2012 February « Off the Charts

Archive for February, 2012

A Role to Live Up To

February 28, 2012

by xcorex/via flickr

By Kinsey Morgan, RN. Kinsey is a nurse who lives in Texas and currently works in the ICU in which she formerly spent three years as a CNA. Her previous posts on working as a new nurse can be found here.

Now in my sixth month as a new nurse, I find every day that there is something new to learn, figure out, or adjust to. The constant stimulation and challenge is part of what makes me love being an ICU nurse.

Recently I was exposed to the simple yet powerful fact that being a “unit nurse” carries more weight than I’d thought. During a code blue on the medical–surgical floor a few weeks ago, I was performing CPR when it became necessary to initiate a dopamine drip to support a failing blood pressure.

One of the medical–surgical nurses spiked the bag and connected the tubing and proceeded to tap me on the shoulder and ask me if he had correctly entered the dosage of dopamine into the IV pump. Time stood still for a split-second while I contemplated the weight of this question. Though my mind and body quickly returned to the task at hand, the implications of that question haven’t left me yet.

The nurse who asked has been an RN for several years and has a lot more experience than I have. In reflection, I am honored and humbled by his trust. Not having encountered vasoactive drugs very often in his practice, this nurse saw me a source he could rely on for accurate information. And it was all because he knows I work in “the unit.”

This experience drives me to want to keep current and knowledgeable, so that I can be relied on in the future if I’m called on to speak for what my role—if unknowingly to me—represents to my coworkers.

Posted in nursing perspective, professional identity | Tagged code blue, competence, CPR, ICU nursing, Intensive-care unit, new nurse | 1 Comment »

Military Medicine Has a Head Nurse – Notes from Our Interview

February 24, 2012

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

“Hi, this is General Patty Horoho,” and so began a phone interview with army nurse Lieutenant General Patricia Horoho, who was sworn in as the 43rd Army Surgeon General in December.

Horoho made history, becoming the first woman and the first nonphysician to assume command of the U.S. Army Medical Command, a $13 billion global health system. She had also been the first nurse to command Walter Reed Army Medical Center, taking over after a report in the Washington Post revealed a host of deficiencies in care, housing, and processes at that facility, leading to the firing of the commanding officer, Maj. General George Weightman.

She was recommended for her new position by the prior Army Surgeon General, Eric Schoomaker, and it then went up the chain to the secretary of the army and the secretary of the defense, who then recommended her appointment to President Barack Obama.

We (there were representatives from four nursing publications on the call) spent over an hour peppering General Horoho with questions about her experience, objectives, strategic plans, and major challenges. Here’s a few of the highlights:

Regarding her experience at Walter Reed, she said she learned the importance of transparency in critically evaluating operations, of having policies, funding and “capability” to deliver. She also was candid, saying that following “the Vietnam era, we lost sight of the importance of rehabilitative nursing and health care,” and noting that this would be a significant area of emphasis for her.
Two special areas of focus for her, she said, will be behavioral health, especially as it relates to the sequelae of traumatic brain injuries, and moving the army from a health care system of delivery of services to a system of health that encompasses health promotion in all areas. “We need to move away from a ‘bricks and mortar’ system and out into the community,” she said.
Continuity of care and practice guidelines across the nine major medical centers is another area that she will prioritize.
Acknowledging that over 2,200 sexual assaults occurred last year, Horoho says this will be a focus of the women’s health task force. She sees the issue as needing a “gender neutral” approach, both for prevention and to provide a “command tone” and environment where women or men who’ve been sexually harassed or assaulted feel comfortable in coming forward.

Horoho’s had a long journey to get to her current position. You can read her bio here.

Posted in combat nursing, nursing perspective, Shawn Kennedy, AJN editor-in-chief | Tagged Patricia Horoho, rehabilitative nursing, sexual assault, Surgeon General, TBI, traumatic brain injury, Walter Reed Army Medical Center | 3 Comments »

Examining Our Biases About Mental Illness

February 24, 2012

“There’s nothing really wrong with him, it’s just anxiety.” How many times have you heard someone say this—or said it yourself? Mental health problems are among the most marginalized health conditions in the United States. They’re viewed as less “real” than physical illnesses; there’s no tumor to be palpated, no abnormality to be spotted on an X-ray. Emotional and psychological problems are often thought to be under a person’s control in a way that, say, multiple sclerosis or cancer is not. And because mental health problems can be construed as signs of weakness, sufferers may hide their symptoms. People who suffer from a mental illness need to feel comfortable seeking care and to trust that they’ll be treated with skill, compassion, and respect. This is vital: studies consistently find that mental illnesses, particularly depression, take a terrible toll on health. Such illnesses have been associated with an increased risk of stroke, coronary artery disease, and dementia, as well as increased mortality in people with cancer, diabetes, or chronic kidney disease and following a myocardial infarction or coronary artery bypass surgery.

That’s from “Examining our Biases About Mental Illness,” the Editorial in the February issue of AJN by clinical managing editor Karen Roush, MS, RN, FNP-C. What biases and assumptions about the mentally ill, the depressed, the anxious have you seen in your practice? Do you ever find yourself slipping into such biases yourself as a kind of default setting?

Posted in Karen Roush, nursing perspective | Tagged anxiety, depression, Mental disorder, mental health, nurses, physical costs of mental illness | 4 Comments »

States Easing Up, Pediatricians Buckling Down on Childhood Immunizations

February 21, 2012

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

Two newspaper reports last week showed the dichotomy that exists in attitudes about mandating vaccines for children.

On February 15, the Wall Street Journal reported that more pediatricians are turning away families who refuse to have their children receive immunizations.

Day 4 measles rash/ CDC, via Wikimedia Commons

The next day, USA Today reported that several states are considering changing laws that currently allow parents to opt out of mandatory vaccines only for religious reasons, and extending the opt-out to include “philosophical reasons.” These reasons invariably come back to parental fears that vaccines put their children at high risk for autism. (See the our November 2011 report on what fueled this controversy.)

Highly publicized resurgences of measles and pertussis seem to have done little to change some parents’ mindsets about the need for immunizations. Has the success of the vaccines campaigns lulled some into a false sense of security—that the “risks” of vaccines, though unproven, are more dangerous than the diseases or their complications?

I shared in an editorial a story of a childhood friend who was left paralyzed in his lower extremities from contracting polio in childhood. And a cousin has a child, now almost 40 years old, who was left blind and speechless from encephalitis following measles contracted when she was five years old.

Cases like these are rarely seen anymore, but will they become more commonplace with more parents refusing to let their children receive vaccines? These are very real risks that many don’t think about. We need to continue to educate parents on the science that supports vaccine administration.

Posted in children's health, Shawn Kennedy, AJN editor-in-chief | Tagged anti-vaccine, autism, Immunization, measles, pediatrician, vaccination | 10 Comments »

Boards of Nursing and the Amanda Trujillo Case

February 17, 2012

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

Amanda Trujillo

Our prior post on the Amanda Trujillo case elicited many comments, on a variety of themes. There were also referrals and crosslinks to other sites supporting, analyzing, and weighing in on the situation, including statements from the Arizona Nurses Association and the ANA, and a post on a physician blog, “White Coat’s Call Room,” which has vowed to carry all the details once the case is decided.

One complaint raised by several people in response to our post was that the Arizona Board of Nursing wasn’t supporting Amanda. State nursing or medical boards are regulatory boards that exist to ensure the protection of the public and to regulate professional practice according to the law (in nursing’s case, according to nursing practice acts). They do not aim to protect the individual nurse, but to assure that all those who claim to be nurses are eligible to claim that title and practice within their scope of practice as defined by law.

Some historical context: Regulatory boards were set up back in the early 1900s, after nursing associations successfully lobbied for registration laws to keep out unqualified women who posed as nurses. In 1903, North Carolina was the first state to enact a nurse practice act; by the mid-1920s, all 48 states had laws regulating who could practice and who could use the title “registered nurse.”

Thus, boards of nursing are intended to protect the consumer and the standards of the profession.

While I agree with several comments saying that nurses should be able to practice within the full scope of their education and training, as recommended by the Institute of Medicine Report on the Future of Nursing, what’s also important to keep in mind is that we must do so in accordance with the law—which unfortunately may not always measure up to our ideals or accurately reflect actual professional practice.

Nurses and state associations need to work to change the law where it needs to be changed—and there are many people who devote themselves to making such change happen—but until the law does change, this is how nurses’ actions will be judged, whatever other motives may appear to be in play or not.

(Editor’s note: A few readers have misconstrued the last paragraph as implying a judgment in the Amanda Trujillo case. This is by no means the intended meaning. The focus here is a more general look at the roles of boards of nursing and the importance for all nurses of not leaving themselves vulnerable to accusations of going beyond their scope of practice, as it has been defined in a particular state’s practice acts.)

Posted in ethical issues, legal issues, Shawn Kennedy, AJN editor-in-chief | Tagged Amanda Trujillo, American Nurses Association, ANA, Arizona, boards of nursing, practice acts, scope of practice | 12 Comments »

On Cats Sucking the Breath Out of Babies, and Other Health Superstitions

February 15, 2012

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.

I recently babysat a friend’s busy toddlers, and was happy to share the long (but lovely) day with a good friend who happens to also be a nurse. We’d just gotten the babies tucked into their cribs and were stepping out of the nursery with a sigh when I noticed the family’s cat lounging in a padded rocking chair, blinking lazily at us.

“Wait!” I said, scooping up the cat. “We can’t leave the cat here. Cats suck the breath out of babies!”

My friend looked at me like I’d lost my mind, and I instantly wished that I hadn’t said it. The absurdity of the statement was clear to me. And yet it felt like a truth I’d known forever, even if I couldn’t remember why.

As it turns out, it was something I was told as a child—by my grandmother. Knowing this makes my statement make sense, at least to me, as I adored my grandma and would have accepted anything she told me as undisputed truth. Even so, I’m surprised (and a little embarrassed) that in spite of higher education and years of nursing experience, despite the obvious physiologic impossibility of a cat sucking the breath from a baby, and despite the fact that I’ve had my own children, and cats, such a notion was lying dormant in my consciousness and escaped unexpectedly and unbidden.

In my curiosity about the idea of cats sucking breath from babies, I came across a 1930 book, Shattering Health Superstitions, by Morris Fishbein, MD. It’s subtitled “An Explosion of False Theories and Notions in the Field of Health and Popular Medicine.” Dr. Fishbein discusses 57 medical claims, asserting their fallacy only after explaining their origin.

Here are some of the chapter titles, verbatim:

Some people think that fish is a brain food and that a lot of mackerel in the diet will convert a moron into an Einstein.
Some people believe that warts can be removed by tying knots in a string and burying the string at a crossroads in the moonlight.
Some people think appendicitis is just an old-fashioned stomach ache and that the doctors developed the disease for their own satisfaction.
An apple a day keeps the doctors away.
When the oldest inhabitant begins to feel pain in his joints, there is going to be a change in the weather.
It takes whiskey to kill a cold.
A favorite Midwestern cure for rheumatism is to carry a buckeye in the trousers pocket.
Kissing can cause trouble, but it doesn’t cause cold sores.
Most people believe that a big head is sure evidence of a massive intellect.

While there may be a shred of truth in a couple of the beliefs alluded to in these chapter titles (many people with arthritis certainly do report worsening symptoms with changes in the weather; many claims have been made for the benefits of fish oil of late; etc.), most have as much basis as certain more recent widely held beliefs regarding the various evils of vaccinations. Read the rest of this entry ?

Posted in children's health, nursing perspective | Tagged Cat, Evidence-based medicine, nurses, popular medicine, superstition | Leave a Comment »

When Lawmakers and Physicians Hold Nurses Back

February 13, 2012

Editor’s Note: Toni Inglis, MSN, RN, CNS, FAAN, writes opinion for the Austin (TX) American-Statesman. She works at the Seton Healthcare Family in Austin as a neonatal ICU staff nurse and also writes a nursing blog for Seton and edits its monthly NursingNews. This article is a reprint of an April 22nd commentary in the Statesman. Toni was inspired to write the column after a particularly disappointing legislative session, in which Texas advanced practice nurses made fewer gains than in past sessions—despite Texas ranking last in access to health care and having the most restrictive laws in the country regarding APRN scope of practice and prescriptive authority. She believes the poor access and barriers to practice are related.

AJN finds the article particularly relevant as legislatures across the country deliberate on APRN barriers to practice. You can read her commentaries at ingliscommentary.com.

Here’s an idea that wouldn’t cost Texas a dime but would save millions of dollars every year: Remove all barriers restraining nurses from practicing to the full extent of their education and training.

by Brian Romig/via Flickr

No state needs primary care providers more than Texas, which has a severe shortage. Texas ranks last in access to health care and in the percentage of residents without health insurance. Of Texas’ 254 counties, 188 are designated by the federal government as having acute shortages of primary care physicians. Of that number, 16 counties have one and 23 have zero.

If every nurse practitioner and family doctor were deployed, we still couldn’t meet the need. Texans are desperate for health care.

Doing the math and to help meet the need, the Legislative Budget Board recommended autonomous practice of advanced practice nurses after a preceptorship.

In Texas, our legislature — session after session — keeps the most restrictive laws in the country. Nurse practitioners don’t want to perform brain surgery. They just want to provide primary care and are quick to refer cases to a doctor when necessary.

Most states with far less need do not legislate practice barriers to nurse practitioners. Given the severity of our problem, shouldn’t we at least bring ourselves in line with those other states? Read the rest of this entry ?

Posted in advocacy/political action, nurse practitioners, nursing perspective | Tagged APRN, nurse practitioner, nurses, primary care, primary care physicians, scope of practice, Texas | Leave a Comment »

A Face in a Village: Remembering a First Encounter with AIDS in Africa

February 8, 2012

We’d already guessed there was a problem at the health post—we hadn’t received the last several monthly statistical reports. As a Peace Corps volunteer in the Central African Republic in the early 1990s, I reviewed these reports as part of my job at the regional health office. Another part of my job was to join a supervisory team as it traveled over dirt roads to check on health facilities from hospitals down to the village health posts staffed by a single nurse. A few months into my assignment, on our way to the provincial hospital, the team decided to stop by this particular health post to find out why we weren’t receiving reports.

That’s from “A Face in a Village,” the February Reflections essay in AJN by Susi Wyss, the author of a well-received recent novel, The Civilized World (Henry Holt, 2011). Set in Africa, the novel, like this essay, was inspired by the author’s international health career. In this essay, Wyss recalls a vivid first encounter with the ravages of AIDS and the hopelessness it inspired. (Click through to the PDF version for a cleaner read.)—JM, senior editor

Posted in HIV/AIDS, international nursing, public health nursing | Tagged AIDS, Central African Republic, Peace Corps, Susi Wyss | 1 Comment »

The Cruel Irony of Alzheimer’s Disease

February 6, 2012

Photo by 50 Watts, via Flickr.

By Amy M. Collins, associate editor

As I watch my grandmother navigate the murky waters of her Alzheimer’s disease, it continues to surprise me that parts of her brain work at warp speed, while other parts seem to be completely defunct. For example, although she can’t remember what she’s done from one minute to the next, she can make up a lie to compensate for the memory loss in less than 30 seconds.

“Where did you get that new necklace, Grandma?” I recently asked at a family party. “Oh I bought it at the place where I work, you know, I type at a school,” she said, with certainty. Or when asked where she got a new sweater, she told my mother she went to the store. “How did you get there?” my mother asked. “I drove,” she said. “But you don’t have a car.” “Oh, well then I must have walked.”

She no longer remembers my name unless prodded, but she does remember that she has a cat in her room at the independent living center, and worries about it constantly. “I have to get back to take care of my cat,” she says when she visits us, becoming increasingly stressed the longer she’s away. Yet it’s hard for her to remember to care for herself, and she often forgets to shower or eat.

She still has a sense of humor, making fun of the “old” people at her facility and bragging about how great her own paintings are. She once complained about a photo of her that hangs in her independent living center’s entrance, together with photos of all the other residents. “Maybe it’s just the lighting, because nobody’s photo looks good,” my aunt said. “Yes, but the other residents really look like that,” my grandmother quipped.

But sometimes even her ability to laugh at things is heartbreaking. She recently called because she was worried about my grandfather—she couldn’t find him in the home. “Dad’s been dead for eight years,” my mother told her, worried at what my grandmother’s reaction might be in revisiting this particular pain. “Oh, well, then that explains it,” she said. “I was wondering how we both fit in a single bed!”

Another unexpected acuity is her ability to outwit her nurses. When it’s time for them to dispense her pills, she sometimes convinces them she’s already taken them. She’s also managed to sidestep nurses’ intervention in her diet. After my grandmother had gained weight over the past few months, the nurse we hired to keep an eye on her told the waiter at her facility not to give her any more ice cream after dinner or bacon for breakfast. While “in her right mind,” she would never have eaten these foods, even once denying my dying grandfather eggs because of “high cholesterol.” But the day after the nurse intervened with the waiter, we found out my grandmother had switched tables, got a new waiter, and got the bacon. Read the rest of this entry ?

Posted in patient perspective | Tagged Alzheimer's disease, dementia, memory loss | 6 Comments »

Off the Charts

Archive for February, 2012

A Role to Live Up To

Military Medicine Has a Head Nurse – Notes from Our Interview

Examining Our Biases About Mental Illness

States Easing Up, Pediatricians Buckling Down on Childhood Immunizations

Boards of Nursing and the Amanda Trujillo Case

On Cats Sucking the Breath Out of Babies, and Other Health Superstitions

When Lawmakers and Physicians Hold Nurses Back

A Face in a Village: Remembering a First Encounter with AIDS in Africa

The Cruel Irony of Alzheimer’s Disease

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