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‘An Immutably Personal Process’: A Hospice Nurse Contemplates Uncontrol

August 27, 2015

Megen Duffy, RN, BSN, CEN, currently works in hospice case management. She writes AJN’s iNurse column, which focuses on technology and nursing.

by mark ahsmann/ wikimedia commons

by mark ahsmann/ wikimedia commons

I started my day the way I often do: watching sunlight begin to filter in and softly illuminate the sunken face of a person who would die, not later, but sooner. I sat curled in the chair I’d been in since 3:00 AM, wrapped in my sweater against the institutional chill, and waited.

This is, perhaps unbelievably, my favorite part of being a nurse. In hospice, there is no deadline. No one needs the room right now. The patient does not have to go to the floor in the next 30 minutes to avoid throughput delays. I do not have five other patients claiming my time. No, I have the gift of being able to sit quietly with only one objective: to do everything I can to make sure this person leaves this life without pain or fear.

I am not bored. It may appear as if I am doing nothing, but that is far from true. I am watching and listening for every breath, every movement, every toe that turns a deep bruised purple, every expression that may say “I am hurting.”

I am merely cooperating with death, and death’s agenda is never known to me. My job is to wait for death to make a move and see how my patient responds. I am fascinated to see how this particular dance will go between death and my patient. I find deep peace in knowing that this is an immutably personal process that will occur the way it occurs and when it occurs. I appreciate the reminder, every time, that I have no power over it. It helps me to remember that I can find similar peace by relinquishing my illusion of control over the rest of my life. Read the rest of this entry »

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As with Ebola Outbreak, Social Determinants of Health Crucial in Recent Rural U.S. HIV Outbreak

August 25, 2015

Rachel Parrill, PhD, RN, APHN-BC, is an associate professor of nursing at Cedarville University in Ohio

by banditob/flickr creative commons

by banditob/flickr creative commons

This past fall, with the world watching, a crisis unfolded in West Africa that challenged our understanding of sociocultural environments, epidemiology, and health. The spread of Ebola and the intercontinental transmission of the disease exposed weaknesses in our epidemiological defense system. It also drew attention to the powerful role that cultural beliefs and practices can have on disease transmission during outbreaks.

In that same time frame, and with similar cultural etiologies, another infectious crisis played out much closer to home. The setting: the rural Midwest, in and around the small town of Austin, Indiana. The disease: HIV. The crisis: an unprecedented outbreak—one with incidence rates (up to 22 new cases a day at the height of the outbreak) estimated to be higher than those in many sub-Saharan African nations and transmission rates through injection drug use higher than in New York City. Contributing to this “perfect storm” were socioeconomic factors characteristic of many rural settings, including poverty, low education levels, limited access to health care, and few recreational or employment opportunities.

In my work as a faculty member in a rural Midwest setting, I introduce undergraduate and graduate nursing students to concepts of public health nursing and try to provide opportunities for them to engage in local health initiatives. However, I often encounter an unconcerned or unengaged attitude towards the health risks associated with rural life—both on the part of my students and the community members that we serve.

Our local rural community seems mostly untouched by notable urban problems such as injection drug use, prostitution, sexually transmitted infections, and rampant violence, and issues seen in surrounding larger metropolitan communities like homelessness and human trafficking typically capture the interest of my nursing students far more than the run-of-the-mill comorbidities they often see in rural community members, such as heart disease, diabetes, cancer, and unintentional injury.

So I was captivated by the story that unfolded this past year in nearby Austin, Indiana, just a three-hour drive from our university. The devastation experienced by this community so similar to the one I call home provided a poignant learning opportunity for my nursing students, and for the broader nursing community.

In my role as a faculty member, I challenge nursing students to consider a broad range of social determinants of health when examining the health of a community. For example, I invite students to examine the income and educational levels of a community in light of important health indicators. We discuss the fact that health is too often connected with wealth, educational opportunities, neighborhood characteristics, race and gender inequalities, and social policy.

Similar to the West African Ebola outbreak, the HIV outbreak in Austin reveals the effects of sociocultural environments on health. The outbreak occurred among a network of injection drug users, mostly within multiple generations of a small group of families. In terms of context, Austin suffered from not only a high rate of prescription drug use, but also a lack of medical and drug rehabilitation services, inadequate public health infrastructure, a knowledge deficit regarding HIV risk, and a strong community-fed stigma surrounding HIV infection very similar to the one that played a role during efforts to combat the Ebola crisis. Read the rest of this entry »

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In a Changing Health Care Landscape, Narrowing Options for Older RNs?

August 21, 2015

Christine Contillo, RN, lives in New Jersey and has been a staff nurse at a university health service in New York City for eight years.

Fork_in_the_road_-_geograph.org.uk_-_1355424I’ve been a practicing nurse for 36 years, working continuously while raising three kids. After first trying a few other jobs, I entered nursing expecting a profession that would give me emotional fulfillment, some flexibility, and a good wage. Nursing has fit the bill for me on every level.

Throughout my career I’ve made every effort to keep advancing my skills. I’ve earned annual continuing education credits as well as attended national conferences and gained two certifications. The titles I’ve held have included supervisor, coordinator, and nurse educator. For the last eight years I’ve held a full-time position that I love in a primary care in a medical home setting. There I’ve had both an independent and a provider support role. I’m adept at use of the EHR, vaccines, triage, finding and booking specialists, travel health, patient education, removing sutures and dressing wounds, among other things.

However, I have a 3.5-hour commute each day. As I get older, my time has become much more precious. With college loans for my three kids finally paid off and my husband’s full encouragement, last year I began to look for a job closer to home.

I envisioned something similar to what I was already good at, as part of a medical team somewhere nearby. When I had worked at the hospital years ago, we used to congratulate the nurses who left for “better” jobs, in a physician’s private practice or in a nine to five clinic position. Hoping to find something like that, I began to put out my feelers.

I started by asking my own physician in a very large practice what the nurses in his office did. I was stunned by the answer. “We got rid of all our RNs,” he told me. “They were too expensive. Now we hire NPs instead of RNs and can get a lot more work out of them.” (That is, they could write prescriptions, order tests, etc.)

That’s when I realized that all the women wearing scrubs and not in lab coats in his office, the ones taking histories, drawing lab work, and documenting vital signs, were unlicensed medical assistants. What about the patient care that I had always loved, and building relationships with the patients? Where could an RN like myself still do that?

My next clue that something was amiss was a full-page glossy ad in a magazine for a plastic surgery practice. It included 12 professionally done head shots of the employees there—two handsome surgeons, two PAs, an IT specialist, a receptionist, an office manager, an insurance specialist . . . but no one who claimed RN as a credential.

Finally I ran into a retired nurse with whom I’d worked a few years earlier. She told me that she and some other retired nurses were all volunteering at a local hospital. They worked side by side with RNs on the units, not getting paid but thrilled to still be using their skills and not affecting their social security benefits. Of course, I didn’t blame them for doing what they wanted to do, but I wondered if an indirect effect of this volunteering was to help the hospital meet it’s bottom line while still being short-staffed.

After a year of talking to headhunters and following up online job posting, I was only offered hard-to-fill hospital positions. What does all of this mean for us as a profession? Read the rest of this entry »

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Measuring a Nurse’s Career Through BLS

August 19, 2015

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog.

ParadisiBLSCertificationCardI was a child when I first heard the term CPR. My father, a volunteer fire captain in our community, had newly certified that day at drill. From the head of our dinner table he proclaimed, “It’s a terrible thing to have to do, but everyone should know how.”

He was right.

It feels as though I’ve known basic life support (BLS; sometimes still referred to as CPR) all my life, but I believe I was 16 years old when I first took a provider course, long before I knew I’d become a nurse.

Since then, as a former pediatric intensive care nurse, I have performed a lot of CPR, and a related professional compliment received during a pediatric resuscitation rests bittersweetly in my heart.

It was one of those codes that begins in the ED, and transfers into the PICU because survival is unlikely. The cause was cardiac. As I did compressions, and my colleague, a respiratory therapist, hand-ventilated the child, blood gases were drawn. The attending cardiologist looked over the results, and told us, “It’s too bad a perfect blood gas isn’t enough to save a life. The two of you are performing superb CPR.”

He was right. It wasn’t enough.

That was nearly 20 years ago. Basic life support recertification is required every two years. Now that I am an oncology nurse navigator, my chance of using the skill is like that of the general public. However, a current BLS card is mandatory.

Recently, I recertified. In the classroom, I reminded myself that the sequence of saving the life of the unresponsive is now circulation–airway–breathing (CAB) after decades of having been airway–breathing–circulation (ABC).

As I looked around the room, there was another change to contemplate: I was the old person in the group. As we paired off to perform the skills check, I saw the briefest flicker of disappointment in the eyes of the young ED nurse who became my partner. Her nose ring and tattoo sleeves defined our age difference. It didn’t help that I wore business casual, not scrubs. She was stuck with the old guy.

Suddenly I was that kid again, this time on the playground. The one picked last on the team. I wanted to tell her, “I used to do this as much as you do . . . I was really good at it,” but I knew this would make me sound even older.

We didn’t even tell each other our names; we just got to it. We completed our two-minute cycles, exchanging roles of first and second responder. The instructor watched in silence. “Okay you two, you’re done,” was all she said, and walked away to observe and correct the other teams, and then correct some more. Read the rest of this entry »

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On Nursing Identity: What We Can Learn from African Nurses’ Oral Histories

August 17, 2015

 By Sylvia Foley, AJN senior editor

Port of Mauritius by Iqbal Osman, via Flickr

Port of Mauritius by Iqbal Osman, via Flickr

“I have chosen this profession and nobody can take it away from me.”—Sophie Makwangwala, study participant

In the summer of 2009, at the International Council of Nurses (ICN) Quadren­nial Congress in Durban, South Africa, a small group met to discuss collaborating on joint history projects. At that meeting, several African leaders of pro­fessional nursing associations reported that their expertise had long gone unrecognized. Seeking to have the stories of African nursing history told, they pro­posed interviews with other retired nurse leaders. Barbara Mann Wall, an American nurse researcher who was in the room that day, found herself intrigued.

The study. In keeping with Braun’s tenet that “indigenous research should be led, de­signed, controlled, and reported by indigenous peo­ple,” Wall first trained three of the African nurse leaders in the oral history method, aided by a grant from the University of Pennsylvania School of Nursing. Then the team embarked on the study reported on in this month’s original research CE, “ ‘I Am A Nurse’: Oral Histories of African Nurses.” Here’s an overview: Read the rest of this entry »

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Editing a Journal: Not Bedside Nursing, But Still an Urgency to Get Things Right

August 14, 2015

By Maureen Shawn Kennedy, MA, RN, AJN editor-in-chief

‘Nurses practice based on what’s in the literature; we need editors who will draw lines and stand firm against publishing biased and inaccurate papers.’

Niklas Bildhauer/ Wikimedia Commons

Niklas Bildhauer/ Wikimedia Commons

I recently returned from a meeting in Las Vegas, the land of lights and bells and six-story marquees—and heat (it hit 109 when I was there, but “a dry heat”). The long flight home gave me time to reflect on the meeting I’d attended (of editors of nursing journals) and on what I do.

When I began my nursing career, I always thought I would stay in the acute care setting. I found the fast pace of the ER challenging and never boring. When I moved into a clinical specialist position and then an administrative one, I could still get involved in challenging situations, from dealing with problems that occurred on clinical units or with staff to navigating the politics of hospital committees and community liaisons.

But time passes and paths twist and turn, and here I am the editor of AJN—and it’s the most challenging and professionally fulfilling job I’ve had.

The International Academy of Nursing Editors (INANE for short) meets annually. It’s a loose networking group, mainly held together through a Web site, blog, and listserv. There are no officers or bylaws, no dues. Each year someone volunteers to host the annual meeting and whoever would like to help joins in. Anyone can propose a project, and those who want to work on it volunteer. We pass the hat to raise funds to support the Web site and incidental expenses and to help new editors attend the INANE meeting.

But don’t accuse this laid-back group of being inactive or frivolous—serious issues are tackled on an ongoing basis. True, they are not as exciting as the situations one might encounter in the clinical arena, but they have an effect on what many nurses do and think and implement in practice.

In Las Vegas, sessions focused on some important topics, including

  • the retraction of articles, i.e., when a publisher basically admits that an article is flawed and should not have been published.
  • the ethics of authorship and what to do when authors don’t want to disclose who actually wrote the paper, thus leaving room for conflicts of interest, bias, and skewed results and conclusions.
  • when and how much to fact-check authors’ references.
  • how to ensure students are getting the correct information about scholarly writing and publishing.
  • how to help new authors get their articles published.

Read the rest of this entry »

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Legionnaires’ Outbreak in New York City: Some Basics for Nurses

August 12, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

11148_loresIn the largest U.S. outbreak of Legionella infection since 1976, when there were 221 cases and 34 related deaths in an outbreak at a Philadelphia American Legion convention, more than 113 cases of the disease have been diagnosed in New York City since mid-July. Twelve people have died.

Legionnaires’ disease is neither rare nor exotic; it is a type of community-acquired pneumonia (it can also be hospital acquired). Symptoms include fever, cough, and progressive respiratory distress. Legionella can also cause a milder, flulike illness known as Pontiac fever that generally resolves without treatment. Because many cases of Legionnaires’ disease are never actually diagnosed, mortality rates are difficult to determine, but the rate currently is estimated at 5% to 30%.

The CDC estimates that 8,000 to 18,000 people are hospitalized with Legionnaires’ disease each year in the U.S., yet only about 3,000 cases are diagnosed and reported. Most cases of Legionnaires’ disease are sporadic, unlinked to any outbreak. The infections often are not recognized as Legionnaires’ disease, for several reasons.

  • Legionella infection is easily treated empirically (that is, without confirmatory lab testing) with common antibiotics, with the patient usually recovering. This is a practical and cost-effective approach to community-acquired pneumonia, but many cases of Legionnaires’ disease are never diagnosed as anything more specific than “pneumonia.”
  • When Legionnaires’ disease is suspected, the most common test ordered—Legionella urinary antigen—tests for only one of more than 46 Legionella species: pneumophila serotype 1. While a significant percentage of cases may be attributable to pneumophila serotype 1, a negative Legionella urinary antigen test does not rule out Legionnaires’ disease.
  • Only a Legionella culture has the potential to identify any Legionella strain, and special culture media is needed. In most labs, a respiratory specimen sent for culture is not routinely tested for Legionella.

Legionella does not spread from person to person. It is transmitted by aerosolized water from sources such as whirlpools, hot tubs, hydrotherapy tubs, showers, indoor waterfalls or decorative fountains, grocery produce misters, or cooling towers on large buildings. Legionella prefers large, complex plumbing systems over natural bodies of water, because plumbing systems provide the temperature range, commensal organisms, and stasis that best support Legionella growth.

Who’s at risk. As with community-acquired pneumonia caused by other organisms, the people most likely to become infected are those with preexisting health problems such as COPD, diabetes, or immunosuppression; smokers; and people over 50. Children are usually not infected with Legionella unless they are immunosuppressed. Read the rest of this entry »

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