Archive for the ‘Nurse practitioners’ Category

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A Physician Finally Gets Nursing

February 14, 2014

RelmanArticleCaptureBy Shawn Kennedy, editor-in-chief

Earlier this month, the New York Review of Books published an article by a patient who described his hospital stay following a life-threatening accident. This was no ordinary patient—the author, Arnold Relman, is a noted physician, emeritus professor of medicine at Harvard, a former editor of the New England Journal of Medicine, and along with his wife Marcia Angell, well known as a critic of the “medical–industrial complex.” His account is very detailed and gives a good example of how it can look when the system works (and when one has access to it).

His understanding of his condition and treatment, his knowledge of the system, and also his relative prominence as an individual, all undoubtedly helped him avoid some pitfalls and make a remarkable full recovery. However, as a number of others have pointed out recently, one comment in his account was surprising.

In reflecting on his hospitalization and recovery, he wrote, “I had never before understood how much good nursing care contributes to patients’ safety and comfort, especially when they are very sick or disabled. This is a lesson all physicians and hospital administrators should learn. When nursing is not optimal, patient care is never good.” After all his years in medicine, he only realized the value of nursing as a 90-year-old trauma patient.

This week, Lawrence Altman, another physician and author, wrote an excellent post for Well, the New York Times health care blog, examining why that might have happened. Altman, attributing a good part of physicians’ attitudes toward nurses (and other health care professionals) to how they have been educated, says that clinical medical education focuses on and values the interpretation of technology—the numbers as indicators of a patient’s progress, as in vital signs, monitor strips, ventilator settings, lab results, medication dosages. But personalized care is left to nurses, Altman argues, and physicians just don’t give it much attention.

Altman recognizes that nurses are sentinels, vigilant watchers who first note potential life-threatening problems, and he urges us to work toward a greater focus on interprofessional teamwork and education. I hope all who work in health care read his article, especially medical and hospital administrators.

While it’s always gratifying to hear that influential people support nursing’s value, the fact that Relman’s insight occurred so late in his life also makes me angry. How can a leading physician, an advocate for a better medical system, an educator of the next generation of physicians, go through most of his career and not realize nursing’s worth? One would hope that working alongside nurses during years of practice would have changed any misperceptions he might have had as a new physician. Read the rest of this entry ?

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More Than a Headache: Migraines and Stroke Risk for Women

February 12, 2014
Photo by author. All rights reserved.

Photo by author. All rights reserved.

By Karen Roush, MS, RN, FNP, clinical managing editor

I used to think I was lucky. Most of the women in my family have migraines—awful, vomiting for three days, intense pain migraines. Not me. Oh, I have migraines. But no pain, no vomiting, just a visual aura—squiggly lines and loss of part of my visual field for about 45 minutes and then I’m good to go.

I was thankful that I just had the aura instead of the pain and vomiting. But now the evidence shows that migraine with aura, especially when there is no vomiting involved, is an independent risk factor for stroke, as much as if I were overweight, smoking cigarettes, and walking around with my blood pressure through the roof.

And it’s not just having migraines that places me at greater risk for a stroke. Read the rest of this entry ?

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What Ever Happened to a Good History?

January 10, 2014
ky olsen/via Flickr

ky olsen/via Flickr

By Karen Roush, MS, RN, FNP, clinical managing editor

What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.

A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.

Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about his father’s death at 58 of a heart attack. And you realize it’s not a cough that has brought him in; it’s something more that doesn’t fit a neat checklist of symptoms. An ECG shows some nonspecific changes—nothing dramatic—but knowing what you do based on the history, you start an IV, give him an aspirin to chew, a little nitro, call an ambulance, and he’s off to the ED. Later you learn that he was immediately sent to a regional care center and into surgery for a triple bypass.

True story.

Any good NP can tell you their own version of this story. It was just something the patient said, or the way they said it, that heightened their alertness and led them to a diagnosis that could so easily have been missed.

But taking a good history is a skill that is in danger of getting lost in this age of computer checklist care. (That and eye contact, but we’ll save that for another blog post!) Two recent visits I made to clinics, one for primary care and one for urgent care, found me looking at the backs of nurses’ heads as they ran through standardized lists of questions, dutifully clicking them off a checklist on the computer. The provider at the urgent care center took a look at the answers and then proceeded, silently, with the exam. This may seem extreme, but unfortunately it or something very much like it is too often the norm. Read the rest of this entry ?

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Bed Bath: The First Day of the Rest of Her Life

January 6, 2014

BedBathIllustration“Bed Bath,” the January Reflections column by pediatric nurse practitioner Kathleen Hughes, is a description of giving a first bed bath as a nurse after many years working in other professions. It’s not the first essay we’ve ever published about giving a bed bath, but it’s wise and meditative and well worth a read. Here’s a small section of this short essay, but please read the whole thing.—Jacob Molyneux, senior editor

An Ivy League degree and 15 years of teaching and writing did not prepare me any better than my mostly 20-something counterparts in the ways of giving a bed bath to a 72-year-old man I’d never met. What might be different for me is that I have known many kinds of professional challenges. What might also be different is that I have lived enough longer to have attended my father’s hospital-bound illness and death, and to have given birth to and cared for two young children. And so when I washed this man, I was washing my father, I was washing my children; I became one of those people who cared for us. Though giving a bed bath is not anything like lecturing to AP students on Faulkner, or writing a newspaper article on gun control or university library funding or modern exorcisms, I am not sure that either of those tasks made me hunker in a corner for five minutes, gathering myself before striding into the room. I’ve also never left a room feeling like I’ve had as simple and visceral an impact as I did that morning.


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The Nursing Report That Didn’t Just ‘Sit on a Shelf’

December 18, 2013

Joyce Pulcini is director of the master’s programs and of community and global initiatives at the George Washington University School of Nursing in Washington, DC. She also is the contributing editor for AJN’s Policy and Politics column.

From otisarchives4, via Flickr

From otisarchives4, via Flickr

IOM speakers and panel focus on a major report’s increasingly visible real world effects—while emphasizing diversity and the roles of every type of nurse at every level.

On December 11, I attended the Institute of Medicine (IOM) event celebrating the three-year anniversary of the The Future of Nursing: Leading Change, Advancing Health report, released in 2010. The event at the National Academy of Sciences in Washington, DC, highlighted the impact of the report so far and discussed the continued work of the Future of Nursing: Campaign for Action in terms of priorities for the nursing profession.

Some highlights:

  • Harvey V. Fineberg, president of the IOM and panel moderator, started with the fact that the The Future of Nursing: Leading Change, Advancing Health report had generated more than 1.3 million hits since it was first launched in 2010 and that this was one of the most successful of all of the IOM reports. The goal was that this report not sit on the shelf like many past reports but that it be used to improve the health care system. All speakers agreed that this goal was being realized.
  • Donna Shalala, president of the University of Miami and chair of the IOM Committee on the Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, said that the response to the report demonstrated that it was “nurses’ time.” She emphasized that all parts of society need to be represented in the health care workforce and that all levels of nursing should play a role in improving the quality of health care. In discussing scope of practice roles for advanced practice nurses, she pointed out that the state of New Hampshire has had full scope of practice for nurses for more than 20 years and that no major safety or quality problems have been reported there.
  • Susan Hassmiller, senior advisor for nursing at the RWJF, discussed the fact that this report was highly rigorous and only used evidence-based studies to validate the findings. She noted that since the report was published, 15 states had introduced new legislation on the scope of practice for nurses. She also said that 51 action coalitions had been activated as a result of the report and that all were working on the so called 80/20 recommendation to increase the proportion of nurses with BSN degree to 80% by 2020. She also emphasized that diversity is the key in this recommendation.
  • Lynda Burnes-Bolton, vice chair of the Committee on the RWJF Initiative on the Future of Nursing and vice president and chief nursing officer at Cedars-Sinai Health System in California, said that lower cost outcomes are the goal and talked about the success of this effort in her home state.
  • Carmen Alvarez, a George Washington University postdoctoral fellow, family nurse practitioner, and certified nurse midwife who practices in Virginia clearly described clearly some of the challenges for APRNs as they try to care for patients. She provided poignant examples of situations in which precious time was lost acquiring physician signatures and the inconvenience to patients that resulted. Read the rest of this entry ?
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NP Develops Innovative Runaway Intervention Program in Minnesota

November 22, 2013

Ten years ago, NP Laurel Edinburgh began to see a number of sexually exploited girls in her practice at the Midwest Children’s Resource Center, a child abuse clinic within Children’s Hospitals and Clinics of Minnesota in St. Paul. The girls, who were runaways, were quickly slipping through the cracks. Half were no longer in school, many hadn’t been reported missing by their parents, and many were staying with gang members. Some had been gang-raped; others had had sex with men in exchange for money or drugs.

Via U.S. Dept. of Health and Human Services Web site

Via U.S. Dept. of Health and Human Services Web site

That’s the start of a profile (“Nurse Develops Runaway Intervention Program”) by editor Amy Collins in the November issue of AJN. It’s about a nurse practitioner in Minnesota who, in the course of her daily practice, noticed a population in need and did something about it, finding ways to establish contact with runaway girls and help them rebuild their lives. The article will be free until December 6. The nurse who started the program, Laurel Edinburgh, RN, CNP, hopes her approach will catch on in other states—so please give it a read.—Jacob Molyneux, senior editor

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Tightly Scripted: One NP’s Experience with Retail Clinics

November 1, 2013

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

Retail health clinics (walk-in clinics that are in a retail setting such as a drugstore or discount department store)KarenRoush have become an effective mode of providing increased access to care for many people and a growing source of employment for nurse practitioners (NPs). Their place in the health care arena may take on even more significance as the Affordable Care Act (ACA) increases access to care for previously uninsured people.

I worked as an NP in a retail clinic for about six months while working on my PhD. I left because of concerns I had about the model of practice. It didn’t have to do with the fact that I had to mop the floor at closing time or collect the fees and cash out the “drawer” every night. Nor because I spent eight hours alone in a small windowless room tucked away in the back of a drugstore. Those aspects were not great, but they weren’t deal breakers.

What was a deal breaker was the rigid programming of my practice. The computer was in control. From the moment the patient checked in at the kiosk outside my door, every action was determined by the computer.

The organization I worked for prided itself on following evidence-based practice, but someone forgot to tell them that the patient’s history, presentation, and personal experience, as well as a clinician’s expert knowledge, are also part of the evidence. And as much as they insisted the programming was guided by evidence, it was clearly also guided by what would result in the highest level billing code.

From the moment I entered the chief complaint in the computer, it directed me on what to include in the history and what to do for the exam. The problem was that unless I filled out all the information, I couldn’t go on to the next screen. Say I have a feverish four-year-old with tonsillitis, screaming in her mother’s arms, and the computer insists I take her blood pressure. Why? Because there is strong evidence that strep throat is associated with pediatric cardiovascular disease? Nope. It’s because the more systems you include in your exam, the higher the billing code. As a result, I find myself struggling to take an unnecessary blood pressure, causing unnecessary distress for a sick toddler. But unless I put a value in the box asking for the blood pressure, I can’t proceed with the exam. Read the rest of this entry ?

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