare! When looking for a certification review course, prioritize access to lots of practice questions! I can’t stress this enough! The practice questions solidify your content knowledge, as well as application of what you know.
- Schedule the test in a realistic timeframe. Give yourself plenty of time to study. I gave myself a solid three months. I then counted back from the exam date to plan my studying, with the last 2 weeks dedicated to taking practice tests over and over. Also, consider whether you will take the test in-person or online. Many organizations offer both. While the online option may be easier to schedule, make sure you will have the technology, space, and solitude you need to be successful.
- When test time comes, get plenty of rest the night before, have a healthy meal and hydrate! Take your time, read each question and answer choice thoroughly, and trust your instincts.
- Celebrate your new credentials!
I am fortunate to work for a publishing company where Certification Review products are available to those who have access through their workplace. Coincidentally, as I was studying, we were working to incorporate those products into Lippincott NursingCenter to offer to individual nurses seeking to become certified. Here’s a look at
Lippincott NursingCenter’s Certification Review:
Best of luck to you on your certification journey!
Alzheimer’s disease (AD) affects over six million people in the U.S. As a nurse, you will likely receive questions from friends and relatives surrounding AD and its potential treatment options. (Lequembi®) is the latest medication approved by the U.S. Food and Drug Administration (FDA) to treat Alzheimer’s.
Alzheimer’s Disease Pathophysiology
First, let’s start with a review of the pathophysiology behind Alzheimer’s. The exact mechanism of AD is unknown, but it prevents cerebral nerve cells from functioning effectively, leading to permanent changes in the brain. Patients with AD appear to have lower levels of choline acetyltransferase resulting in reduced acetylcholine synthesis and impaired cortical cholinergic activity, processes that are important in learning, memory and cognitive function (Press & Buss, 2021). In addition, the development of plaques and tangles within the brain contribute to neuron damage. Plaques are deposits of beta-amyloid proteins that build up in the space between nerve cells, while tangles are twisted fibers of tau proteins that accumulate within cells. These proteins block communication among neurons and play a role in cell damage leading to mental decline. This process naturally occurs in most of us as we age, however in individuals with Alzheimer’s, there’s an increased accumulation of plaques in areas of the brain responsible for memory function.
AD is marked by progressive memory loss and cognitive decline that interferes with activities of daily living. Advanced symptoms include disorientation; mood and behavior changes; confusion surrounding events, time, and place; false suspicious feelings; and difficulty talking, swallowing, and walking (Alzheimer’s Association, n.d.). There is no cure for Alzheimer’s, however advances in research have led to the approval of several medications that have shown to slow the progression of the disease. Cholinesterase inhibitors have been available since the late 1990’s and are often the first-line drugs to treat mild to moderate AD. Three are currently available in the US: galantamine (oral), rivastigmine (oral and transdermal) and donepezil (Aricept®) (oral and transdermal); all work by increasing levels of acetylcholine. Memantine (Namenda®), an N-methyl D-aspartate (NMDA) receptor antagonist, was approved in 2003 to treat symptoms of moderate to severe AD. Both drug classes have shown to produce a small improvement in cognitive abilities, neuropsychiatric symptoms, and activities of daily living (Press & Buss, 2021), however, individual patient responses are highly variable.
NEW! Monoclonal antibodies
Two monoclonal antibodies have been approved by the FDA to slow the progression of AD in patients with mild disease: Aducanumab (Aduhelm®) in 2021 and more recently, lecanemab (Leqembi®) in July, 2023. Both treat and remove specific types of beta amyloid proteins that develop into plaques in the brain but they work differently at distinct stages of plaque formation (Alzheimer’s Association, n.d.). Clinical efficacy data is limited and conflicting among clinical trials for aducanumab. Lecanemab met all primary and secondary efficacy endpoints, meaning it showed meaningful clinical outcomes. For the purposes of this blog, we’ll focus on lecanemab.
Lecanemab (Leqembi®) FAQ
Since lecanemab is new to the market, you are likely to receive many inquiries. Below are some frequently asked questions and simple answers to provide to your patients, family, and friends.
Are all patients with AD candidates for lecanemab?
If in the early stages of AD (mild cognitive function) as assessed by a healthcare provider, lecanemab may be an option. A positron emission tomography (PET) scan or lumbar puncture (spinal tap) will be required to confirm the presence of beta amyloids in the cerebrospinal fluid. In addition, testing for the apolipoprotein E gene variant called APOE4 may be indicated. Approximately 25% of people carry one copy of APOE4, and 2 to 3% carry two copies. APOE4 is the strongest risk factor gene for AD and can lead to severe side effects (Bryan, 2021).
Will lecanemab cure Alzheimer’s disease?
Lecanemab will not cure Alzheimer’s nor will it improve memory or cognitive abilities. In research studies, lecanemab slowed cognitive decline by 27% at 18 months compared to placebo, however it will not completely stop AD from getting worse.
How is lecanemab administered and how long will the patient be on the medication?
Lecanemab is administered by the intravenous (IV) route once every 2 weeks. Treatment will be halted once there is evidence of progression to moderate or severe stages of AD.
Is any additional testing needed?
Magnetic resonance imaging (MRI) of the brain is required prior to starting lecanemab and periodically for the duration of treatment to identify potential side effects.
What are the side effects?
Lecanemab can cause diarrhea and cough. Close monitoring for signs of an infusion reaction such as fever, chills, aches, shaking, joint pain, hyper- or hypotension, headache, changes in eyesight, or allergic reaction is important.
Are there any risks associated with lecanemab?
Lecanemab can cause mild to moderate cerebral edema or bleeding (microhemorrhages) that may resolve on its own or could be life-threatening. These risks are known as amyloid-related imaging abnormalities (ARIA). Irregular gait, dizziness, focal neurologic deficits, headache, nausea, and visual disturbance may result. People taking blood thinners and those with the APOE4 gene (particularly two copies) are at higher risk of these side effects.
How much does it cost?
At the time of this writing, the cost of lecanemab is $26,500 annually. The additional cost of regular clinic visits, periodic MRI and other tests required should also be considered.
Will my insurance cover it?
Private insurance will not cover lecanemab, however Medicare will cover 80 percent of the cost for those who are enrolled in Medicare, diagnosed with mild cognitive impairment or mild Alzheimer’s disease dementia, with documented evidence of beta-amyloid plaque in the brain, and currently being treated by a provider who participates in a qualifying registry with an appropriate clinical team and follow-up care (Centers for Medicare & Medicaid Services [CMS], 2023). A registry is the collection of data about how these drugs work outside of clinical trials.
In conclusion, while these drugs offer a glimmer of hope in the fight against Alzheimer’s, it is important to emphasize that these drugs do not provide a cure. Patients and their families should consult with their healthcare provider to carefully weigh the risks and benefits to determine whether lecanemab or other treatments are clinically appropriate options.
More Reading & Resources
I was thrilled when I learned that
Nursing Drug Handbook launched an app this year! While I do love the touch and feel of the book, I know how quickly drug information is updated. And while caring for patients in our
clinic, an up-to-date drug reference is essential!
I have been using the app for several months now and here are a few of my favorite things:
- 100% of the content from the print version of the book is included, even the images.
- Getting notified about content updates is a game changer. Now I know about critical changes to indications or dosages right away, as well as when new research is published that could affect patient care.
- I can ‘favorite’ a drug or any other feature or appendix, such as the handy table on Prescription drug abuse: Identifying and treating toxicity.
- The search bar really streamlines finding the right information.
- The Pharmacology NCLEX Questions are a go-to when working with students – keeps them engaged and learning!
Download
a two-week free trial of the
Nursing Drug Handbook App from the
App Store or
Google Play.
Have you ever heard of the Animal Naming Test (ANT)? To me, it sounds like a game you might play with kids on an elementary school playground! I had never heard the term until I read through the latest
Clinical Practice Guideline on the Management of Hepatic Encephalopathy (HE). The ANT is a quick, easy, and reliable verbal questionnaire used to assess for minimal or covert hepatic encephalopathy (MHE). It doesn’t require any special equipment and can be administered in an outpatient setting or at the bedside.
You may recall, HE is a neurological abnormality caused by liver dysfunction and marked by changes in personality, consciousness, cognition, and motor function (Weissenborn, 2019). MHE is a mild form of HE in patients with cirrhosis of the liver. MHE can be difficult to diagnosis as mental status irregularities may not be detected upon routine physical examination. The ANT evaluates cognitive functions such as verbal recall, retrieval, and self-monitoring (i.e., tracking animal names already stated), skills that require intact memory and executive functions.
How to Perform the Animal Naming Test
Agarwal and colleagues (2020) describe the ANT as follows:
- Ask the patient to say as many animal names as possible in one minute.
- Record the patient’s responses.
- If the patient stops before 1 minute, ask if there are any more animals they would like to add.
- If the patient does not speak for 15 seconds, give them a hint. For example, “A tiger is an animal. Can you name any more animals?”
- After 1 minute, count all responses excluding repeated and non-animal words.
In clinical studies, the ANT correlated with the Psychometric Hepatic Encephalopathy Score (PHES), the current recommended test for MHE consisting of six tests that take approximately 10 to 15 minutes to administer (Rodenbaugh et al., 2020; Agarwal et al., 2020). However, PHES is time-consuming and often impractical as the test must be conducted by a neuropsychologist (Rodenbaugh et al., 2020). ANT also correlated with the severity of liver disease assessed using the Model of End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores (Agarwal et al., 2020).
Campagna and colleagues (2017) found that the ANT was affected by limited education (less than 8 years) and advanced age (greater than 80 years of age). They developed an age and education adjusting procedure and created the simplified ANT (S-ANT). Using the S-ANT, the team broke down the scoring into three tiers:
- 0 = S-ANT greater than or equal to 15
- 1 = S-ANT between 10 and 15
- 2 = S-ANT less than 10
The S-ANT tool may be used to detect MHE in patients with cirrhosis in clinical practice. A score of 15 or more correlates with normal cognitive function. A score between 10 and 15 indicates mild cognitive impairment requiring further evaluation. An S-ANT value of 10 or lower strongly indicates deficient cognition and may be associated with the development of overt HE among individuals with cirrhosis (Tapper et al., 2022).
Next time you encounter a patient with a history of liver cirrhosis and a normal neurologic examination, suggest or try administering the Animal Naming Test. Let us know how well it worked in the comments below.
References:
Agarwal, A., Taneja, S., Chopra, M. Duseja, A., & Dhiman, R.K. (2020). Animal Naming Test – a simple and accurate test for diagnosis of minimal hepatic encephalopathy and prediction of overt hepatic encephalopathy. National Library of Medicine, National Institute of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7380476/
Campagna, F., Montagnese, S., Ridola, L., Senzolo, M., Schiff, S., De Rui, M., Pasquale, C., Nardelli, S., Pentassuglio, I., Merkel, C., Angeli, P., Riggio, O., & Amodio, P. (2017). The animal naming test: An easy tool for the assessment of hepatic encephalopathy. Hepatology (Baltimore, Md.), 66(1), 198–208. https://doi.org/10.1002/hep.29146
Labenz, C., Beul, L., Toenges, G., Schattenberg, J. M., Nagel, M., Sprinzl, M. F., Nguyen-Tat, M., Zimmermann, T., Huber, Y., Marquardt, J. U., Galle, P. R., & Wörns, M. A. (2019). Validation of the simplified Animal Naming Test as primary screening tool for the diagnosis of covert hepatic encephalopathy. European journal of internal medicine, 60, 96–100. https://doi.org/10.1016/j.ejim.2018.08.008
Rodenbaugh, D., Vo, C. T., Redulla, R., & McCauley, K. (2020). Nursing Management of Hepatic Encephalopathy. Gastroenterology nursing : the official journal of the Society of Gastroenterology Nurses and Associates, 43(2), E35–E47. https://doi.org/10.1097/SGA.0000000000000434
Tapper, E. B., Kenney, B., Nikirk, S., Levine, D. A., & Waljee, A. K. (2022). Animal Naming Test Is Associated With Poor Patient-Reported Outcomes and Frailty in People With and Without Cirrhosis: A Prospective Cohort Study. Clinical and translational gastroenterology, 13(1), e00447. https://doi.org/10.14309/ctg.0000000000000447
Weissenborn K. (2019). Hepatic Encephalopathy: Definition, Clinical Grading and Diagnostic Principles. Drugs, 79(Suppl 1), 5–9. https://doi.org/10.1007/s40265-018-1018-z
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Clinical Nurse Specialist Recognition Week
September 1-7, 2023
Theme: LEAD the Next Generation.
#CNSWeek
National Pediatric Hematology/Oncology Nurses Day
September 8
Vascular Nurses Week
September 10-16, 2023
#IAMSVN
Nephrology Nurses Week
September 10-16, 2023
#NNW23 #nephrologynursing
Nursing Professional Development Week
September 10-16, 2023
#NPDWeek
Neonatal Nurses Week
September 10-16, 2023
#neonatalnursesweek
Healthcare Observances
Sepsis Awareness Month
World Sepsis Day
September 13, 2023
#sepsisawarenessmonth #WorldSepsisDay
National Atrial Fibrillation Awareness Month
Ovarian Cancer Awareness Month
Pain Awareness Month
Prostate Cancer Awareness Month
World Alzheimer's Month
World Alzheimer’s Day: September 21, 2023
Theme: Never too early, never too late
National Suicide Prevention Week
September 10-16, 2023
World Suicide Prevention Day: September 10, 2023
Theme: Talk Away the Dark
Falls Prevention Awareness Week
September 18-23, 2023
Theme: From Awareness to Action
#FallsPreventionAwarenessWeek
More Observances in September
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
The story is too common – a person feels unwell and after a few days ends up going to their primary care provider or an urgent care center. They are evaluated, sent home, and several days later end up back in the office and evaluated again. This cycle continues until eventually the person’s health deteriorates to the point of crisis and they end up in the emergency department (ED). Once they arrive in the ED, they’re found to have sepsis and admitted. In many cases, they arrive profoundly hypotensive and are admitted to the intensive care unit with septic shock.
What went wrong? There’s a failure to recognize sepsis.
In 2011, the Sepsis Alliance named September as Sepsis Awareness Month (Sepsis Alliance, 2023). According to the Centers for Disease Control and Prevention (CDC), 1.7 million Americans develop sepsis annually of which 350,000 die or are discharged to hospice. Sepsis is a global issue; 11 million people worldwide die of sepsis each year with 65% of those being between 65 and 79 years of age and 89% older than 80 years (CDC). A recent study published in
Critical Care Explorations looking at sepsis medical-legal claims in Canada, found that in admitted sepsis patients, 49% of patients had made multiple visits to primary care providers, walk-in clinics, or the ED 72 hours prior to admission (Neilson et al., 2023).
Lack of sepsis awareness is a multifactor issue.
According to the literature, failure to recognize sepsis can be divided into three categories based on provider, team, and system factors.
- Provider factors include lack of knowledge about sepsis, failure to manage and monitor the patient appropriately.
- Team factors include communication breakdown across the care team which delays follow up with the patient and their family.
- System factors tend to cluster around access to care and resources, admission and transfer delays.
Regardless, lack of time to adequately assess and then follow up with the patient, lack of sepsis knowledge, and lack of access to care resources are consistently evident. These problems are not unique to sepsis; they’re a consistent issue across an ailing healthcare system.
Let’s change the trajectory of sepsis.
The healthcare system needs to invest in improving access to care and improving coordination of professionals and resources available to assess, treat, and follow up with patients. The multidisciplinary team needs continual education and training on sepsis recognition and management based on the latest evidence-based guidelines. The public needs further education on sepsis awareness and where to go for help if they can’t get into see their primary care provider. The CDC has recently issued
Hospital Sepsis Program Core Elements to optimize sepsis identification, management, and education, as well as improve hospital leadership commitment and accountability.
As healthcare professionals, we have the power to initiate change and alter the trajectory of sepsis and sepsis awareness. We need to continually update our knowledge and skills related to
sepsis recognition and
the guidelines for sepsis management. We need to teach our patients and their families to advocate for themselves. We need to improve everyone’s access to care so we can stop sepsis from claiming another life.
References:
Centers for Disease Control and Prevention (CDC). (2023, August 24). Hospital sepsis program core elements. https://www.cdc.gov/sepsis/core-elements.html
Centers for Disease Control and Prevention (CDC). (2022, August 9). Sepsis technical resources & guidelines. https://www.cdc.gov/sepsis/clinicaltools/index.html
Neilson, H. K., Fortier, J. H., Finestone, P. J., Ogilby, C. M., Liu, R., Bridges, E. J., & Garber, G. E. (2023). Diagnostic Delays in Sepsis: Lessons Learned From a Retrospective Study of Canadian Medico-Legal Claims. Critical care explorations, 5(2), e0841. https://doi.org/10.1097/CCE.0000000000000841
Sepsis Alliance. (2023). Sepsis Awareness Month. https://www.sepsis.org/get-involved/sepsis-awareness-month/
In the United States, approximately 1.7 million adult hospitalizations and more than one-third of hospital deaths each year are due to sepsis (Rhee et al., 2017). Current recommendations and guidelines focus on early recognition and management of sepsis, and rightly so as we know early interventions improve outcomes and survival. However, adding or improving hospital sepsis programs along with interventions for long-term management and recovery to our fight against sepsis has the potential to improve those outcomes even more.
The 2022 National Healthcare Safety Network (NHSN) annual survey, which evaluates the prevalence and characteristics of sepsis programs in acute care hospitals, found that of the 5,221 hospitals surveyed, 73% have sepsis teams and 55% provide dedicated time for team leaders to manage sepsis programs (Dantes et al., 2023). We can do better.
Hospital Sepsis Program Core Elements
Supporting hospitals and healthcare systems to ensure effective teams and resources to optimize sepsis programs and outcomes is essential. In August 2023, the Centers for Disease Control and Prevention (CDC) launched the
Hospital Sepsis Core Elements Program. This new program focuses on 7 elements to structure the multifaceted care necessary for managing sepsis:
- Hospital leadership commitment
- Accountability
- Multi-professional expertise
- Action
- Tracking
- Reporting
- Education
For each of these 7 elements, the CDC includes “priority examples” and “additional examples” to help hospital programs organize tasks to best achieve their goals. For those institutions that are newly establishing a program or those with limited resources, a targeted list to “get started’ is also included to prioritize the initial activities of identifying program leaders/co-leaders, securing support from hospital or healthcare system leadership, conducting a needs analysis, and establishing initial goals based on those results (CDC, 2023).
Supporting those on the frontlines in the fight against sepsis
The work toward improving sepsis care and outcomes is ongoing and it’s refreshing to see a leading organization create this program to support those on the frontlines. As nurses, we know that the statistics on sepsis outcomes are alarming, and we also know that those statistics are actual people with important lives to live and with family and friends who love them.
As evidence and new tools become available, it’s critical that we take those next steps not only to translate the research and use those tools, but to share them with our healthcare colleagues, patients, families, and the public.
References:
Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP). (2023, August 24). Hospital Sepsis Program Core Elements. https://www.cdc.gov/sepsis/core-elements.html
Dantes, R. B., Kaur, H., Bouwkamp, B. A., Haass, K. A., Patel, P., Dudeck, M. A., Srinivasan, A., Magill, S. S., Wilson, W. W., Whitaker, M., Gladden, N. M., McLaughlin, E. S., Horowitz, J. K., Posa, P. J., & Prescott, H. C. (2023). Sepsis Program Activities in Acute Care Hospitals - National Healthcare Safety Network, United States, 2022. MMWR. Morbidity and mortality weekly report, 72(34), 907–911. https://doi.org/10.15585/mmwr.mm7234a2
Rhee, C., Dantes, R., Epstein, L., Murphy, D. J., Seymour, C. W., Iwashyna, T. J., Kadri, S. S., Angus, D. C., Danner, R. L., Fiore, A. E., Jernigan, J. A., Martin, G. S., Septimus, E., Warren, D. K., Karcz, A., Chan, C., Menchaca, J. T., Wang, R., Gruber, S., Klompas, M., … CDC Prevention Epicenter Program (2017). Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA, 318(13), 1241–1249. https://doi.org/10.1001/jama.2017.13836
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National Midwifery Week
October 1-7, 2023
Theme: Midwives - Strengthening Communities
#MidwiferyWeek2023
National Pediatric Nursing Week
October 2-6, 2023
#ProudPediatricNurse
Emergency Nurses Week
October 8-14, 2023; Emergency Nurses Day: October 11, 2023
#ENWeek
National Case Management Week
October 8-14, 2023
Theme: Keeping the person at the heart of collaborative care.
International Orthopaedic Nurses Week
October 30-November 3, 2023
#OrthoNursesWeek2023, #IAmAnOrthoNurse
Healthcare Observances
Domestic Violence Awareness Month
#WeAreResilient
National Breast Cancer Awareness Month
National Metastatic Breast Cancer Awareness Day October 13
#MoreThanBCAM
Mental Illness Awareness Week
October 1-7, 2023
Theme: Together We Care. Together We Share
International Infection Prevention Week
October 15-21, 2023
Theme: Celebrating the Fundamentals of Infection Prevention
#IIPW #IIPW23
National Healthcare Quality Week
October 15-23, 2023
#HQW2023
National Health Education Week
October 16-20, 2023
Theme: Advancing health, equity & civil rights
#NHEW2023
More Observances in October
Nursing Events
See all events for 2023 here!
Anything missing? Please let us know in the comments!
Have a good month!
How often have you asked yourself, “What’s the plan?” You may ask the question when you’re caring for a patient, as a leader, or even in your personal life. Over the past few months, I’ve recognized a growing trend — patients don’t know their options and their plan of care. It’s grown more common with each passing month since the COVID-19 pandemic ended. During the pandemic, it was straightforward — try to keep the patient from decompensating and dying. Now as we get back to focusing on wellness and managing patients’ different diagnoses and prognoses, it’s time to refocus on collaboration and communication.
What’s changed over the past year?
Healthcare providers and caregivers are busier than ever and have less time with their patients, let alone time to speak with consultants or review their recommendations. In outpatient settings, patients often must wait weeks or months for an appointment with a specialist, further delaying diagnosis and the plan of care. Why should a patient have to wait months to get an MRI or an appointment with a cardiologist, neurologist, or oncologist? Why is it so difficult to get pharmacologic therapy approved that isn’t on formulary?
Many of these issues are due to lack of healthcare professionals, time, access to care, and healthcare costs. There has been an increased turnover of physicians, nurses and other healthcare professionals leaving the bedside, along with limited appointment opportunities and not enough time in the day. In addition, the complexity of patient care has increased due to pandemic-related disruptions to care for disease prevention and chronic disease management which have led to complications. Healthcare expenses continue to rise adding on another complex layer to the equation. The result is poor patient/provider communication and poor patient outcomes, which is a recipe for disaster!
Collaboration: the key to coordinating the plan
Nurses are known for their ability to coordinate patient care and foster collaboration among the disciplines. Case managers do this regularly in acute care, and there are
nurse navigators or nurse care coordinators in some specialty areas. They’re able to negotiate the “politics” of working collaboratively with specialties and with 3
rd party payers so a collaborative plan that includes patient input and agreement can be implemented. Primary care practices need to consider hiring these patient advocates (or training current staff) to facilitate timely diagnostics, consults, and interdisciplinary, patient-centered plans of care.
Nurse navigators: facilitating collaboration and informed patient care
True collaboration in healthcare means all members of the interdisciplinary team are open to other points of view and are willing to change course to address the most critical issues first. One cannot forget
the patient is at the center of the team and needs evidence-based information to make informed healthcare decisions. Nurse navigators are responsible for working directly with the patient, providers, and 3
rd party payers to facilitate the collaborative plan of care in a timely manner.
We need to improve communication and collaboration in healthcare. Our workforce issues and lack of access to care are not going to end anytime soon. Focusing on interdisciplinary collaboration and navigation through the system will only improve patient outcomes and access to care.
When a loved one is critically ill, the emotional toll on the family can be overwhelming. In such challenging times, having a family member with a medical background can be a beacon of support and a source of invaluable information. This unique perspective allows them to bridge the gap between the complex medical world and the immediate family members of the patient.
First and foremost, a family member with a medical background can act as a liaison between the medical team and the family. They can translate medical jargon into understandable terms, helping family members grasp the situation more clearly. They can help interpret and synthesize daily updates from the myriad of medical specialists that are often involved in the care of patients with multisystem organ failure. This can alleviate some of the anxiety and uncertainty that often accompanies a loved one's ICU stay.
Additionally, their medical knowledge can aid in making informed decisions. Critical illness often requires families to make tough choices about treatment options and end-of-life care. Having a family member who understands the medical nuances can provide essential guidance during these difficult discussions.
Furthermore, emotional support is a vital aspect of caregiving during these times. A medical family member can offer reassurance, empathy, and a sense of hope to the immediate family members, helping them cope with the stress and anxiety that naturally arise in such situations.
In conclusion, the presence of a family member with a medical background can be a tremendous asset when a loved one is critically ill in the ICU. Their ability to facilitate communication, provide essential medical insights, and offer emotional support can make a significant difference in helping the entire family navigate the challenging journey of critical illness.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Medical-Surgical Nurses Week
November 1-7, 2023
#MSNW23
Urology Nurses and Associates Week
November 1-7, 2024
#UrologyNurseWeek23
Forensic Nurses Week
November 5-11, 2024
#FNWeek
Perioperative Nurses Week
November 12-18, 2024
#PeriopProud
National Nurse Practitioner Week
November 12-18, 2024
#NPweek
Healthcare Observances
American Diabetes Month
National COPD Awareness Month
National Hospice Palliative Care Month
More Observances in October
Nursing Events
See all upcoming events here!
Anything missing? Please let us know in the comments!
Have a good month!
For those of us in the United States, November is a month we reflect on our lives and give thanks for what we have. Many may be struggling this year to find things to be thankful for. In our nursing profession, enrollment in undergraduate and graduate programs declined for the first time in years, and nurses and other healthcare professionals are striking or walking away due to challenging work conditions.
Despite all of this, I’ve witnessed some amazing bright spots too. The past few months, I’ve been attending conferences and I’ve seen a renewed spirit demonstrated by those attending and presenting. They genuinely love our profession and are doing their very best to support it. These remarkable nurses are rising to the challenges of our times by responding with innovation and leadership to support our communities and advance the nursing profession.
Communication and collaboration driving change
At the ANCC Magnet/Pathway Conference in October, I had the opportunity to hear some great examples of practice innovations being used to improve patient outcomes. What all these organizations had in common was an established dynamic of true collaboration between leadership, professional development, and frontline nursing staff to address the issues that would make the greatest impact on patient outcomes. The leadership empowered the nurses at the bedside to use evidence-based practice and quality improvement principles to institute change that really made a difference for those in practice and their patients.
It’s clear that many healthcare systems are listening to nurses at the bedside and giving nurses a seat at the table. It’s important that nurses at all levels take that seat and make sure our voices are heard. And even if not offered a seat, we must be willing to stand up, take responsibility, and articulate why having us at the table is beneficial to all. That means being prepared to speak about challenges and offer collaborative, innovative solutions.
Continued support of communities
Nurses are finding new, innovative ways to deliver care to those in need outside of the four walls of their institutions. Nurses and nurse practitioners are taking the lead in community centers, clinics, schools, and home and public health departments. They are bringing healthcare to rural areas where care is not easily accessible and providing direct care while also educating the public, promoting healthy lifestyles, and instituting wellness programs.
Innovation and enthusiasm leading change to support new nurses
Some healthcare organizations are stepping up by investing in less experienced nurses by initiating orientation units where preceptors and resource nurses can provide needed support. Other healthcare systems are starting safety-net programs where they employ experienced nurses to float around the hospital and provide ad hoc support to the less experienced nurses completing their orientation or nurse residency programs. Other hospitals are starting virtual resource nurse programs where an experienced nurse is a phone call or link away to support those at the bedside with their questions.
Amidst all the challenges in our profession, nurses are stepping up and finding innovative ways to improve practice so quality outcomes can be achieved. This November, I am thankful for the opportunity to attend these conferences, learn how these outstanding organizations are transforming care through innovation, and witness how enthusiastic nurses take charge and prepare for our future.
The muscle groups of the extremities are divided into multiple compartments that are formed by strong fascial membranes. Acute compartment syndrome (ACS) occurs when there is an increase in tissue pressure within the closed fascial space leading to compromise of the circulation and function of the tissues within that space (Hammerberg, 2023). Delayed recognition and treatment of compartment syndrome is catastrophic and can lead to significant nerve dysfunction, muscle loss, and myonecrosis leading to rhabdomyolysis, acute renal failure, and irreversible ischemic endpoints including foot drop, irreversible nerve injury, or paralysis (Klingensmith et al., 2008).
The causes of ACS include long bone fracture, tightly applied casts/dressings, critical limb ischemia with reperfusion, burn or crush injury, spontaneous hematoma, soft tissue injuries, non-traumatic myonecrosis/myositis/rhabdomyolysis, or massive volume resuscitation (Hammerberg, 2023).
ACS is a surgical emergency and patients at risk for developing ACS should be identified early and examined frequently. Early surgical intervention (ideally within four hours of symptom onset) is critical, as this can save the extremity. Assessment and identification of “the Five P’s” is commonly used to aid in the diagnosis. These include:
- Pain: Pain out of proportion to the injury and with passive motion of the involved muscle is the most common presenting symptom of ACS. A patient may have an increasing or disproportionate demand for narcotics and poor response to appropriate doses of analgesia.
- Paresthesias: Paresthesias in the distribution of the nerves that traverse the affected compartment is another early sign of ACS.
- Paralysis
- Pallor
- Pulselessness
*Paralysis, pallor, and pulselessness are late signs of ACS and represent irreversible soft tissue injury (Klingensmith et al., 2008).
Additional clinical features of ACS include tense/firm compartment, increase in extremity girth, acidosis or hyperkalemia following reperfusion of the extremity, and clinical evidence of rhabdomyolysis (Hammerberg, 2023).
ACS is a clinical diagnosis based on patient history, injury, presentation, and clinical suspicion. In some cases when the clinical presentation and/or physical examination are uncertain or in a patient who is unresponsive, compartment pressures can be measured to aid in diagnosis. Compartment pressures are typically measured with a handheld manometer and should be measured in each compartment. Compartment pressures reading within 30mmHg of the diastolic blood pressure with equivocal physical examination warrants surgical intervention (Klingensmith et al., 2008).
ACS is a surgical emergency and once clinical suspicion is raised the patient should have emergent surgical consultation and proceed to the operating room for a fasciotomy. All external pressure on the affected extremity should be removed, including casts, dressing, splints or any other restrictive coverings. A four-compartment fasciotomy is the only recognized treatment of ACS; it involves surgical incision of all four compartments of the lower extremity to allow for decompression (Modrall, 2023).
ACS is a surgical emergency and requires prompt recognition and treatment in order to reduce morbidity and need for amputation.
References
Hammerberg , M. (2023, March 9). Acute compartment syndrome of the extremities. UptoDate. https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities
Klingensmith, M., Chen, L. E., Glasgow, S., Goers, T., & Melby , S. (2008). The Washington Manual of Surgery (5th ed., p. 593). Lippincott Williams and Wilkins.
Modrall, J. G. (2023, January 10). Lower extremity fasciotomy techniques. UptoDate. https://www.uptodate.com/contents/lower-extremity-fasciotomy-techniques
Caring for a
patient with dementia presents many challenges. Watching a
loved one progress through the stages of dementia is also challenging. Communication is often especially difficult as people with dementia can become frustrated by the changes in their memory and the difficulties with talking and comprehending, especially in later stages of the disease.
Whether you are providing care as a professional or family caregiver, there are some strategies to help you navigate these waters and communicate more effectively – easing the stress on both the person with dementia and you. As the nurse in the family, many come to me for advice and guidance as we are caring for our own loved one with dementia. Here are some “do’s and don’ts” for communicating with patients with dementia that I’ve come across.
Tips for Communicating with Patients with Dementia
- Speak clearly.
- Remain calm; avoid raising your voice.
- Use simple words and short sentences.
- Speak at a slow pace.
- Be conversational; avoid a lot of questions.
- Be respectful.
- Position yourself close, at eye-level, and ensure adequate lighting.
- Remain open and relaxed.
- Use prompts, such as photos or objects, to help the person understand what you are talking about.
Things to Avoid when Communicating with Patients with Dementia
- Don’t complete the person’s sentences.
- Avoid saying, “Remember when…?” or asking, “Do you remember…?” Use a statement, “I remember when…” and the person may or may not join in but won’t feel embarrassed if they don’t remember.
- Avoid being frustrated with repeated questions. Take a break if necessary.
- Don’t remind them of a loved one’s death. You can try encouraging them to talk about the person if they ask.
- Avoid asking questions about them or their past. Instead, focus on the present, tell them about your day to stimulate conversation.
- Don’t ask the person if they recognize you or anyone else. As you greet them, tell them who you are and what your relationship is to them.
The best advice I found is to remember that there is a person “behind” the dementia. Use their name as often as possible and be respectful. Prioritize keeping their dignity intact. It’s not easy to see a loved one struggle with any illness, and dementia is no different.
Here’s a glance at what’s happening this month, along with some resources for your learning and professional development.
Healthcare Observances
World AIDS Day
December 1, 2023
#RockTheRibbon
National Influenza Vaccination Week (NIVW)
December 4-8, 2023
#FightFlu
Nursing Events
See all upcoming events here!
Anything missing? Please let us know in the comments!
Have a good month!
As we enter the last month of the year, I find my brain is filled with a jumble of tasks I need to accomplish, problems that need addressing, and endless worries. There is no doubt that my life is busy — I’m a mother, grandmother, and spouse, I work full-time and have multiple other side hustles. I know my life mirrors many of yours. Each of us has our own roles, responsibilities, and worries, but we all get to the point of feeling pulled in a hundred directions and overwhelmed by our inability to solve every problem. What we all need is peace.
Peace can be elusive, especially for those who live or work in an area that is unsafe or toxic, and for those with mental illness. It’s no secret that our mind and emotions are tied together, a mind and body connection. When the mind is in hyperdrive, so is our body. It can feel like we are carrying our worries in our bones. Though we can’t solve every conflict, we can work steadily to establish peace within ourselves. Finding peace allows us to recognize our ‘why’ and our purpose. It allows us set aside the weariness of the present, make better decisions, and live life more fully. So how do we find our inner stillness, our inner peace?
Let’s find our peace…
The first step to finding peace is to distinguish between what you can change and what you can’t. So often we waste valuable time and energy trying to change things over which we have no control. We can’t change people, and we may not be able to change situations; the only thing we
can change is how we react to them. This may mean recognizing the situation isn’t going to change so you need to change your circumstance. Focus on what you can change and move on from what you can’t.
The second step to finding peace is to forgive. That means forgiving others and forgiving yourself. Many of us spend a great deal of time and energy ruminating about people or situations that we felt have wronged us in some way. We’ve all made decisions in our lives that we regret or think we should have handled differently. We’ve all failed to live up to our own expectations. We can’t change the past, but we can work to do better in the present. It’s time to recognize the feelings, forgive yourself and others, and move on. When you set aside the shortcomings of the past and focus on the people currently before you, you’ll start to find peace within yourself.
The third step to finding peace is to invest in your own self. If we’re always busy helping and doing things for others, we become exhausted and have nothing left to invest in ourselves. It’s time for each of us to take time just for ourselves and do things we enjoy. Some find quietness and peace in walking through the woods or garden, others through meditation, exercise, or prayer. Find what works for you, remembering that the key concept is to clear your mind of distracting thoughts and center yourself in the world around you. Give your attention to something you might otherwise pass by without a thought.
Joy and peace are linked…
Last year I wrote about
finding your joy and this year I am adding peace. The truth is joy and peace are linked together. Joy is finding happiness; peace is finding harmony and serenity. When we are happy, our minds are at peace, our hearts are open, and we can be the best versions of ourselves.
Have you ever wondered why nurses are perceived as effective for board service? Since 2018, through a national think tank and subsequent published evidence, the discipline of nursing has collectively defined our professional identity in nursing (Godfrey, 2022). Professional Identity in Nursing (PIN) is defined as a sense of oneself, and in relation to others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse. This definition is operationalized by four key domains: values and ethics, knowledge, nurse as leader, and professional comportment (Godfrey, 2022). These domains exemplify what we do every day and how we can enable change and transformation culturally for more effective board service (Joseph et al., 2023).
1. How do values and ethics translate into the boardroom?
As we navigate issues related to human services, patient care, and health, we will be expected to act in alignment with the discipline’s core values. As a board member, ensure the consistent use of objective lenses to enable health and equity for all, regardless of location, race, income etc.
2. How does knowledge translate into the boardroom?
We are knowledge brokers, educators, and lifelong learners. Therefore, we must constantly be prepared to engage in discourse on issues related to health based on experiences, the context of nursing and other disciplines, critical reflection, and scientific discovery. As a board member, stay current with trends and lifelong learning opportunities to ensure preparedness and influence.
3. How does nurse as leader translate into the boardroom?
We are called by society to enable the health of the public. In 2010, the Institute of Medicine stated, that while the public is not used to viewing nurses as leaders, and not all nurses begin their careers with thoughts of being a leader, all nurses need to be leaders (IOM, 2011, chp 5.). As a board member, always assert leadership to ensure transformation at every board meeting.
4. How does professional comportment translate into the board room?
This domain requires using open and respectful communication demonstrated through words, actions, and presence. As a board member, always evaluate your tone, body language, and language to ensure healthy relationships.
"Understanding and embracing Professional Identity in Nursing offers new language and new knowledge for the journey—helping nurses heal, flourish and expertly care for others. Professional identity incorporates formation, or professional growth, and as such, points to the nurse as person and professional, encouraging development in the areas of values and ethics, knowledge, nurse as leader, and professional comportment. These four domains can act as “signposts” for professional development as the nurse progresses in the discipline.”
Nelda Godfrey, PhD, ACNS-BC, RN, FAAN, ANEF
Professor and Associate Dean, Innovative Partnerships and Practice, University of Kansas School of Nursing
References:
Godfrey, N. (2022). New Language for the Journey: Embracing a Professional Identity of Nursing.
Journal of Radiology Nursing, 41(1), 15–17. https://doi.org/10.1016/j.jradnu.2021.12.001
Joseph, M. L., Edmonson, C., Godfrey, N., Kuhl, L., Shaffer, F., Owens, R., Bickford, C., Cusack, C., Dickow, M., Liebig, D., O'Rourke, M., Priddy, K., & Sommer, S. (2023). A Conceptual Model for Professional Identity in Nursing: An Interdependent Perspective. Nursing science quarterly, 36(2), 143–151. https://doi.org/10.1177/08943184221150265
Posted:
12/11/2023 4:07:52 PM by
Lisa Bonsall, MSN, RN, CRNP, CCRN | with
0 comments
Categories:
Fundamental skills such as the ability to prioritize, multi-task, and delegate are essential for nurses to care for their patients safely and effectively. Over time, I learned how to prioritize and multi-task, but delegation proved to be very challenging for me for many reasons. First, I didn’t want to appear incapable of handling my assignment and I certainly didn’t want to burden anyone with my work. I needed to prove that I belonged in the intensive care unit and had to earn my position on the team. Second, I felt responsible for every aspect of my patient’s care and was afraid to relinquish control. Lastly, I didn’t necessarily feel empowered to delegate to any of the nursing assistants; they were my peers and I didn’t want to tell anyone what to do. I always felt that their tasks should be delegated by the charge nurse, or someone else in a leadership position. As I gained more experience, I grew more comfortable with delegation. However, nurses of all levels need to have a clear understanding of what they can delegate and who they can delegate to.
The
National Council of State Boards of Nursing (NCSBN) and the
American Nurses Association (ANA) developed guidelines to standardize the delegation process for boards of nursing (BONs), health care employers, community-based settings, professional associations, nurse educators, nurse leaders, staff nurses, and delegated individuals (or delegatees).
What is nursing delegation?
According to the ANA (2019), nursing delegation can be summarized by the following:
- The delegatee (person being delegated to) may complete a nursing activity, skill or procedure that is legally appropriate and allowed by the facility’s policies.
- The delegatee has had education and training needed to perform the delegated task.
- The licensed nurse who delegates the task maintains overall accountability for the patient.
- The delegatee is responsible for the delegated activity or procedure.
- Clinical reasoning, nursing judgement, and critical decision-making shouldn’t be delegated.
- Nursing responsibilities can be delegated by someone who has the authority to delegate.
- The delegated task must be within the delegator’s scope of practice under their state nurse practice act (NPA).
These guidelines apply to:
- Advanced practice registered nurses (APRNs) when delegating to registered nurses (RNs), licensed practical nurses/vocational nurses (LPN/VNs), and unlicensed assistive personnel (UAP)
- RNs when delegating to LPN/VNs, and UAP
- LPN/VNs (as permitted by their state) when delegating to UAP
It is important to note that states have different laws, NPAs, and regulations about delegation. Clinicians are responsible for knowing what is legally permitted in their state.
What are the benefits of delegation?
According to the ANA (n.d.) there are many benefits of delegation in nursing such as:
- Empowering employees
- Decreasing burnout
- Increasing commitment
- Improving job satisfaction
Five rights of nursing delegation
The process of delegation includes “five rights” to remember. These are summarized in the table below.
Five Rights |
Nursing Considerations
(ANA, 2019; NCSBN, 2019; ANA, n.d.) |
Right task |
- Delegate tasks that are legally appropriate and allowed by your facility’s policies.
|
Right circumstance |
- Assess the patient’s needs prior to delegating the task to ensure all resources and supervision are available.
- The patient’s medical condition must be stable.
- The delegatee must communicate any changes in condition to the licensed nurse who must then reassess if the delegation is still appropriate.
|
Right person |
- Ensure the delegatee has the skills and knowledge to perform the activity; identify the individual who is best able to complete the job.
|
Right direction and communication |
- Provide clear information on what the task involves, when it needs to be completed, documentation, patient limitations, and expected outcomes, and allow the delegatee to ask clarifying questions.
- The delegatee must agree to accept the delegated task and not make changes to the task without consulting the licensed nurse.
|
Right supervision and evaluation |
- Provide appropriate supervision for all tasks delegated and be ready to intervene when needed.
- Monitor the delegated activity, evaluate patient outcomes, and complete documentation when the activity is completed.
- The delegatee must communicate patient information to the licensed nurse.
- Offer advice and support, and provide feedback upon task completion.
|
Successful delegation requires effective communication, collaboration, competence and knowledge of the delegatee, and role clarity (NCSBN, 2019). Continue to work on your delegation skills and share your stories with us in the comments below.
Abdominal compartment syndrome (ACS) refers to end organ dysfunction caused by intra-abdominal hypertension (IAH) (Gestring, 2023). ACS is defined as a sustained intra-abdominal pressure greater than 20 mm Hg that is associated with new end-organ dysfunction (Gestring, 2023). The causes for ACS include traumatic injury, severe burns, post liver transplant patients, bowel obstruction, massive ascites, intra-abdominal surgery, intra or retroperitoneal hemorrhage, and edema secondary to massive volume/blood resuscitation (Klingensmith & Wise, 2019). When in intra-abdominal pressure rises, venous return is compromised causing impaired cardiac and pulmonary function, renal impairment, decreased gut perfusion and increased intracranial pressure (Gestring, 2023).
Signs and symptoms of ACS
Most patients who develop ACS are critically ill and likely unable to communicate, however those who can communicate may report weakness, abdominal pain/bloating, and dyspnea (Gestring, 2023). Physical exam findings of ACS include tensely distended abdomen, progressive oliguria, increased ventilatory requirements, hypotension, tachycardia, elevated jugular venous pressure, peripheral edema and abdominal tenderness (Gestring, 2023).
Diagnosis of ACS
ACS is diagnosed with measurement of intra-abdominal pressure, which should always be performed even if there is low evidence of suspicion based on clinical findings. Measurement of bladder pressure is the standard method of screening for IAH or ACS. Bladder pressure is measured using a foley catheter; the pressure is measured with the patient supine, at end-expiration after ensuring abdominal muscle contractions are absent (use of chemical paralytics may be necessary). Measurement of 20 mm Hg to 30 mm HG with evidence of end-organ dysfunction is diagnostic for ACS and requires prompt intervention (Klingensmith & Wise, 2019).
Management of ACS
Management of ACS includes supportive care and temporizing measures with patient positioning, pain control and sedation, chemical paralysis, nasogastric decompression, evacuation of ascites/hematoma, or bladder or bowel decompression (Klingensmith et al., 2008). Surgical decompression is typically indicated for patients with intra-abdominal pressure > 20 mm Hg. Surgical decompression can be performed at the bedside in the intensive care unit if the patient is unstable, or in the operating room. The standard technique is a decompressive laparotomy (Gestring, 2023). Most often when surgical decompression is performed for ACS, an open abdomen is maintained with temporary abdominal wall closure with delayed primary closure once edema improves (Klingensmith & Wise, 2019).
ACS is a life-threatening complication with high morbidity and mortality. Failure to recognize ACS may lead to multisystem organ failure and death.
References:
Gestring, M. (2023, June 20). Abdominal compartment syndrome in adults. UpToDate. https://www.uptodate.com/contents/abdominal-compartment-syndrome-in-adults
Klingensmith, M., & Wise, P. (2019). The Washington Manual of Surgery, 8th edition. Wolters Kluwer.
Here’s what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
National CRNA Week
January 21-27, 2024
#crnaweek
IV Nurse Day
January 25, 2024
#IVNurseDay
Healthcare Observances
Here are some of the healthcare observances being recognized in January.
Thyroid Awareness Month
#thyroidawareness
National Human Trafficking Prevention Month
#HumanTraffickingMonth
Cervical Health Awareness Month
#CervicalHealthMonth
More Observances in January
Nursing Events
See all events for 2024 here!
Anything missing? Please let us know in the comments!
Have a great month and year!
Safety is defined as a condition of being protected from or not causing danger, injury, risk or loss (Joint Commission, 2021). Safety from physical harm as well as psychological harm should be ensured in all workplaces. When we are at our worst, stricken by malady or injury, it is healthcare workers that we turn to for healing. But these same healthcare workers are being assaulted in their own workplaces. Though healthcare workers often support each other as they work under difficult circumstances, they are also impacted by
lateral violence from their colleagues (USBLS, 2018). Incidents of physical and psychological harm to healthcare workers are reported in the news on a weekly basis. The stress caused by workplace violence is also contributing to the crisis of nurse suicide. Violence against healthcare workers needs to stop. What can be done to promote a culture of safety and well-being everywhere healthcare professionals work?
Let’s address the basic need of psychological safety.
Lateral violence, also known as “bullying” or “incivility” in nursing, is still present in our profession (Joint Commission, 2021). Between 40% and 70% of nurses experience lateral violence in their career and 27% of surveyed nurses report they experienced it in the past six months (Goh, Hosier, & Zhong, 2022).
Psychological safety refers to feeling safe to speak up, take risks, and make mistakes without fear of negative consequences (Bush, 2018). Psychological safety is not a luxury; it is imperative to a culture that works to improve performance to mitigate patient harm. All healthcare teams make mistakes; however, many teams are not forthcoming about these errors due to fear of retribution. Those who work in an environment which has a culture of psychological safety are more willing to speak up. Organizations that support and encourage all members of the team to speak up about the need for practice and process change tend to have a culture that promotes well-being and safety (Bush, 2018).
We need to protect healthcare workers from physical harm.
According to the World Health Organization, up to 38% of nurses suffer from healthcare violence during their career and healthcare workers in general have a six times greater risk of workplace violence compared to other industries (WHO, 2022). OSHA recently reported that one in four nurses are assaulted at work (OSHA, 2023). These statistics are not surprising; areas like the emergency department, psychiatric units, long-term care facilities, and waiting areas see the most violence because they are high stress areas (Lim et al., 2022). There is an increased risk of violence towards healthcare professionals when there is a stressful situation which involves patients, family members, or other visitors, long wait times to see a healthcare professional, overcrowding in treatment and waiting areas, or communication issues due to cultural and language differences (Lim et al., 2022). For the staff, the risk of violence increases when there is an inadequate number of experienced staff that are adequately trained to handle escalating situations (Lim et al., 2022).
Let’s keep healthcare workers safe.
Every healthcare worker deserves to be safe at work. Healthcare organizations are supporting this mission by investing in ways to provide healthcare workers physical and psychological safety. Having an adequate number of experienced and properly trained staff is paramount to keeping healthcare professionals safe. The use of technology and tools can help to ensure safe staffing across the entire institution and flex staffing up when needed. Providing more security officers and training them in de-escalation techniques is important for staff safety and reduces the risk of injury to the person or persons causing the situation. Many healthcare organizations are installing metal detectors to help protect their employees and patients from weapons. Despite these precautions, some violent acts will still occur. In these cases, affected healthcare workers should work with their supervisor to pursue legal remedies.
Physical and psychological safety in healthcare can only work if the culture supports it and leadership is visible within the healthcare organization, is open to conversations, and has a zero-tolerance policy for bullying, physical violence, and verbal threats and harassment. Anyone who enters the door must act from a place of mutual respect.
It’s time to keep healthcare workers safe by ending violence where we practice and promote psychological and physical safety for all.
References:
Bush, M. C. (2018). A Great Place to Work for All. Oakland, CA: Berrett-Koehler Publishers.
Goh, H. S., Hosier, S., & Zhang, H. (2022). Prevalence, Antecedents, and Consequences of Workplace Bullying among Nurses-A Summary of Reviews. International journal of environmental research and public health, 19(14), 8256. https://doi.org/10.3390/ijerph19148256
Lim, M. C., Jeffree, M. S., Saupin, S. S., Giloi, N., & Lukman, K. A. (2022). Workplace violence in healthcare settings: The risk factors, implications and collaborative preventive measures. Annals of medicine and surgery (2012), 78, 103727. https://doi.org/10.1016/j.amsu.2022.103727
Occupational Safety and Health Administration. (2023). Workplace violence. U.S. Department of Labor. https://www.osha.gov/healthcare/workplace-violence/
The Joint Commission. (2021, June). Quick Safety 24: Bullying has no place in healthcare. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-24-bullying-has-no-place-in-health-care/bullying-has-no-place-in-health-care/
U.S. Bureau of Labor Statistics (USBLS), (2018). Workplace Violence In Healthcare. 2018. https://www.bls.gov/iif/factsheets/workplace-violence-healthcare-2018-chart2-data.htm
The COVID-19 Public Health Emergency expired in May of 2023. That meant that universal masking in healthcare facilities was not tied to guidance from the Centers for Disease Control and Prevention (CDC) but would be determined by risk-based assessments of health care systems, stakeholder input and local metrics (AHA, 2023).
Recently, here in the northeast US, spikes in respiratory illnesses including COVID-19, influenza, and respiratory syncytial virus (RSV), have prompted the reinstitution of masking requirements for many healthcare settings. I decided to take a deeper look at what the evidence shows and recommendations on masking to prevent transmission of these respiratory illnesses, outside of a pandemic or public health emergency.
The research on masking
There is a lack of clinical trials related to masking, however, it is argued that masking during clinical interactions between patients and healthcare workers should be considered a patient safety measure. Laboratory studies have demonstrated that surgical masks and respirators limit the spread of aerosols and droplets from individuals infected with influenza, coronaviruses, and other respiratory viruses (Leung et al., 2020) and substantially reduce the amount of virus expelled when coughing or talking (Adenaiye et al., 2022).
Presenteeism
One thing to consider is
presenteeism, which is when healthcare workers work while ill. Reasons for this can include an unwillingness to place burdens on colleagues, feeling that some respiratory infections may be trivial, a fear of punishment for missing work, a moral obligation to care for patients, or a lack of paid sick leave (Palmore & Henderson, 2023).
Researchers at the NIH Clinical Center studied presenteeism during the pandemic via contact tracing interviews and found that among staff who chose an asymptomatic rather than a symptomatic testing pathway and tested positive, more than 50% acknowledged having had some symptoms of COVID-19 at the time of testing (Palmore & Henderson, 2023).
Guidance from the World Health Organization (WHO)
The WHO makes the following recommendations (WHO, 2023):
- If COVID-19 is widely circulating and impacting the health system, visitors, healthcare workers, and caregivers should wear a well-fitting surgical mask in all common areas and when caring for non-COVID-19 patients.
- Those caring for COVID-19 patients should wear a respirator or a surgical mask.
What’s happening in your area?
The CDC has a
handy tool to view the transmission of respiratory illness in your area. Simply input your state and county to view the illness activity and trends of COVID-19, influenza, and RSV based on healthcare visits and visits to emergency departments.
References:
Adenaiye, O. O., Lai, J., Bueno de Mesquita, P. J., Hong, F., Youssefi, S., German, J., Tai, S. H. S., Albert, B., Schanz, M., Weston, S., Hang, J., Fung, C., Chung, H. K., Coleman, K. K., Sapoval, N., Treangen, T., Berry, I. M., Mullins, K., Frieman, M., Ma, T., … Milton, D. K. (2022). Infectious Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Exhaled Aerosols and Efficacy of Masks During Early Mild Infection. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 75(1), e241–e248. https://doi.org/10.1093/cid/ciab797
American Hospital Association (AHA). (2023, May 10). CDC updates masking guidelines for health care facilities. https://www.aha.org/news/headline/2023-05-10-cdc-updates-masking-guidelines-health-care-facilities
Leung, N. H. L., Chu, D. K. W., Shiu, E. Y. C., Chan, K. H., McDevitt, J. J., Hau, B. J. P., Yen, H. L., Li, Y., Ip, D. K. M., Peiris, J. S. M., Seto, W. H., Leung, G. M., Milton, D. K., & Cowling, B. J. (2020). Respiratory virus shedding in exhaled breath and efficacy of face masks. Nature medicine, 26(5), 676–680. https://doi.org/10.1038/s41591-020-0843-2
Palmore, T. N., & Henderson, D. K. (2023). For Patient Safety, It Is Not Time to Take Off Masks in Health Care Settings. Annals of internal medicine, 176(6), 862–863. https://doi.org/10.7326/M23-1190
World Health Organization (WHO). (2023, October 10). Coronavirus disease (COVID-19): Masks. https://www.who.int/news-room/questions-and-answers/item/coronavirus-disease-covid-19-masks
Late last year, the Top 10 Patient Safety Concerns 2023 Special Report was released. This is an annual report from Emergency Care Research Institute (ECRI) and the Institute for Safe Medication Practices (ISMP). The goal of this report is to recognize “serious issues that threaten the safety of patients and healthcare workers when processes and systems are not aligned” (ECRI, 2023).
2023 Patient Safety Concerns
In the report, discover background and evidence which demonstrate the critical nature of these top concerns identified in 2023:
- The pediatric mental health crisis
- Physical and verbal violence against healthcare staff
- Clinician needs in times of uncertainty surrounding maternal-fetal medicine
- Impact on clinicians expected to work outside their scope of practice and competencies
- Delayed identification and treatment of sepsis
- Consequences of poor care coordination for patients with complex medical conditions
- Risks of not looking beyond the “five rights” to achieve medication safety
- Medication errors resulting from inaccurate patient medication lists
- Accidental administration of neuromuscular blocking agents
- Preventable harm due to omitted care or treatment
How can nurses make an impact?
The action recommendations provided by ECRI and ISMP are organized by four pillars: culture, leadership, and governance; patient and family engagement; workforce safety; and learning system. As the largest group of healthcare providers, nurses are instrumental in improving patient safety and there are opportunities within each pillar for nurses to make a difference. From screening, referrals, and education to communication, competence, and advocacy, we are positioned to tackle these concerns and improve care.
While we make a difference each and every day, we also need to make sure our voices are heard to impact change within our organizations and throughout health care. Consider joining a committee or board committed to patient and workplace safety, engage patients and caregivers as partners, support efforts and research to improve quality of care and safety, and advocate for total systems safety.
Here’s what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
PeriAnesthesia Nurse Awareness Week
February 5-11, 2024
#aspan #PANAW
Ambulatory Care Nursing Week
February 5-9, 2024
#ambcarenurse24
Critical Care Transport Nurses Day
February 18, 2024
Healthcare Observances
Here are some of the healthcare observances being recognized in February.
American Heart Month
National Wear Red Day
February 2, 2024
#heartmonth, #ourhearts
World Cancer Day
February 4, 2024
#WorldCancerDay #CloseTheCareGap
National Black HIV/AIDS Awareness Day
February 7, 2024
#NBHAAD #StopHIVTogether
More Observances in January
Nursing Events
See all events for 2024 here!
Anything missing? Please let us know in the comments!
Have a good month!
Someone recently asked me why I still practice nursing and whether I was tired of it. I immediately answered without hesitation, “Because I love it.” My response was genuine – I really do love this profession, even with all the challenges around safe work environments, adequate staffing, and feeling valued. My nursing journey has been a long one. My career has taken me from staff nurse and preceptor to education in staff development and adjunct faculty in graduate and undergraduate programs, and to nurse practitioner. While I understand what it is to love my family, what does it mean to really love a profession? Am I feeling love for the nursing profession or is it something else like duty to the profession? I spent a lot of money earning my degrees – am I feeling obligated to practice as long as I can?
When you look in the Oxford Dictionary, the definition of love is an intense feeling of deep affection. That didn’t seem adequate to me, so I looked further. The Urban Dictionary defines love as the act of caring and giving to someone else; having someone’s best interest and wellbeing as a priority in your life; to truly love is a selfless act. The Urban Dictionary definition seems more in line with what I feel about the profession because the profession is one that is grounded in caring for others, looking out for a person’s best interest, and giving selflessly while using evidence from science and the art of humanity. We use the art of being present with patients during the best and worst times of their lives, we are giving of our time, and we use the simple gesture of touch to let the patient know they are not alone.
I believe I love the nursing profession, but the thought of duty returns to mind. Duty is defined as something one is expected or required to do by moral or legal obligation. No one is forcing me to stay in any of my nursing roles, yet I feel I need to. I’m the one who is making myself morally obligated to stay in the profession. The bigger question is, “Why?” I’m sure many of you have asked yourself the same question.
I feel an obligation to give back to the profession because it has given me so much. When I was a student and then as a new graduate nurse, I was lucky enough to have faculty, preceptors, professional development practitioners, and managers who invested their time in my success as a nurse. Throughout my entire career, I’ve had incredible coaches and mentors who helped move me along a career path by harnessing my passion for the profession into something constructive. That’s why I have this sense of obligation for the profession. Because of what others did for me, I want to give back to others.
As I look to all the new nurses coming up through the ranks and to those who’ve been here for years in one capacity or another, I say, “Thank you!” Thank you for teaching me to love our profession and to give back to those who will be filling our shoes in the future. We all have days where we question whether we want to stay in the profession or walk away. I encourage you to stop and reflect. Think about what it really means to love a profession. Enduring love is a choice – we must choose to stay and make a difference!
A google search for “nurse suicide” results in a list of headlines of heartbreaking stories… a 28-year-old who had written a letter five months prior to her death “comparing the healthcare industry to an abusive partner” (Becker’s Hospital Review, 2023); two nurse deaths by suicide “rocked the Bay Area nursing community in early 2022” (Wells, 2023); a critical care travel nurse who left during a shift to get something from his car and never returned (evidence points to suicide) (NPR, 2022); and the list goes on.
The research on suicide among nurses
The research is clear that nurses are at risk:
- Between 2007 and 2018, nurses were 18% more likely to die from suicide than the general population; among female nurses, this risk was almost twice the risk of the general population, and 70% more likely than female physicians (Davis et al., 2021).
- From 2017 to 2018, an estimated 729 American nurses committed suicide, the highest reported number on record (Davis et al., 2021).
We can’t ignore this data and we must pay attention to the fact that these findings were reported
before the COVID-19 pandemic. And even in 2017,
survey results published in the American Journal of Nursing, found burnout was strongly associated with suicidal ideation among U.S. nurses. In addition, nurses were more likely than other U.S. workers to contemplate suicide and less likely to seek help from a professional (Kelsey et al., 2021).
Protecting the well-being of clinicians
Dzau et al. (2020) identified five high-priority actions during and after the COVID-19 pandemic at organizational and national levels: integrating chief wellness officers or clinician well-being programs during the crisis, ensuring psychological safety of clinicians through anonymous reporting mechanisms, sustaining and supplementing existing well-being programs, allocating federal funding to care for clinicians who experience physical and mental health effects, and allocating federal funding to set up a national epidemiologic tracking program to measure clinician well-being and report on the outcomes of interventions.
How can nurses improve the well-being of fellow nurses?
As nurses are the largest group in the health care workforce, we must improve our own well-being and that of our colleagues to ensure the overall health of the population. What can we do?
- Recognize risk factors, such as relationship stress, difficulty on the job, burnout, feelings of inadequacy, bullying, medical errors or adverse events, lawsuits, or depression (Lange, 2023).
- Be alert for warning signs of suicide, such as talking about wanting to die, guilt or shame, or being a burden; or feeling empty, hopeless, sad, anxious, full of rage, or unbearable emotional or physical pain (NIMH, n.d.).
- Access and/or share available resources and programs, such as 988 Suicide & Crisis Lifeline, NAMI Frontline Wellness, Therapy Aid Coalition, and ANA’s Well-Being Initiative.
As individuals, let’s work toward normalizing conversations about mental health and wellness. We often tell patients, “It’s ok to not be ok” and ask, “Are you feeling like ending your life?” We should be having these conversations with one another as well. By showing the same compassion we show patients to each other, we can help overcome the stigma associated with mental health treatment.
References:
Chatterjee, R. (2022, March 31). A nurse's death raises the alarm about the profession's mental health crisis. NPR. https://www.npr.org/sections/health-shots/2022/03/31/1088672446/a-nurses-death-raises-the-alarm-about-the-professions-mental-health-crisis
Davis, M. A., Cher, B. A. Y., Friese, C. R., & Bynum, J. P. W. (2021). Association of US Nurse and Physician Occupation With Risk of Suicide. JAMA psychiatry, 78(6), 1–8. https://doi.org/10.1001/jamapsychiatry.2021.0154
Dzau, V. J., Kirch, D., & Nasca, T. (2020). Preventing a Parallel Pandemic - A National Strategy to Protect Clinicians' Well-Being. The New England journal of medicine, 383(6), 513–515. https://doi.org/10.1056/NEJMp2011027
Kayser, A. (2023, November 14). ER nurse who died by suicide addressed letter to healthcare system. Becker’s Hospital Review. https://www.beckershospitalreview.com/workforce/er-nurse-who-died-by-suicide-addressed-letter-to-healthcare-system.html
Kelsey, E. A., West, C. P., Cipriano, P. F., Peterson, C., Satele, D., Shanafelt, T., & Dyrbye, L. N. (2021). Original Research: Suicidal Ideation and Attitudes Toward Help Seeking in U.S. Nurses Relative to the General Working Population. The American journal of nursing, 121(11), 24–36. https://doi.org/10.1097/01.NAJ.0000798056.73563.fa
Lee, K. A., & Friese, C. R. (2021). Deaths by Suicide Among Nurses: A Rapid Response Call. Journal of psychosocial nursing and mental health services, 59(8), 3–4. https://doi.org/10.3928/02793695-20210625-01
National Institute of Mental Health (n.d.). Warning Signs of Suicide. Accessed February 7, 2024: https://www.nimh.nih.gov/health/publications/warning-signs-of-suicide
Olfson, M., Cosgrove, C. M., Wall, M. M., & Blanco, C. (2023). Suicide Risks of Health Care Workers in the US. JAMA, 330(12), 1161–1166. https://doi.org/10.1001/jama.2023.15787
Shah, M., Roggenkamp, M., Ferrer, L., Burger, V., & Brassil, K. J. (2021). Mental Health and COVID-19: The Psychological Implications of a Pandemic for Nurses. Clinical journal of oncology nursing, 25(1), 69–75. https://doi.org/10.1188/21.CJON.69-75
Wells, S. (2023, August 25). Suicide Among Nurses: We have to talk about it. American Association of Critical Care Nurses. https://www.aacn.org/blog/suicide-among-nurses-we-have-to-talk-about-it
Here’s what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Health Workforce Well-Being Day
March 18, 2024
Theme: A Healthy Workforce Means a Healthy You
Certified Nurses Day
March 19, 2024
GI Nurses & Associates Week
March 17-23, 2024
#Proud2BGI
Healthcare Observances
Here are some of the healthcare observances being recognized in March.
National Kidney Month
World Kidney Day
March 14, 2024
#KidneyMonth, #ShowYourKidneys
National Nutrition Month
Theme: Beyond the Table
#NationalNutritionMonth
National Colorectal Cancer Awareness Month
#ColorectalCancerAwarenessMonth
Brain Injury Awareness Month
#MyBrainInjuryJourney
Patient Safety Awareness Week
March 10-16, 2024
Multiple Sclerosis Awareness Week
March 10-16, 2024
More Observances in March
Nursing Events
See all events for 2024 here!
Anything missing? Please let us know in the comments!
Have a good month!
As I’ve grown in my years of experience, I can clearly see the difference that certification makes in my practice. I am a more knowledgeable nurse and nurse practitioner because of the requirements to maintain my certification. For me, this lifelong learning involves attending professional conferences, taking journal continuing professional development courses, and adding to the professional literature through presenting at conferences and writing articles for peer reviewed publications. Without a doubt, experience is important; however, specialty certification demonstrates dedication to the profession and to patients.
Why should nurses become certified?
Healthcare is evolving quickly, and nurses must invest in lifelong learning to ensure they remain knowledgeable and are delivering the latest, evidence-based care. According to the American Nurses Credentialing Center, certification in a nursing specialty allows nurses to demonstrate their specialty expertise and validate their knowledge to employers and patients.
If you feel unsure whether certification is something you should consider, don’t hesitate. Nurses provide the highest quality care to their patients and the
correlation between certified nurses and patient outcomes is clear, including lower percentages of falls, medical errors, and healthcare associated infections (Boyle, 2022; Halm, 2021). Certification also enhances nurses’ professional growth and promotes satisfaction, as well as creating stability in an organization by improving retention (Edwin, 2023).
How can a nurse become certified?
To become certified, passing a national standardized specialty nursing exam is required. There are many
nursing specialty certification boards. Reviewing what certifications are available and the necessary requirements is a good place to start your certification journey. Create a study plan which includes
certification review resources mapped to the exam blueprint, as well as plenty of practice questions. Start with a comprehensive test to see where your knowledge gaps are and then prioritize those areas as you study. Taking – and retaking – practice tests can help solidify your content knowledge, as well as application of what you know.
Why does certification matter?
Patients expect to receive the best quality care when they come to a healthcare organization. Competency is important, but the value of specialized knowledge, skills, and experience in a specialty cannot be emphasized enough. In addition, healthcare organizations are required to measure patient outcomes to receive reimbursement from Centers for Medicare and Medicaid and other third-party payers. This is where certification comes in – it matters to patients, to colleagues, and to the institutions where we work.
References:
Coelho P. (2020). Relationship Between Nurse Certification and Clinical Patient Outcomes: A Systematic Literature Review. Journal of nursing care quality, 35(1), E1–E5. https://doi.org/10.1097/NCQ.0000000000000397
Edwin H. S. (2023). Strategies to Increase Nursing Certification: A Progressive Care Certification for Nurses-Pathway for Success. Journal for nurses in professional development, 39(5), E112–E118. https://doi.org/10.1097/NND.0000000000000874
Halm M. A. (2021). Specialty Certification: A Path To Improving Outcomes. American journal of critical care: an official publication, American Association of Critical-Care Nurses, 30(2), 156–160. https://doi.org/10.4037/ajcc2021569
Measles is in the news again this year! According to the Centers for Disease Control and Prevention (CDC), during the first 2 months of 2024, there were already 41 reported cases in the United States (US) in 16 different jurisdictions. In comparison, there were a total of 58 cases in 20 jurisdictions in 2023 (CDC, 2024). As nurses, we need to stay well-informed of public health trends and be knowledgeable of how we can protect ourselves and our population from the spread of dangerous communicable diseases. Understanding measles transmission, clinical presentation, prevention strategies, and current trends in the US are essential elements to ensure we can actively protect our patients.
Measles is a highly contagious, acute febrile rash illness. Infection is spread by direct contact with infectious droplets or by means of airborne spread when an infected person breaths, coughs, or sneezes in close vicinity to a susceptible individual. The virus can remain infectious in the air for up to two hours, contributing to its high transmissibility. There is a 90% secondary attack rate among immunocompromised and unvaccinated populations (Sanyaolu et al., 2019), meaning if a contagious individual is in a room, 90% of those susceptible in close contact will contract the virus.
Measles is vaccine-preventable making it a unique public health threat. The measles vaccine is highly efficacious. Full vaccination in accordance with CDC recommendations will prevent measles in 97% of individuals (McClean et al., 2013). Measles vaccination became available in the 1960s. Prior to it’s wide-spread availability, the US had seasonal outbreaks of measles and immunity was conferred after active infection. Measles has been well controlled in the US and was considered eliminated in 2000 but since that time, there have been sporadic outbreaks, the most significant of which was in New York during 2018-2019.
This newsworthy outbreak began on September 30, 2018, when an unvaccinated child acquired measles infection internationally and returned home to their close-knit Orthodox Jewish community in Brooklyn, New York (NY). This patient was linked to 702 cases of measles over the next 9.5 months. There was a total of 375 cases in the US in 2018 which included other internationally imported cases. The second major incident contributing to the 2018-2019 measles outbreak was a foreign visitor to NY state on October 1, 2018. This patient was linked to 412 cases in NY state over a 10.5-month period (Patel et al., 2019). These late 2018 outbreaks partially contributed to a total of 1249 measles cases in 2019, representing the most US cases reported in a single year in the US since 1992. 2019 saw a total of 22 outbreaks in 17 states but cases were reported in 31 states total. Overall, 89% of cases in the 2018-2019 outbreak were in under immunized close-knit communities (Patel et al., 2019).
Let’s fast forward to recent history. Once 2018-2019 was under control, 2020 only saw 13 cases, there were 49 cases in 2021, and 121 cases in 2022 with 85 cases in central Ohio between October and December. Ninety-four percent of the 2022 Ohio cases were in unvaccinated children. As noted above, in the first 2 months of 2024, we have already seen 41 cases!
Undervaccination, lack of vaccination, and international travel remain the largest threats to widespread measles in the US. Despite lessons learned in the 2018-2019 outbreak, international travel and vaccination remains at the crux of measles outbreak which is the case in the 2023-2024 reported cases. As cases across the world increase, the risk of international travel bringing disease back to the US is a threat. Measles cases are increasing internationally as well. The CDC and World Health Organization found an 18% increase in measles cases and a 43% increase in measles related deaths worldwide in 2022 compared to 2021. Furthermore, vaccination rates are below the 95% rate necessary for population level protection or herd immunity. The CDC’s Morbidity and Mortality Weekly Report published in January 2023 showed that measles vaccination rates among kindergarteners for the 2021 to 2022 school year was only 93% (Minta et al., 2023). The COVID-19 pandemic has contributed to under vaccination. Between 2020 and 2022, there were 61 million doses of measles vaccine delayed or missed (Minta et al., 2023).
While many factors are out of our control as healthcare providers, it is important that we are aware of these trends, able to recognize early signs and symptoms of measles, and cognizant of the necessary steps to take for those with suspected or confirmed measles infection.
Clinical Presentation of Measles (Maaks et al., 2020)
The characteristic clinical syndrome associated with measles infection is an acute febrile, respiratory illness that has three distinct phases.
1. Incubation Period: once an individual is exposed to measles there is a 10-to-14-day asymptomatic period.
2. Prodromal Period: 2-4 days before the onset of rash, typically 4 to 5 days of illness
Clinical Manifestations:
- Fever: develops during this period and typically lasts the duration of the rash
- “The 3 Cs”: cough, coryza (nasal congestion), and conjunctivitis
- Koplik spots: characteristic small, irregular, bluish white granules on an erythematous base in oral mucosa/buccal mucosa; pathognomonic of measles
- Extreme malaise common
3. Rash Stage: Day 0
- Fever may increase; often up to 105℉
- Rash onset: maculopapular (small raised or flat red bumps, may enlarge and coalesce) start on face, hairline, behind ears and over 24-hour period, spreads downward to neck, trunk, and extremities
- As legs become more involved, face begins to clear.
- Expect respiratory symptoms to peak in severity on day 3 of rash.
- Rash typically begins to fade and may develop a residual desquamating light-colored pigmentation for up to 1 week.
- Immunocompromised patients may not develop rash.
- Transmissibility: measles infection is considered contagious 4 days before and 4 days after the onset of rash
Diagnosis of Measles
- Diagnostic criteria: fever, rash, one of the 3 C’s
- Laboratory diagnosis:
- Serum IgM: may be positive 1-2 days after rash, and may remain positive for 6-8 weeks following clinical syndrome
- risk false positives if low clinical suspicion
- Oral/nasal swab: real time (rt)- PCR to detect measles RNA
- higher sensitivity and specificity comparted to serum IgM
- All confirmed cases must be reported to the state within 24 hours of diagnosis.
Treatment of Measles
- Supportive management
- Antipyretics, rest, hydration, air humidification
- Post-exposure prophylaxis to confer protection or reduce disease severity.
- In vaccine eligible individuals, administer measles vaccine within 72 hours; 1st line for infants between 6 and 12 months.
- Consider immunoglobulin in vaccine ineligible patients (infants younger than 12 months, pregnant women, immunocompromised individuals).
- Vitamin A, once daily for 2 days
- Under 6 months – 50,000 IUs
- 6 to 11 months – 100,000 IUs
- 12 months or older – 200,000 IUs
- Treat secondary bacterial infections
- Isolation – 4 days after rash onset, longer for certain immunological conditions
- Utilize standard and airborne isolation precautions in the healthcare settings.
Complications of Measles
- 90% of suspectable household contacts will develop illness.
- Bacterial superinfection and viral complications manifested as diarrhea, acute otitis media, laryngitis, mastoiditis, pneumonia
- Encephalitis
- Subacute sclerosing panencephalitis
Prevention of Measles
- Measles, mumps, rubella (MMR) vaccine (McClean et al., 2013)
- Dose # 1 between 12 to 15 months
- Dose #2 between 4 and 6 years of age (at least 28 days after 1st dose)
Our responsibility as nurses is to recognize suspected measles, isolate those with suspected or confirmed infection to prevent the spread of disease, be aware of high-risk travel, and promote immunization in the communities in which we work. Measles is preventable; keeping our patients well informed and having non-judgmental conversations about vaccine hesitancies can improve vaccination rates and reduce the impact of measles in the US.
References:
CDC (2024, March 4). Measles cases and outbreaks. National Center for Immunization and Respiratory Disease, Division of Viral Illness. https://www.cdc.gov/measles/cases-outbreaks.html
Maaks, D.L. G., Starr, N., & Gaylord, N. (2020). Burns' Pediatric Primary Care (7th ed.). Elsevier Health Sciences (US). https://pageburstls.elsevier.com/books/9780323581967
McLean, H. Q., Fiebelkorn, A. P., Temte, J. L., Wallace, G. S., & Centers for Disease Control and Prevention (2013). Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports, 62(RR-04), 1–34.
Minta, A. A., Ferrari, M., Antoni, S., Portnoy, A., Sbarra, A., Lambert, B., Hatcher, C., Hsu, C. H., Ho, L. L., Steulet, C., Gacic-Dobo, M., Rota, P. A., Mulders, M. N., Bose, A. S., Caro, W. P., O'Connor, P., & Crowcroft, N. S. (2023). Progress toward measles elimination - Worldwide, 2000-2022. MMWR, Morbidity and mortality weekly report, 72(46), 1262–1268. https://doi.org/10.15585/mmwr.mm7246a3
Patel, M., Lee, A. D., Clemmons, N. S., Redd, S. B., Poser, S., Blog, D., Zucker, J. R., Leung, J., Link-Gelles, R., Pham, H., Arciuolo, R. J., Rausch-Phung, E., Bankamp, B., Rota, P. A., Weinbaum, C. M., & Gastañaduy, P. A. (2019). National update on measles cases and outbreaks - United States, January 1-October 1, 2019. MMWR. Morbidity and mortality weekly report, 68(40), 893–896. https://doi.org/10.15585/mmwr.mm6840e2
Porter, A. & Goldfarb, J. (2019). Measles: A dangerous vaccine-preventable disease returns. Cleveland Clinical Journal of Medicine 86(6), 393-398. https://doi.org/10.3949/ccjm.86a.19065
Sanyaolu, A., Okorie, C., Marinkovic, A., Ayodele, O., Abbasi, A. F., Prakash, S., Gosse, J., Younis, S., Mangat, J., & Chan, H. (2019). Measles outbreak in unvaccinated and partially vaccinated children and adults in the United States and Canada (2018-2019): A Narrative review of cases. Inquiry: a journal of medical care organization, provision and financing, 56, 46958019894098. https://doi.org/10.1177/0046958019894098
Strebel, P. M., & Orenstein, W. A. (2019). Measles. The New England journal of medicine, 381(4), 349–357. https://doi.org/10.1056/NEJMcp1905181
Suran M. (2024). Measles Cases Are Spreading in the US-Here's What to Know. JAMA, 10.1001/jama.2024.1949. Advance online publication. https://doi.org/10.1001/jama.2024.1949
The COVID-19 pandemic, which emerged in late 2019, wreaked havoc globally not just on healthcare systems, but also disrupting daily life and altering societal norms. The highly contagious and deadly virus spread rapidly and claimed the lives of approximately 1.5 million Americans (Centers for Disease Control and Prevention [CDC], 2024). Various measures were implemented such as lockdowns, social distancing, masking mandates, and travel restrictions in order to contain the spread of the virus. Despite the most unprecedented challenges that the COVID-19 pandemic presented globally, it also sparked remarkable scientific advancement, collaboration, and innovation with the acceleration of the development of a vaccine. Due to the effectiveness of protective tools such as the COVID-19 vaccine, and the high degree of population immunity, there are now fewer hospitalizations and deaths from COVID-19 (CDC, 2024). According to the CDC, weekly hospital admissions have decreased by 75% and deaths have decreased by more than 90% when compared to January 2022 (CDC, 2024).
Updated isolation guidelines released
On March 1, 2024, the CDC released updated isolation guidelines for COVID-19. Although COVID-19 remains an important public health threat, it no longer is the emergency that it once was. Its health impacts increasingly resemble those of other respiratory viral illness such as influenza and respiratory syncytial virus (RSV), prompting the CDC to issue Respiratory Virus Guidance, rather than virus specific guidance. This brings a unified approach to addressing the risk associated with common respiratory viruses that have similar routes of transmission and also similar preventions strategies such as COVID-19, influenza, and RSV (CDC, 2024).
Active recommendations from the CDC on core prevention steps include staying up to date with vaccinations, practicing good hygiene (covering coughs and sneezes, frequent handwashing, and cleaning frequently touched surfaces), and taking steps for cleaner air. When an individual becomes ill with a respiratory virus, the CDC recommends that they stay at home and away from others to curb the spread of disease (CDC, 2024). For those with COVID-19 or influenza, treatment options may be available and can lessen the symptoms and decrease the risk of severe illness. The new recommendations state that one may return to normal activities, without isolation, 24 hours after improvement of symptoms or cessation of fever without the use of fever reducing medications. Once normal activities are resumed, it is encouraged to take additional steps to prevent the spread of disease such as enhancing good hygiene practices, wearing a well-fitting mask, and keeping distance from others (CDC, 2024).
Impact of the updated guidance
Simplification of the respiratory virus recommendations helps to provide a unified approach and make guidelines easier to follow. “The bottom line is that when people follow these actionable recommendations to avoid getting sick, and to protect themselves and others if they do get sick, it will help limit the spread of respiratory viruses, and that will mean fewer people who experience severe illness” (CDC, 2024).
The updated guidance also outlines specific recommendations for those at risk for severe illness such as those who are immunocompromised, those with disabilities, pregnant persons, children, and older adults. The updated guidance is for community settings only and there have been no changes made to the respiratory virus guidance and isolation for health care settings, according to the CDC.
March 18 has been established as
Health Workforce Well-Being (HWWB) Day to “bring together national and institutional leaders, policymakers, patients and communities, and health workers of all professions to acknowledge our collective progress and pledge to continue advancing health worker well-being” (National Academy of Medicine [NAM], 2024). System-wide changes are critical in this effort to sustain our health system, ensure quality care, and improve outcomes. The NAM collaborative along with founding partners is recognizing HWWB Day as not just a day of awareness, but also a day for action. Find a schedule of events, toolkit, and ways to participate in HWWB Day
here.
The importance of focusing on health workforce well-being can’t be overstated. Each of us plays a role in prioritizing the well-being of ourselves, our colleagues, and the healthcare workforce.
Here’s what’s happening this month, along with some resources for your learning and professional development.
Nursing Recognition Dates
Occupational Health Nurses Week
4/7-4/13/2024
#OHNWeek
Wound, Ostomy, and Continence (WOC) Nurse Week
4/14-4/20/2024
#WOCNurseWeek2024
Transplant Nurses Week
4/22-4/29/2024
#transplantnursesweek
Healthcare Observances
Alcohol Awareness Month
Irritable Bowel Syndrome Awareness Month
#IBSAwarenessMonth
STI Awareness Month
World Immunization Week 4/24-4/30/2024
National Infant Immunization Week 4/22-4/29/24
More Observances in April
Nursing Events
See all events for 2024 here!
Anything missing? Please let us know in the comments!
Have a good month!
If you’re like me, you look for good news about the nursing profession. We finally received some good news from researchers tracking the registered nurse (RN) workforce! In a recent study by Auerbach et al. (2024), we are finally seeing an improvement in RN numbers and nurses under the age of 35 are leading that growth. In addition, nurses between the age of 35 to 49 years are 38% of practicing nurses today and will account for nearly half of the workforce by 2035 (Auerbach et al., 2024). This is welcome news for our workforce; however, the research revealed a shift away from nurses practicing in hospitals to ambulatory and community settings.
It should come as no surprise to anyone that nurses are leaving the bedside in acute care. Since the pandemic, we’ve known the main issues in acute care are providing adequate numbers of qualified and competent nurse at the bedside, recruitment, retention, and supporting the emotional health and well-being of staff (AONL, 2023). Nurses move to ambulatory care and community settings looking for flexibility in their schedules, the ability to develop better relationships with their patients, and in some cases, working remotely in telehealth.
It’s time to adopt initiatives that keep nurses at the bedside.
How can we ensure adequate staffing of competent nurses in acute care? Healthcare systems must listen to nurses and look at strategies to meet their needs.
- Adopt flexible staffing and scheduling that includes nurse competency and patient severity of illness/acuity. During the pandemic, acute care hospitals were very flexible but have regressed post-pandemic. Nurses today want flexibility in their schedules and hours to achieve work/life balance. While 12-hour shifts work for some, they don’t work for everyone. Healthcare systems need to adopt technology to assist them with scheduling and staffing. Nurse managers want scheduling and staffing to incorporate nurse competency and patient acuity into the equation. Patients are sicker than ever before. It’s imperative the hospital is staffed with the right nurse for the right patient; nurse competency and patient acuity matter when it comes to improving patient outcomes.
- Invest in nurse career support, recruitment, and retention. It’s not enough to bring nurses in the door; you need to retain them once they arrive. Institute career opportunity support so nurses feel that they have room to grow into more fulfilling positions, whether it’s laterally or up the career ladder. Nurse turnover and burnout decline if staffing is adequate, and the nurses feel supported in a safe work environment. Providing clinical decision support tools and life-long learning resources demonstrates an investment in nursing clinical practice.
- Offer flexible roles to keep more experienced nurses involved in patient care. Virtual nursing was originally used for patient follow-up post discharge or for telehealth. The pandemic and the nursing shortage changed how we utilize virtual nursing. Virtual nursing is now being used as a support for new graduate nurses and those with less experience. Having access to an experienced nurse with a click of a button can be a game-changer for keeping less experienced nurses by showing they are worth the investment. The virtual nurse has access to the patient’s electronic healthcare record and real time data to support clinical decision making.
- Be a beacon for nurse well-being and emotional health. Nurses, especially new nurses, are often traumatized by patient emergencies. Offering mental health support, conducting incident debriefs, and instituting a zero-tolerance policy for violence and lateral bullying is crucial. No nurse should have to worry about being physically or emotionally assaulted by staff, patients, or visitors.
It’s time to rewrite our narrative…Being a bedside nurse is the most challenging and most rewarding job in nursing.
Too often we hear, “I’m just a nurse.” I’ve watched bedside nurses throughout my career and without a doubt, it’s the most challenging job in our profession. Bedside nurses need to be generalists; they need to know a large amount of knowledge and they need to apply that knowledge in every situation. If they don’t know the answer, they need to know where to go for the best, evidence-based answers. Nurses are patient advocates, patient educators, expert negotiators, and care coordinators. They are the alarm system when a patient’s getting into trouble, and they don’t rest until the patients’ needs have been met.
Nurses, let’s be happy our numbers are starting to increase but, let’s not be complacent about what we need to do to retain a healthy, experienced, happy workforce.
In nursing education, debriefing after clinical – whether in person or in simulation – is essential. It is a time where educators provide feedback, analyze actions, and encourage reflections to improve future performance (Fegran et al., 2023). It is a process that must be intentional and should encourage students to “know what,” “know how,” and “know why” (Lippincott Nursing Education, 2018).
Goals of Debriefing (Jett, 2023)
Foster a safe learning environment
It is important for students to know that they are in a safe space when they are debriefing, where
psychological safety is prioritized, and privacy and confidentiality are maintained.
Link the simulation to learning objectives, which then feed to learning outcomes
Debriefing is a time to “pull it all together” and allow the student to make connections between didactic learning and what they experience during clinicals and simulation.
Opportunity for feedback, involvement, behavior, & clinical judgement
During debriefing, the faculty member or instructor can provide feedback and help the student work through the thoughts behind their decision-making and actions.
Reflection
This is an opportunity for students to review the case or situation and look back on their actions and interactions. Serious thought can follow to help them understand the “why” behind their actions.
Growth
Debriefing is often the time where students have those “Ah-ha” moments where things start to come together!
“This isn't a time to reteach. This isn’t the time to lecture. This is a time to understand that doorway to decision, that path to why they did something and help them critically think and clinically judge that situation to make better decisions or to make the good decisions again. That's really the heart and soul of it.”
--Katie Jett, DNP, RN, MSN, FNP-BC; Associate Professor and Undergraduate Program Director at Goldfarb School of Nursing at Barnes-Jewish College in St. Louis, MO
6 Debriefing Models
Debriefing for Meaningful Learning© (Dreifuerst, 2015)
Debriefing for Meaningful Learning
© emphasizes reflective thinking. This model uses Socratic questioning and principles of active learning to uncover thinking associated with actions. It helps to develop clinical reasoning skills and help students become reflective practitioners.
3D Model of Debriefing (Zigmont et al., 2011)
The 3D Model of Debriefing includes three sections: defusing, discovering, and deepening. It incorporates common phases prevalent in the debriefing literature, including description of and reactions to the experience, analysis of behaviors, and application or synthesis of new knowledge into clinical practice. It can be used to enhance learning after real or simulated events.
Plus-Delta Debriefing (Cheng et al., 2021)
The Plus/Delta model of debriefing emphasizes questions such as
“What went well and what would you do differently next time?”; “What did you do well, and what did not go well, and why?”; or
“What was easy and what was challenging for you?” This approach promotes learners’ capacity for a self-assessment.
Advocacy Inquiry (Castillo, 2023)
The advocacy-inquiry model is an approach to cultivate a constructive conversation. In this framework, an advocacy statement is used to make an objective observation and is followed by an inquiry to help identify the thought processes and beliefs that inform the student’s actions. Active listening and targeted teaching to offer alternative paths and resources are prioritized.
Practitioners of Debriefing with Good Judgment© (Buttimer, n.d.)
This method uses advocacy-inquiry as a conversational strategy to explore what students were thinking during specific points in simulations, using the mnemonic PAAIL:
Preview – State what you’d like to talk about
Advocacy – I saw (state what was observed, in objective terms)
Advocacy – I think (your perspective and the impact of the observed behavior)
Inquiry – I wonder (ask what was on the student’s mind at the time)
Listen – To understand the frames behind the observed action
PEARLS (Eppich and Cheng, 2015)
The PEARLS (Promoting Excellence and Reflective Learning in Simulation) framework integrates three common educational strategies: learner self-assessment, focused facilitation (including advocacy-inquiry), and providing information or direct feedback/teaching. A tool to make this framework more accessible as a cognitive aid and that supports educator training can be downloaded
here.
If you have another tool or tips to help with debriefing, please let us know by leaving a comment! Thank you!
References:
Bajaj, K., Meguerdichian, M., Thoma, B., Huang, S., Eppich, W., & Cheng, A. (2018). The PEARLS Healthcare Debriefing Tool. Academic medicine: journal of the Association of American Medical Colleges, 93(2), 336. https://doi.org/10.1097/ACM.0000000000002035
Buttimer, M. (n.d.). PAAIL: A Conversational Strategy. Center for Medical Simulation. https://harvardmedsim.org/blog/paail-a-conversational-strategy/
Castillo, A. Y., Chan, J. D., Lynch, J. B., & Bryson-Cahn, C. (2023). How to disagree better: utilizing advocacy-inquiry techniques to improve communication and spur behavior change. Antimicrobial stewardship & healthcare epidemiology : ASHE, 3(1), e201. https://doi.org/10.1017/ash.2023.457
Cheng, A., Eppich, W., Epps, C., Kolbe, M., Meguerdichian, M., & Grant, V. (2021). Embracing informed learner self-assessment during debriefing: the art of plus-delta. Advances in simulation (London, England), 6(1), 22. https://doi.org/10.1186/s41077-021-00173-1
Dreifuerst, K. (2015). Getting started with debriefing for meaningful learning. Clinical Simulation in Nursing. https://doi.org/10.1016/j.ecns.2015.01.005
Eppich, W., & Cheng, A. (2015). Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simulation in healthcare : journal of the Society for Simulation in Healthcare, 10(2), 106–115. https://doi.org/10.1097/SIH.0000000000000072
Fegran, L., Ten Ham-Baloyi, W., Fossum, M., Hovland, O. J., Naidoo, J. R., van Rooyen, D. R. M., Sejersted, E., & Robstad, N. (2023). Simulation debriefing as part of simulation for clinical teaching and learning in nursing education: A scoping review. Nursing open, 10(3), 1217–1233. https://doi.org/10.1002/nop2.1426
Jett, K. (2023). Implementing Debriefing to Enhance Reflection and Clinical Judgement. Lippincott Nursing Education Innovation Summit.
Jett, K. (2023). Debriefing: It Should Always Be About the Learner. Lippincott NursingCenter interview: https://www.nursingcenter.com/journals-articles/video-library/debriefing
Laerdal. (2024). 5 Most Important Debriefing Questions for Nursing Simulation. https://laerdal.com/information/5-most-important-debriefing-questions-for-nursing-simulation/
Lippincott Nursing Education. (2018, May 1). The 411 on debriefing in clinical simulation: How nursing simulations & debriefing create better nurses. Wolters Kluwer. http://nursingeducation.lww.com/blog.entry.html/2018/04/30/debriefing_clinical-22AD.html
Zigmont, J. J., Kappus, L. J., & Sudikoff, S. N. (2011). The 3D model of debriefing: defusing, discovering, and deepening. Seminars in perinatology, 35(2), 52–58. https://doi.org/10.1053/j.semperi.2011.01.003