Archive for October, 2010

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Halloween Nurse

October 29, 2010

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

by indigoprime/via Flickr

When I was a little girl about six or seven years old, I decided that I would dress up as a nurse one Halloween. My mother bought me a play nurse’s kit.  It was a pink plastic “little nurse bag” containing a white nurse’s cap, a stethoscope, a tongue depressor, blue-framed plastic glasses that perched on your nose, a plastic thermometer with the “mercury line” painted to 101 degrees, a plastic hypodermic syringe, a small notepad and pencil, cotton balls, and Band-Aids.  (For your information, the “junior doctor kit” contained pretty much the same things, except it was black plastic, had a yellow and orange plastic otoscope, and a headband with a reflector disc. My brother received one of those.) I wore a white blouse and tan skirt (my mother drew the line at buying clothes for one day) and used a safety-pin to clip a blue towel around my neck as a cape. I wore the nurse’s cap and glasses. My brother dressed in his Catholic school uniform (white shirt and navy blue pants and red tie) and wore his stethoscope around his neck and his little blue glasses perched on his nose. We were quite the medical team. I wonder how many nursing or medical career seeds were planted with those play kits.

by rosmary/via Flickr

With Halloween this weekend, many schools celebrated throughout the week, and I saw a few princesses and superheroes and at least five Buzz Lightyears around the neighborhood, but no nurses. Do children dress up as nurses or physicians nowadays? I googled “play nurse kit” and a few sites came up. Target offers kid-size scrubs or a lame smock with stethoscope and other items sort of painted onto the pockets; everything else on the site relates to nursing as in breast-feeding. The only kits you can still find are a combined, unisex, one-size-fits-all sort of “nurse/doctor kit.” 

So now I’m wondering—what would real nurses put in a play nurse’s kit now? 

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Finding a Job as a Nurse In a Digital Age — and Keeping It

October 26, 2010

Will at Drawing on Experience manages to post a new comic almost every day. A regular theme is the progress of his career—having finished his accelerated nursing program, he’s now looking for a job. To the left is a thumbnail of a recent drawing he did about one of the more annoying aspects of the process (click the image to visit his blog and see a larger version).

A nurse returns to work at age 68 and finds her biggest challenge is computers.Of course, this isn’t the first downturn we’ve had in the U.S. economy; as AJN clinical editor Christine Moffa wrote back in May, newly minted nurses have struggled to find work before. Once you actually do get a job as a nurse, there’s the small matter of doing it for the first time. Or for the second or third time—but as if it’s the first time, at least in some respects. The October Reflections essay, “Paper Chart Nurse,” gives another perspective on the ways computers have changed the lives of nurses. It’s by an oncology nurse who returned to practice two years ago, at age 66. Her struggles with adapting to using an electronic medical record system were at times profoundly discouraging; she just wasn’t as proficient as the younger nurses at computer use, despite all her skills and experience. Have a look and please, tell us what you think.—JM, senior editor

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Enough with the Scare Tactics: Some Follow-Up on the IOM Report on the Future of Nursing

October 21, 2010

flying pig/aturkus, via Flickr

Shawn Kennedy, AJN’s interim editor-in-chief, already posted here about the importance of the recently released Institute of Medicine Report on the Future of Nursing. Its implications are particularly profound at a time when we have a scarcity of primary care providers—and also at a time when the Affordable Care Act (i.e., health care reform) has designated more resources to nursing education and to generally making better use of nurses’ expertise. A number of bloggers have written about the IOM report, several of them expressing chagrin about the predictably naysaying American Medical Association response. Rebutting the AMA, the Center for Health Media and Policy at Hunter College had this to say. One working NP who weighed in on this topic is Stephen Ferrara, who noted (almost two weeks ago, in fact, though we missed it until now) the real world implications of the current situation for NPs in New York State, in a succinct post on his blog, A Nurse Practitioner’s View:

The bottom line is (at least in NY where I practice), without a collaborating physician on record, the 14,000 or so NPs are unemployed and can’t legally do anything that we were trained or educated to do. It is time to remove these non-evidence based barriers and retrospective reviews and allow us to function as true partners on the health care team. Collaboration among providers would still continue to happen and I promise pigs wouldn’t start to fly. Fourteen states have already transitioned to to an autonomous model of practice model for NPs. Lawmakers must not cave to special interests and make the tough decisions that will enable greater access to care.

Of course, the IOM report wasn’t just about letting nurses practice what they were trained to do. It also dealt with nursing education and a number of other related issues. And we’ll be covering its many implications in upcoming issues. In the meantime, we’d love to hear the perspectives of more working RNs and NPs. Are you happy with the role of nurses in the health care system, just as it is? If so, why? If not, why not?—JM, senior editor/blog editor

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No Explanation Required: A Preceptor’s Tale

October 20, 2010

By Marcy Phipps, RN, whose essay, “The Soul on the Head of a Pin,” appeared in the May issue of AJN. She has also contributed a number of thought-provoking posts to this blog (here’s the most recent).

puddle reflection/by joiseyshowaa, via Flickr

I’ve been precepting a new ICU nurse intern, which I generally enjoy doing. The only downside (from the preceptor’s perspective) is that I’m obliged to call ahead and request “unstable” assignments. This is meant to enhance the clinical aspect of the internship, and it definitely does.  Considering that I work in a trauma center, though, reserving the sickest patient in the unit feels a bit like ordering up a large serving of chaos. And although I can request the assignment, I can’t predict what will be learned.

Our most recent patient was a new admission with a traumatic brain injury. At the start of our shift he had a grim neuro prognosis and was hemodynamically unstable. His condition deteriorated throughout the day and he was eventually diagnosed as brain-dead. His family chose to donate his organs.

Taking care of an organ donor is difficult. Brain-dead patients are inherently unstable, yet certain parameters must be maintained to ensure adequate organ perfusion. It’s tedious and meticulous.  It also requires a shift of perspective—ironically, even though the patient is legally dead, the medical interventions are aggressive and the stakes feel higher than ever. Despite the fact that for the patient, at least, there is nothing left to lose, the potential organ recipients weigh heavily on our minds. Read the rest of this entry ?

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What Keeps You Up at Night?

October 18, 2010

Peggy McDaniel, BSN, RN, is an infusion practice manager and occasional blogger on this site

By Ballistik Coffee Boy/via Flickr

A recent national survey revealed that nurses as a profession are the most dependent on coffee (the survey was commissioned, in part, by Dunkin’ Donuts, though at least conducted by Harris Interactive). The survey asked 3,600 people about their productivity as it related to coffee consumption. The results are interesting if not surprising. Physicians fall in just behind nurses, and hotel workers hold third place.

While working the night shift early in my career, I got my caffeine jolt from diet soda. Not too many years later I developed a taste for coffee by adding hot chocolate to it, in effect creating “mochas” before they were sold for $3.50 each. I still prefer fancier concoctions such as flavored lattes, but in a pinch can be found clutching a packet of powdered creamer over a black cup of hotel room coffee. Some may venture to compare my progressive caffeine consumption to an addiction, and I can’t totally discount that theory. But if you consider that the top three positions on the survey may require work during the night, is it surprising that those who do these jobs also report some dependence on a stimulant? Since many of us seem to depend on caffeine to perform our jobs, perhaps the real question is whether we’re getting any benefit from all those cups of joe. Read the rest of this entry ?

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What Is Meaningful Use? One Savvy Nurse’s Take

October 14, 2010

By Jared Sinclair, an ICU nurse in Nashville who has a blog about health care and technology

If you follow health care news regularly, and yet you still feel unsure what “meaningful use” means and how it will affect your job as a nurse, then you have something in common with even the most knowledgeable people on the subject. Despite the fact that discussion of meaningful use among health care IT and informatics folks has reached a fever pitch since the HITECH (Health Information Technology for Economic and Clinical Health) Act was passed last February, in many ways we are no closer to understanding how it will change health care than when discussion first began.

What do we know for sure? The HITECH Act promises incentive payments to providers and hospitals that use electronic health records in ways that meet a minimum set of requirements called “meaningful use.” That sounds simple enough; however, there isn’t just one set of requirements. The criteria for meaningful use will come in three stages, and the requirements for stages two and three have yet to be determined. This is why your local hospital’s nurse informaticists may be less than enthusiastic about the next five years of their jobs. They bear the responsibility for preparing their hospitals for huge changes—without the luxury of knowing what those changes will be.

We can get a glimpse of stages two and three by taking a closer look at the requirements for stage one. There are dozens of requirements, ranging from the use of computerized physician order entry (CPOE) to providing an electronic copy of a health record to a patient upon their request. To qualify for the incentive payments, hospitals must meet all of the requirements, but only to a specified degree. In the case of CPOE, for example, the Final Rule (see PDF link here) states:

More than 30% of unique patients with at least one medication in their medication list [must] have at least one medication order entered using CPOE.

In plain English, that means that a physician must order at least one drug for one third of his patients directly via a computer, and not with a handwritten order entered into a computer by a clerk.

The really worrisome issue. All of the meaningful use criteria merit discussion, but CPOE in particular stands out above the rest.  According to a comment made in the Final Rule (see PDF link above), CMS has received more concerned responses about CPOE than any of the other criteria. Stage one only requires a fraction of orders to be entered via CPOE, but the general opinion among industry leaders is that either stage two or three will require as much as 100% CPOE adoption. Consider what it would mean for a hospital to permanently do away with paper charts:

1. How would the transition be accomplished: all at once, or by one group of physicians at a time?

2. If a hospital physician can write an order via his office computer, how will the bedside nurse be alerted that an order has been written?

3. What if two physicians, one of whom has not been transitioned to CPOE, unknowingly order the same stat drug, one on paper and the other by the computer? Will the bedside nurse be able to manage keeping track of orders on two systems?

There have been some eyebrow-raising studies on the impact of CPOE on patient outcomes in the past several years, with stunning contrasts between their conclusions. Read the rest of this entry ?

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The Latest From a Persistent Campaign to Increase the Accuracy and Usefulness of Health News Reporting

October 12, 2010

Here at AJN we’ve always been inspired by the work of Gary Schwitzer, whose Web site Health News Review has grown increasingly influential in its role as a watchdog of the accuracy of health news reporting. Schwitzer has recently been blogging from the “Selling Sickness” conference in Amsterdam. Below is a short video interview he shot with the Australian physician Dr. Peter Mansfield, who runs an organization called Healthy Skepticism—and who compares “industry-occupied medicine” to a communist state in its power to control information and drown out dissenting voices. Whether you’re a journalist, a provider, or a potential patient, Schwitzer’s ongoing analysis of health care news provides a model for understanding and filtering the flood of information we get about medications, testing, and various conditions.—JM, senior editor/blog editor



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Do Patients Have a Right to Choose Providers Based on Race?

October 11, 2010

By mmarcotte51/via Flickr

By Shawn Kennedy, AJN editorial director

We have a wonderful librarian here at AJN who is always on the alert for news about nursing and nurses. Recently she sent me a clipping about a legal case, Chaney v. Plainfield Healthcare Center in Indiana’s Court of Appeals, which has important ramifications for nurses. The court ruled in favor of Brenda Chaney, a certified nursing assistant, and reversed the decision of the lower court that had ruled in favor of the Plainfield Healthcare Center nursing home.

Brenda Chaney brought suit against the nursing home for complying with a resident’s request not to have any black health care workers provide care or enter her room. (She also claimed her firing had been racially motivated. The court agreed that it seemed discriminatory.) The court agreed with Chaney that by acceding to the patient’s wishes, her employer created a hostile workplace and violated her rights. The nursing home claimed it was protecting the patient’s rights and that not doing so “risked violating state and federal laws that grant residents the rights to choose providers, to privacy, and to bodily autonomy.” The court did not agree. The crux of the decision is this:

“In any event, Indiana’s regulations do not require Plainfield to instruct its employees to accede to the racial preferences of its residents. The regulations merely require Plainfield to allow residents access to health-care providers of their choice. 410 IND. ADMIN. CODE 16.2-3.1-3(n)(1). If a racially-biased resident wishes to employ at her own expense a white aide, Indiana law may require Plainfield to allow the resident reasonable access to that aide. But the regulations do not say that a patient’s preference for white aides that Plainfield employs trumps Plainfield’s duty to its employees to abstain from race-based work assignments.”

I can’t believe this has been the only case of such discriminatory patient assignments—and wonder if nurses elsewhere have dealt with similar situations.

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(Editor’s note: For a little more context, here’s a San Francisco Chronicle story that gets at the role the patients’ rights movement may have inadvertently played in determining the nursing home’s approach.-JM)

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IOM Report: The Evidence Shows the Future of Health Care Rests on the Backs of Nurses

October 8, 2010

By Shawn Kennedy, AJN interim editor-in-chief

This past Tuesday, I attended the release of the highly anticipated (at least by nursing) report by the Institute of Medicine (IOM) on the future of nursing. Spearheaded and supported by the Robert Wood Johnson Foundation (RWJF), the report provides a review of nursing’s role in health care and details what changes need to occur for the future—not just of nursing, but for the future health of the health care system.

While the findings support what nursing has been claiming all along—that nurses have a critical role in health care and the health care system needs nurses to practice to the full extent of their capability—what is especially important about this report is that it is backed by the IOM’s multidisciplinary panel and an “objective evaluation of evidence according to the robust evaluation processes of the National Academy of Sciences,” said John Rowe, a committee member and professor at Mailman School of Public Health at Columbia University.

The panel at the public briefing for the release of the report included some health care heavyweights who voiced strong support for the findings:

Harvey V. Fineburg, president of the IOM: “One thing shouts out—nurses are critical to the nation’s health and central to the goals of high quality care.”

Risa Lavizzo-Mourey, president and CEO of the RWJF: “This is not a report about nursing but a report about a key missing piece to fixing health care; it establishes the centrality of nursing in providing safe, high quality, patient-centered care.”

Donna Shalala, president, University of Miami: “This report will usher in the golden age of nursing. Nursing has to be allowed to practice to the full extent of its scope of practice and to be a full partner with other professions in redesigning the U.S. health care system. It’s not about one profession substituting for another but about true collaboration.”

Later, in an interview I conducted with ANA CEO Marla Weston, she made a point of saying that allowing nurses to fully practice “isn’t just about NPs—nurses in all settings need to be allowed to practice according to their education and professional scope.  Nurses in institutional settings are often limited by bureaucratic policies and procedures.”

Prior reports by the IOM have spurred transformation of health care delivery—think of the 1999 report on medical errors, To Err is Human: Building a Safer Health System, and how that initiated a focus on creating a culture of safety and brought about new standards for hospital safety. I’m hoping the same will happen now with this report.

What the MDs say. And I hope our professional colleagues will be open to the report’s findings, though I have some doubts. The American Medical Association issued a statement that, after initially noting that “health care professionals will need to continue to work together,” goes on to reveal that the AMA believes in  “a physician-led team approach to care—with each member of the team playing the role they are educated and trained to play.” Further, it says, “increasing the responsibility of nurses is not the answer to the physician shortage.”

In that they are correct—the report is not about nurses taking on the functions of physicians; it’s about nurses doing nursing and yes, some nursing and medical tasks and procedures are the same. Physicians need to change their entrenched way of thinking that they and only they know what’s best for patients (case in point: see “No Country for Old Women,” a recent blog post by AJN associate editor Amy Collins about her grandmother) and for health care. Otherwise, we will all fail those we purport to serve.

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Promoting Awareness of Patient-Centered Care

October 7, 2010

By Shawn Kennedy, AJN interim editor-in-chief

October is, among other things, patient-centered care awareness month. At AJN, we’ve been focusing on patient-centered care for some time, most recently by virtue of our collaboration on a series of articles with Planetree, a nonprofit that “facilitates patient-centered care in healing environments.” The first article, Creating a Patient-Centered System, appeared in March 2009; the final article (from which we took the image above) was published in September 2010, and they’re all available in a collection on our Web site. Articles focus on such topics as creating quieter hospital environments and promoting patient access to medical records. We’re excited that this collaboration evolved into a four-part free webinar series supported by the Picker Institute. The final webinar, A Patient-Centered Approach to Visitation, presented by Planetree vice president Jeanette Michalak, MSN, RN, along with Wendy Tennis, BA, and Nancy Jane Schreiner, BSN, RN, will be on October 19 at 1 pm EST. We hope you will register and learn how to facilitate family visitation that meets patient needs. (The Planetree Web site also offers a downloadable toolkit and suggestions to focus attention on patient-centered care.)

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