Archive for November, 2011

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Bad News, Good News: Berwick, a Casualty of Politics, Succeeded at CMS Helm by a Nurse

November 30, 2011

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

Marilyn Tavenner

When Donald Berwick steps down from his post as administrator of the Centers for Medicare and Medicaid Services (CMS) on December 2, he’ll turn the reins over to Marilyn Tavenner, MHA, BSN, RN. Tavenner is not a new face at CMS—she served as acting administrator prior to Berwick’s July 2010 appointment by President Obama and has been principal deputy administrator at CMS since February 2010.

As noted by an article in The Washington Post, Berwick is stepping down in the face of organized opposition to his nomination by Republicans in Congress, who have vowed to block the confirmation he’d need to continue after his recess appointment expires on December 31.

On November 23, President Obama announced his intent to nominate Tavenner for the top post. In her e-mail to CMS staff (carried on the Kaiser Health News site), Kathy Sebelius, secretary of  Health and Human Resources, says of Tavenner, “Her career as a nurse, hospital administrator, and Virginia Secretary of Health and Human Resources give her unique insights that position her well to serve as Administrator.”

I certainly hope so. Berwick’s reputation and track record for pinpointing problems in our health system—and more importantly, working to do something about them through the Institute for Healthcare Improvement—was stellar, and he carried this zeal into his government position as he grappled with the daunting task of implementing reforms in the Affordable Care Act. Read the rest of this entry ?

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From the Blogs: Negotiating Medicare, Nurses Doing Research, Reader Comments

November 29, 2011


Medicare is confusing for providers who aren’t yet familiar with it. Here’s a Nursetopia post that draws attention to its complexity and notes the useful video above (it’s one of a series of videos on different aspects of Medicare). Those of you who know all about it already: Drop by her thoughtful (and consistently updated!) blog and let her know your own tips on handling the ins and outs of Medicare and Medicaid.

EBP matters. Terri Schmitt at Nurse Story has a frank and engaging post on evidence-based practice (EBP): “Translation of EBP: Why Creating Nurse Scientists is the Way to Improve Patient Outcomes.” Here’s what she promises to cover in it:

  • Research is sometimes far removed from bedside nurses
  • Research is COOL!
  • Research is about PATIENTS and not fame/fortune of researcher
  • Research is critical to practice and there are big gaps that nurses need to fill
  • Bedside nurses may be the most crucial link in research ideas, translation, and practice.

(Shameless plug for related AJN content: See our recent, amazingly useful step-by-step CE series on how nurses can get involved in evidence-based practice.)

Plus a brief note on reader comments: we’ve been getting a lot of great comments lately on this blog, and we’re grateful for that. So thank you. A fair number of the comments were on posts from previous months, such as this post comparing U.S. and Australian health care systems. Is somebody by chance teaching a nursing course that requires students to leave thoughtful, respectful, engaged comments in the blogosphere? If so, bless you!—JM, senior editor/blog editor

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Posted in continuing education, nursing research | Tagged , , , , | Leave a Comment »

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On Euphemisms and Learning to Be Present

November 28, 2011

By Alicia Marie Hinton, who is a BSN student at the College of New Rochelle School of Nursing in New Rochelle, NY. This is her first post for this blog.

by grepsy, via flickr

My senior year preceptorship was an assignment on a palliative and acute care unit at a busy medical center. When I received the assignment, I prayed that no patient of mine would die during my time on the unit. Every nursing student is afraid of their first patient death. Simulation and course work prepare students in various ways for this experience, but nothing can really prepare you for the emotions you’ll feel. Some students experience a patient death during an undergraduate nursing program, but for others it may not happen until their first year or two working as an RN. I hoped to never endure it, but knew it was inevitable.

During report, working alongside my preceptor, I listened anxiously to the status of the various patients. Since my first day on the unit, I’d practiced my therapeutic techniques and researched different cultural needs pertaining to the death of a patient. I felt culturally competent and well informed about what a nurse should do when a patient dies, but I couldn’t shake my fear. What would I say to the family? Would they value my presence?

Finally, during morning rounds on my third day on the unit, I was told that a certain Mr. P wasn’t doing too well and might “expire” that day. Our focus would be to provide comfort for him and his family.

How did they know he was to “expire”? Was that the politically correct term for dying? I was familiar with “passed away,” “deceased,” or “gone to a better place.” But the word “expire” didn’t feel right. I’d cared for Mr. P since his admission and interacted daily with his family, and news of his impending death hit me hard, increasing my anxiety about how I’d respond when it happened. While I was anxious about my own feelings about the patient’s death, I was preoccupied with my ability to comfort that family. Read the rest of this entry ?

Posted in nursing students, palliative care, professional identity | Tagged , , , , , | 7 Comments »

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Thanksgiving in the ICU: Woven into the Tapestry of Traditions

November 22, 2011

By Marcy Phipps, RN, a regular contributor to this blog. Her essay, “The Soul on the Head of a Pin,” was published in the May 2010 issue of AJN.

cranberries

I’ll be working this Thanksgiving. I’ve worked so many Thanksgivings that the ICU feels woven into the tapestry of my own traditions. I don’t really mind; the cafeteria serves a fitting feast that’s embellished by the homemade treats we bring in, and although we won’t actually be watching it, the Macy’s parade will be on. Somehow, the smells and sounds I associate with the holiday will mix and mingle with the usual bustle of critical care, and it’ll feel like Thanksgiving. It’s actually a nice day to be at the hospital—for the nurses, that is.

For our patients and their families, I know hospital holidays fall far short. We have one patient, in particular, who’s been with us for a while. Her husband’s been a fixture at her side throughout her stay, and I expect to find him stationed there this Thanksgiving. Hospital turkey and television won’t give him the comfort or peace that he seeks, and I don’t know that he’ll be giving thanks. For many weeks I’ve watched him skirt a fine line between gratitude and despair; things could always be worse, but they could certainly be better.

When I stop to count my blessings, I’m overwhelmed. I belong to a profession that I’m passionate about—one that brings me great joy. I work with people I care about and like so much that I look forward to spending a holiday with them. And at the end of the day I’ll be going home, where my family will be waiting for me, and I’ll hug my kids and count my blessings all over again.

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Editor’s note—some AJN Thanksgiving posts from past years:

Brief Notes on Thankfulness (and the Nursing Profession)

Turkey, Sweet Potatoes, and Living Wills

Posted in nursing perspective, patient perspective, professional identity | Tagged , , | 2 Comments »

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That Acute Attention to Detail, Bordering on Wariness…

November 21, 2011

via Wikimedia Commons

By Kinsey Morgan, RN. Kinsey is a new nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA. Her last (and first) post at this blog can be found here.

It seems that nursing schools across the world subscribe to certain mantras regarding the correct way to do things. Different schools teach the same things with utmost urgency. Hand washing is one of the never-ending lessons that comes to mind. How many times do nursing students wash their hands while demonstrating the correct way to perform a procedure? I vividly remember actually having to be evaluated on the skill of hand washing itself.

Another of the regularly emphasized points of nursing school is double-checking. One of my first clinical courses required students to triple-check patient identification before giving medications. We were to look at the medication administration record, the patient’s wristband, and then actually have the patient state their name.

As a new nurse learning several new computer systems for charting, etc., I’ve noticed that the old attention to detail, ground into my soul during my school days, now seems easy to overlook, since computers do so much of the work. Of course, computer charting and electronic MARs* have simplified tasks and made time management much less daunting. But sometimes I worry about the hidden cost of such improvements.

I intend, vow, resolve to make an effort to remain aware of how easily errors can happen when we don’t double- and triple-check things. I want to always retain that astute attention to detail, bordering on wariness, so that I can practice as safely as possible, even with the advent of electronic methods.

*MARS = medication administration records

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Posted in health information technology (HIT), nursing students, patient safety | Tagged , , , , , | 2 Comments »

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Addressing Traumatic Injury in Older Adults

November 18, 2011

By Sylvia Foley, AJN senior editor

Frank Jones, age 83, arrives at a local trauma center after falling down a flight of stairs in his home. Initially diagnosed with two fractured ribs, a fractured ulna, and a fractured tibia, he’s admitted to the ICU.  At first, things seem to go well—his electrolytes and bloodwork appear to be within normal limits, and his vital signs are stable. But the next day he becomes increasingly unstable. What’s going on?

Stairs by spivvo, via Flickr

Trauma is currently the seventh leading cause of death in older adults—and older adults are more likely to suffer complications and die than are younger ones. But as author Christine Cutugno points out in this month’s CE, “The ‘Graying’ of Trauma Care: Addressing Traumatic Injury in Older Adults,” advanced age isn’t a predictor of trauma outcome. Many trauma-related complications are preventable.

What guides current care? While standards of care for geriatric patients and for trauma patients exist, as yet none have been specifically developed for and tested in geriatric trauma patients. Until that happens, Cutugno writes, “nurses will need to be guided by measures known to prevent iatrogenic complications in other patient populations.”

To that end, Cutugno first reviews common mechanisms of traumatic injury in older adults and discusses the effects of aging and comorbidities. She points out that older adults usually have poorer physiologic reserves and are less able to maintain homeostasis. Their compensatory responses may be inadequate. The drugs taken to manage many comorbidities can mask warning signs. In short, it can be challenging for nurses to recognize when a geriatric trauma patient is in trouble. Read the rest of this entry ?

Posted in continuing education, home care nursing, nursing perspective, palliative care, practice tips | Tagged , , | 2 Comments »

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Physician-centric vs. Patient-centric?

November 16, 2011

By Shawn Kennedy, AJN editor-in-chief

Last week, we posted here a piece by AJN’s clinical managing editor Karen Roush, decrying the use of the term “physician extender.” It reminded me of a recent article from the New York Times on nurses with doctorates, which reported that if some physicians have their way and their legal strategy succeeds, they will be the only group permitted to use the honorific “doctor.”

Degrees vs. licenses. This borders on the ridiculous, as the title is an academic title that signifies achievement in a field of study; it is not a license. Doctoral degrees are awarded in just about every field of study, from astronomy to zoology. Physicians are awarded a doctor of medicine, dentists are awarded a doctor of dental science, and so it goes. In health care, there are dentists, psychologists, social workers, physical therapists, pharmacists, and yes, nurses too, with doctoral degrees. Nurses have been earning PhDs and EdDs (doctorates in education) and the DNSc (doctorate in nursing science) for years, and now there’s a new nursing doctorate degree—a DNP, doctor of nursing practice—that’s specific to nurses in clinical practice. They are still licensed as nurses, as that’s what they are.

This parochial thinking is held by those physicians (not all, but far too many) who still adhere to the traditional view that they, and they alone, know what’s best for patients and for health care; they’re in favor of teamwork, but only as long as the team recognizes that they are the leaders and decision makers.

Both the media and the health care system bear some responsibility for this. The system itself is physician-centric rather than patient-centric—hospital policies, practitioner admitting privileges, purchasing (especially in the OR), and scheduling have often developed around physician preferences; reimbursements almost always must go through physicians, whether or not they’re actually involved in the delivery of care.

Most media portrayals, both fiction and documentary, focus on physicians as the only important providers in health care, relegating other health professionals to low-level supporting roles (or, as Roush noted,“extensions” of physicians). Read the rest of this entry ?

Posted in advocacy/political action, legal issues, media depictions of nursing, nurse practitioners, professional identity, Shawn Kennedy, AJN editor-in-chief | Tagged , , , | 1 Comment »

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Autumn Leaves and Colorful Lives

November 14, 2011

By Julianna Paradisi, who normally blogs at JParadisi RN and has written for this blog before. Her artwork appeared on the cover of the October 2009 issue of AJN, and her essay, “The Wisdom of Nursery Rhymes,” was published in the February issue.

autumn leaves between sun halos and flashlight
by oedipusphinx—theJWDban via Flickr

The autumn leaves are particularly beautiful in Oregon this year. An arborist interviewed on the evening news attributed the extraordinary orange and gold to an unusually cold, wet spring, which lasted until July, followed by the intense heat and warm evenings of a brief Indian summer. According to the arborist, the combination caused a greater than normal amount of sugar in the leaves, resulting in the brilliant colors. I think about this on my morning run, as my feet scatter fallen leaves along the sidewalk.

The Season of Eating is, however, not the only messenger of the approaching holidays in a nursing unit. There is something about the holiday season that signals Death to harvest a higher than normal number of the patients we have grown to love through the course of their illnesses. Some of the deaths are expected, but not all of them. I don’t know why more people seem to lose their battles with illness around the holidays than at other times of year.

When I first began working in outpatient oncology, it took me by surprise that my coworkers gleaned the obituaries of our local paper, clipping the ones of our patients. I soon learned that sometimes this was the only way we nurses learned that one of these patients had died, since physicians’ offices don’t necessarily have a mechanism for notifying us.

I make it a point to read each of the obituaries I find pinned on a wall near the nurses’ desk. No matter how well I got to know a patient, their obituary always teaches me something I didn’t know about them: they made quilts for the needy, they formed a foundation for the education of underprivileged children, they were a war hero, an educator, a talented cook or gardener. The names of those they loved.

This fall, I hold a handful of newspaper clippings in my hands, as if they are a bouquet of dried autumn leaves. The obituaries tell the stories of people blessed by both rain and sun, who created lives of intense color.

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Posted in nursing perspective, writing and nursing | Tagged , , , , , | 4 Comments »

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Nurse Practitioners Are Not ‘Physician Extenders’

November 11, 2011

By Karen Roush, MS, RN, FNP-C, AJN clinical managing editor

“Physician extender.” It’s way past time to kill that term.

A study published in the October issue of Surgery found that adding an NP to the surgical team decreased the number of unnecessary ED visits by 50% and increased the use of visiting nurse, physical therapy, and occupational therapy services. A Medscape article (registration required) on the study explained the importance of the findings in this way: “According to the researchers, physician ‘extenders,’ such as NPs, help maintain continuity of care while resident work hours are kept at a maximum of 80 per week. . . .”

Sure enough, the stated purpose of the study was to determine if “integrating this physician extender into the surgery team” would improve outcomes and resource allocation. Ouch.

Experts in our own right. Nurse practitioners are not physician extenders. We are highly skilled and educated nurses who provide evidence-based care grounded in the nursing model. We are not “extensions” of anyone. We are colleagues and collaborators, independent clinicians and experts in our own right. Our purpose is to provide comprehensive care, promote health, educate, and advocate. It is not to relieve interns, supplement physician education, or be the low-cost alternative when physicians have to “do more with less,” as Medscape quoted one of the study authors. Yes, we should be integrated into health care teams, surgical and otherwise—because nurses provide a distinctive aspect of care that research has repeatedly shown to be essential to good patient outcomes. Read the rest of this entry ?

Posted in media depictions of nursing, nursing perspective, nursing research, professional identity | Tagged , , , , | 8 Comments »

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Learning to Serve Others: The Key to Happiness

November 10, 2011

With Veterans Day tomorrow, it seems appropriate to highlight the achievements of Charles Kaiman, an artist and a clinical nurse specialist in psychiatric mental health who works with veterans, primarily those with posttraumatic stress disorder (PTSD). Kaiman recently received the Excellence in Behavioral Health Nursing Award at the 2011 New Mexico Nursing Excellence Awards for his work as a caregiver for veterans at the New Mexico Veterans Affairs Health Care System in Albuquerque.

In this video interview, posted on YouTube by KASA FOX 2, an affiliate of the Fox Broadcasting Company, Kaiman speaks about how he decided to become a nurse, the symptoms of and treatment strategies for PTSD, and what he sees day to day while working with Iraq and Afghanistan war veterans—an experience he calls “one of the most rewarding” of his life.

When asked why he became a nurse, Kaiman said he was first inspired when he was 10 years old, reading a book by Albert Schweitzer that argued no one could be happy unless they learned to serve others. Later, when Kaiman was trying to make ends meet as an artist, his father suggested becoming a nurse because he would “never be out of work.” And his father was right.

Kaiman has now worked as a nurse for 31 years, 26 of those specifically with veterans. When asked about the rewards of helping others and what he would say to those interested in entering the nursing profession, his answer was clear:

“I can’t believe I get paid for this. It’s the greatest thing you can do for the world and for yourself. I completely and absolutely urge everyone who is interested to become a nurse.”

Kaiman’s artwork has been featured in AJN‘s monthly Art of Nursing and twice on AJN’s cover (September 2009 and September 2011). His painting “America the Beautiful” appeared on our September cover in honor of the 10th anniversary of 9/11; for more about that cover, read our blog post and see On the Cover.—Amy M. Collins, AJN associate editor

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Posted in art and nursing, male nurses, videos | Tagged , , | 1 Comment »

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