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Evidence-Based Practice and the Curiosity of Nurses

July 27, 2015

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

karen eliot/flickr

by karen eliot/via flickr

In a series of articles in AJN, evidence-based practice (EBP) is defined as problem solving that “integrates the best evidence from well-designed studies and patient care data, and combines it with patient preferences and values and nurse expertise.”

We recently asked AJN’s Facebook fans to weigh in on the meaning of EBP for them. Some skeptics regarded it as simply the latest buzzword in health care, discussed “only when Joint Commission is in the building.” One comment noted that “evidence” can be misused to justify overtreatment and generate more profits. Another lamented that EBP serves to highlight the disconnect between education and practice—that is, between what we’re taught (usually, based on evidence) and what we do (often the result of limited resources).

There’s probably some truth in these observations. But at baseline, isn’t EBP simply about doing our best for patients by basing our clinical practice on the best evidence we can find? AJN has published some great examples of staff nurses who asked questions, set out to answer them, and ended up changing practice.

  • In a June 2013 article, nurses describe how they devised a nurse-directed protocol that resulted in fewer catheter-associated urinary tract infections (CAUTIs).
  • A 2014 article relates how oncology nurses discovered the lack of evidence for the notion that blood can only be transfused through large-bore needles. These nurses were able to make transfusions safer and more comfortable for their patients. Read the rest of this entry »
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An Oncology Nurse’s Heart: Helping Dying Patients Find Their Own Paths Home

July 24, 2015

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

Heart Break = Heartache  graphite, charcoal, water color, adhesive strip by julianna paradisi

Heart Break = Heartache
graphite, charcoal, watercolor, adhesive strip, by julianna paradisi

The disadvantage of building a nursing career in oncology is that a fair number of patients die. Despite great advances in treatment, not every patient can be saved. Oncology care providers struggle to balance maintaining hope with telling patients the truth.

Sometimes, telling the truth causes anger, and patients criticize providers for “giving up on me.” In a health care climate that measures a provider’s performance in positive customer satisfaction surveys, paradoxes abound for those working in oncology.

Providers may also be criticized for delivering care that is futile. “Don’t chemo a patient to death” and “A cancer patient should not die in an ICU” are common mantras of merit.

Maybe because I live in Oregon, a state with a Death with Dignity law, or maybe it’s the pioneer spirit of Oregonians, but I don’t meet a lot of patients choosing futile care to prolong the inevitable. In fact, many patients I meet dictate how much treatment they will accept. They grieve when they learn they have incurable cancer, and most choose palliative treatment to reduce symptoms, preserving quality of life as long as possible.

But they also ask questions: “How will I know when to stop treatment?” or “What will the end look like?” Their courage in facing death amazes me. It often brings me to tears, too.

One advantage of building a nursing career in oncology is that I feel no compulsion to hide my tears from a patient during these discussions. In the context of compassionate presence, tears represent emotional authenticity, theirs and mine.

While nurses may sometimes grieve with patients, they can also offer them therapeutic support.

I have developed a few tricks so I don’t let dying patients down during the moments they need me most. My favorite is to ask a patient what he or she does—or, if they’re retired, did—for a living. As I listen to the story, I picture what they looked like in a business suit, wielding a hammer, baking a cake, or writing a novel. I picture her at the head of a classroom, teaching children to read. In my mind I say, “I see you,” and they become their authentic self, not the person cancer tries to reduce to a recliner chair. Read the rest of this entry »

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Heatstroke in Older Adults: A Short Step from Heat Exhaustion

July 22, 2015
Signs and Symptoms of Heat Illness

Signs and Symptoms of Heat Illness

Older adults tend to be more vulnerable than younger adults in a number of ways, one of which is in their reaction to intense heat.

Given the increase in extreme weather events in recent years, an article that we published a few years back, “Heatstroke in Older Adults” (free until September 1), is as timely now as ever. A high percentage of heat-related deaths in the U.S. occur among people who are 65 or older. Here are some of the reasons:

Older adults’ normal temperature-regulating processes may be impaired by illnesses such as diabetes or cardiovascular disease or by medications such as vasoconstrictors or diuretics, leaving them more vulnerable to heat exhaustion, which can progress to heatstroke, a far more dangerous condition. Those who are immobilized or suffer from disorientation secondary to dementia may fail to recognize dangerous symptoms or to drink appropriate types and amounts of fluids or move to a cooler location. Isolation, which is also frequently associated with heat injury, is common among older adults, particularly in cities, which are more susceptible to extreme heat waves because they create ‘heat islands,’ where surface and air temperatures are as much as 10°F higher than those in surrounding areas.

This short article gives nurses essential information on:

  • the differences in symptoms and treatment between heat exhaustion and heatstroke
  • the two types of heatstroke (exertional and classic)
  • the various risk factors for heat exhaustion and heatstroke in older adults
  • prevention strategies and public health resources

We hope you find the article helpful.—Jacob Molyneux, senior editor

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Working a Shift with Theresa Brown

July 20, 2015

bookBy Maureen Shawn Kennedy, AJN editor-in-chief

Many of you may be familiar with Theresa Brown, nurse and author of Critical Care: A New Nurse Faces Death, Life, and Everything in Between, as well as a blogger for the New York Times. Brown also writes a quarterly column for AJN called What I’m Reading (her latest column, which will be free until August 15, is in the July issue). Her new book, The Shift: One Nurse, Twelve Hours, Four Patients Lives, will come out in September, and I was able to read a prepublication copy. (You can pre-order it.)

I don’t usually write book reviews. I think of most books like food: what one person finds delicious may be less savory to another. But I’m making an exception because this book is an accurate and well-written portrayal of nursing (at last!).

Anyone who wants to know what it’s like to be a nurse in a hospital today should read this book. Patients, families, and non-nurse colleagues tend to see nurses as ever-present yet often in the background, quietly moving from room to room, attending to patients, and distributing medications or charting at computers. But what they don’t understand about what nurses do is what Brown so deftly describes—the cognitive multitasking and constant reordering of priorities that occur in the course of one shift as Brown manages the needs of four very different patients (she was working in a stem cell transplant unit at the time); completes admissions and discharges; and communicates with families, colleagues, and administrators. Read the rest of this entry »

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Hepatitis A, B, and C: The Latest on Screening, Epidemiology, Prevention, Treatments

July 16, 2015
One of several posters created by the Centers for Disease Control and Prevention to raise awareness that millions of Americans of all ages, races, and ethnicities have hepatitis C—and many don’t know it. Posters are available to order or download for printing at www.cdc.gov/knowmorehepatitis/media/posters.htm. Poster © Centers for Disease Control and Prevention.

One of several CDC posters intended to raise awareness that millions of Americans of all ages, races, and ethnicities have hepatitis C—and many don’t know it. Posters are available to order or download for printing at http://www.cdc.gov/knowmorehepatitis/media/posters.htm. Poster © Centers for Disease Control and Prevention.

It’s crucial that nurses in all health care settings stay informed about the changing landscape of viral hepatitis in the United States. Hepatitis affects the lives of millions, too many of whom are unaware that they have been infected.

Right now, there’s good news and bad news about hepatitis in the U.S. While the incidences of hepatitis A and B in the United States have declined significantly in the past 15 years, the incidence of hepatitis C virus infection, formerly stable or in decline, has increased by 75% since 2010. Suboptimal past therapies, insufficient provider awareness, and low screening rates have hindered efforts to improve diagnosis, management, and treatment of viral hepatitis.

The authors of a CE feature in the July issue of AJN, Viral Hepatitis: New U.S. Screening Recommendations, Assessment Tools, and Treatments,” are thoroughly versed in the subject. Corinna Dan is viral hepatitis policy advisor, Michelle Moses-Eisenstein is a public health analyst, and Ronald O. Valdiserri is director, all in the Office of HIV/AIDS and Infectious Disease Policy, U.S. Department of Health and Human Services (HHS).

Their article succinctly and clearly covers

  • the epidemiology, natural history, and diagnosis of viral hepatitis.
  • new screening recommendations, assessment tools, and treatments.
  • the HHS action plan, focusing on the role of nurses in prevention and treatment.

Read the rest of this entry »

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More than ‘Just’ Fragile Skin and Loose Joints: A Nurse’s Guide to Ehlers-Danlos Syndrome

July 14, 2015

By Sylvia Foley, AJN senior editor

“Most of the local doctors … thought I was making this up.”—patient on online forum

Joint hypermobility is often characteristic of EDS. Photo © 2015 Suzbah / Dreamstime.com.

Joint hypermobility is often characteristic of EDS. Photo © 2015 Suzbah / Dreamstime.com.

You might not have heard of Ehlers–Danlos syndrome (EDS), but chances are you’ve had a patient with this hereditary connective tissue disorder, which affects an estimated one in 5,000 people worldwide. The real number is probably higher. There are six types of EDS with widely varying presentations—and given the lack of consensus regarding diagnostic criteria, underrecognition seems likely.

Primary symptoms can include skin hyperelasticity, joint hypermobility, and general tissue fragility; the effects can be disabling and even life threatening. In one of this month’s CE features, “Nursing Management of Patients with Ehlers–Danlos Syndrome,” author Linda K. Anderson offers nurses a clear guide to this condition. Here’s a short summary: Read the rest of this entry »

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The Huddle: A New Mother’s Experience of Discharge Planning

July 10, 2015

By Amy M. Collins, AJN managing editor

John Martinez Pavliga/Flickr Creative Commons

By John Martinez Pavliga/Flickr Creative Commons

Three months ago, I gave birth to my first child under somewhat traumatic circumstances. After a fast and furious labor onset, I was all set to be given an epidural when I was informed the baby’s heart rate had dropped dramatically and I needed to have an emergency C-section. Thankfully, everything turned out okay, and my son was born healthy.

Nurses changed shifts every 12 hours during my four-day hospital stay, and each of them provided excellent care. They spent massive amounts of time with me, helping me to get up and walk around, showing me how to expertly swaddle my baby like a burrito, and even helping me get the hang of feeding my child.

On my last day, two nurses were assigned to get me ready for my discharge. They had tons of printed information for me on postnatal care, wound care, postpartum depression, etc. I was told by one of the nurses that we were going to now have a “mother–child huddle.” She then said to the other nurse, with what I took to be a little irony in her tone, “Are you ready for the mother–child huddle?” Curious, I asked why the emphasis on the word.

“I just think the word ‘huddle’ is silly,” she said, adopting a mock football pose. I thought about this for a moment. Sometimes at work we also use the term instead of “meeting,” and I had to admit that it often gave me football visuals or made me picture my team in a circle with our arms around each other’s shoulders. I told her this—and added that I worked at AJN and thought the topic of word choice in this particular nursing context might be of interest to our readers.

They joked that they’d like to be interviewed and featured in the journal, but then they spoke more seriously about their ambivalence in using this term.

“Huddle doesn’t mean anything in this context,” one nurse said. “What does it actually mean to the patient? We use it because we’re told to by the hospital.” She mentioned patient satisfaction surveys and I wondered to myself if the hospital might provide nurses with various scripts or terminology in order to plant specific words and concepts into patients’ heads for when it came time to fill out these surveys. Read the rest of this entry »

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