Archive for the ‘professional identity’ Category

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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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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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AJN July Issue: Hepatitis Update, Ehlers-Danlos Syndrome, Nursing’s Blind Spots, More

July 1, 2015

World_Hepatitis_Day_AJN_July_CoverOn the cover of AJN‘s July issue is the 2015 logo for World Hepatitis Day, which takes place on July 28. About 400 million people around the globe live with viral hepatitis, a disease that kills 1.4 million people every year—approximately 4,000 a day. While incidences of hepatitis A and B have declined in the United States in recent years, hepatitis C infection, formerly stable or in decline, has risen at an alarming rate. To learn more about hepatitis in the U.S.—and the role nurses can play in prevention and treatment—read our July CE, “Viral Hepatitis: New U.S. Screening Recommendations, Assessment Tools, and Treatments.”

The article reviews the epidemiology and diagnosis of viral hepatitis, new screening recommendations and innovations in assessment and treatment, and an updated action plan from the Department of Health and Human Services, in which nurses can play an important role in the coordination of care.

Some other articles of note in the June issue:

• CE feature: “Nursing Management of Patients with Ehlers–Danlos Syndrome.” An often debilitating condition, Ehlers–Danlos Syndrome (EDS) refers to a group of hereditary connective tissue disorders that has historically been misunderstood and underdiagnosed due to a lack of familiarity with its signs and symptoms. As awareness and recognition of the syndrome improve, nurses are increasingly likely to care for patients with EDS. This article gives an overview of the syndrome and provides guidance on ways to manage symptoms, recognize and prevent serious complications, and improve patients’ quality of life. Read the rest of this entry ?

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Surveys Aside, One Crucial Precondition for Real Patient Satisfaction

June 29, 2015

callbellBy Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN

During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?
1. Never
2. Sometimes
3. Usually
4. Always
5. I never pressed the call button

Everyone is talking about patient satisfaction these days. Purposeful rounding, responsiveness, and customer service are discussed in meetings, on blogs, and in conversations at work. An entire science has been created out of satisfaction, with whole journals devoted to patient experience and paid officers tracking scores and strategies. Since hospital reimbursement is linked to how happy patients are, we’ve suddenly gotten serious about satisfaction.

But behind the sterile questions on the HCAHPS survey, real stories about real people reside. I find myself often forgetting the flesh and blood that’s represented by each checked box, and am learning to realize that, while satisfaction is something to be striven for, dissatisfaction is something to be learned from.

In a series of posts, starting with this one, I’ll share stories of my own missteps—ones that may have caused my patients to answer never instead of always to questions about my care. The events described here helped me realize that, score or no score, responding to call bells actually matters at the human level:

Sarah was a difficult patient. Not even five years my senior, she looked five times older than us both. Sarah had a cache of needs that most of my colleagues found infuriating, but she was also deathly ill from a congenital disease, and hooked up to the most complex monitoring devices the ICU had available, making it almost impossible for her to find a position of comfort. The other nurses whispered. They refused to take her as their assigned patient, and rolled their eyes at Sarah’s requests and her steadily ringing call bell.

As a young nursing student, I had a professor tell me that whenever a patient presses a call bell multiple times, they’re doing so for two reasons. If the obvious reason—bathroom assistance, pain medicine, thirst—were the only reason, they’d likely stop calling at some point. However, patients who constantly call may be using the call bell to say something their voice, and their tangible requests, cannot—that they are afraid, don’t trust their care, or feel better with a nurse present.

My professor gave an all-money-back-guaranteed solution: solve every physical need in a timely or upfront way, and then set care intervals: intentionally tell your patient you will return in a set amount of time, and then keep your appointment. Promise again, deliver on the promise, and repeat at increasingly longer intervals, until they no longer call.

As a new nurse, I tried this, and it worked like magic. It always worked, in fact, so it became how I always patterned my care. Patients like Sarah didn’t bother me—I knew her reputation for frequently calling, so I started my first shift with her by being overwhelmingly present. I pulled up a chair and introduced myself. I began by asking her what she wanted from me during our time together, what she expected, and what she needed.

She grew to trust me, not because I always came when she called, but because I made her an active part of her care, and I helped her to see that I was proactive in meeting her needs. Also following my professor’s advice, I set limits with Sarah, but they were soft limits–“I’ll come back in 15 minutes, okay?”

This didn’t mean she stopped calling me; it just meant she called me purposefully, because I also attended to her subliminal need to call.

She didn’t want her hair combed or her bed changed, as much as she wanted to sleep and be pain free. But her care expectations were rigorous, and I answered, and bargained, and advocated, and propped, and pulled up, to make sure that her pain was gone and she felt safe under my watch. So, after a time, when Sarah did call, I ran, because I knew she really needed me. Our agreed-upon schedule kept me in and out of her room so often that the unsolicited sound of her bell rang like an alarm.

Because I was able to push past her “neediness” and see it for what it was, I got assigned to her all the time, and I got to know her as a person. Sarah’s voice sung like a tiny yellow bird, and she was smart. We talked about real life things, joked about her stack of bills—“Last time you looked at those, you got tachycardic; please take it easy tonight”—and began to know and respect each other far beyond the nurse–patient level.

One night, I came in to find Sarah assigned as one of my patients. I said my hellos, asked her what was up, settled her in, sharing her hopes that she’d be able to sleep. My other patient, a change-of-shift admission, needed my minutes more urgently, so I couldn’t spend my usual time chatting at Sarah’s bedside to start my shift.

This new patient had a serious infection, was smothered under a bipap mask, and painfully anxious. She squirmed as I worked, swatting at the mask, confused about my instruction to relax and be still. My patience was slight with her—I had too much to do trying to save her life and little time for the tenderness I bestowed on sick-but-stable Sarah.

As I struggled with her confusion, which affected my ability to administer her ordered care, I ran through my new patient’s orders. Penicillin stuck out. I knew that an order for antibiotics was crucial, but I thought penicillin a rare choice to make in the land of high-powered antibiotics like vancomycin and Zosyn that I so frequently gave in the medical ICU. I checked her allergies and penicillin wasn’t one of them.

But this “hmm” moment shot up a tiny red flag in my mind—first dose, watch for reaction. I made a plan to stay in the room while the bag infused, even though it wasn’t required and I had plenty of other things I needed to run for.

My new patient was already confused, but her mood changed almost as soon as the penicillin hit her bloodstream. She flushed and scratched at her chest, and from under her bipap mask, I heard her moan. I knew what this was, and was glad for the extra caution I’d taken. I stopped the penicillin, broke the seal of the mask on her face, and she answered the question I was about to ask: “I’m itching! I’m itching!”

With saline flushing in its place, I pitched the penicillin. Benadryl, steroids, cool air, a break from the bipap, an assessment from the resident, and my new patient immediately improved. With oxygen running in a high-flow mask, she held my hand and we breathed together. I could still see the redness in the soft tissues of her neck, but its spread soon slowed. The worst was over, but there was no way I’d leave her side until I was sure that the reaction had fully subsided.
Read the rest of this entry ?

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Soul-Satisfied, but Heartbroken: The ‘Soft’ Skills of Oncology Nurse Navigators

June 22, 2015

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog. The illustration below is part of a series on mountains as barriers that she is working on.

Untitled oil stick & charcoal on paper by Julianna Paradisi

Untitled oil stick & charcoal on paper by Julianna Paradisi

When I introduce myself to nurses as an oncology nurse navigator, they often respond, “Oh, that’s great,” staring blankly. Sometimes, in the midst of patient care, they say, “Yeah, that’s great, but I’m really busy. Come back later.”

Nurses caring for patients are really busy—so busy that this is one of the reasons the relatively new specialty of nurse navigators exists. Another reason is that oncology care is increasingly complex, and mostly occurs in the outpatient setting where vulnerable patients must fend for themselves.

Patient navigation was founded in 1990 by Harold P. Freeman at Harlem Hospital Center to improve outcomes for poverty-stricken African-American women presenting with stage III and IV breast cancer. Freeman declared, “The core function of patient navigation is the elimination of barriers to timely care across all segments of the healthcare continuum.”

In 2010, the Affordable Care Act (ACA) mandated patient navigation for oncology by 2015. No longer aimed only at serving the poor, the ACA requires navigation services be offered for a defined interval of cancer treatment. The goal is a reduction of health care costs and an increase in quality by decreasing delays in access to care while utilizing a targeted set of health services. Patient navigation improves outcomes, and saves money.

Barriers to care include, but are not limited to: lack of community cancer screening, poverty, lack of transportation to appointments, medical illiteracy, patient anxiety, and fear.

Navigation programs differ among institutions. In many, navigators are registered nurses with extensive backgrounds in oncology. In others, navigators are nonmedical, often social workers, with special certification. The monikers nurse navigator and patient navigator distinguish between the two.

The benefit of hiring nurses as oncology navigators is that our licenses allow us to assess patients, provide education, manage side effects, and offer psychosocial support. On a typical day, I spend time assessing by phone if the rash a patient casually mentions should to be seen by their oncology provider. Does another patient understand their discharge instructions? What resources are available to patients struggling to pay monthly bills? If patients drive in from a rural community to their appointments, are they eligible for gas cards?

When patients are discharged from the hospital, nurse navigators oversee their needs. Nurse navigators are part triage nurse, part case manager, a bit of a social worker, a confidant, and support group for our patients.

“Wait a minute,” you’re thinking, “what you’ve described is a nurse, a plain old nurse. That’s the work of all nurses.” Read the rest of this entry ?

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An Updated Code of Ethics for Nurses as a Call to Action

June 17, 2015

By Katheren Koehn, MA, RN, executive director of the Minnesota Organization of Registered Nurses (MNORN) and a member of AJN‘s editorial board.

YearofEthics2015In January, the American Nurses Association declared 2015 to be “The Year of Ethics,” to highlight the first revision to the Code of Ethics for Nurses with Interpretive Statements since 2001. Last week, in Baltimore, ANA hosted an Ethics Symposium to facilitate a dialogue about just what the Code means to nursing practice.

This was not your typical esoteric ethics conference, with terms like beneficence, nonmaleficence, fidelity, and utilitarianism floating throughout the sessions. At this symposium the Code of Ethics became a unifying “Call to Action” for the profession.

In welcoming comments, Patricia Davidson, dean of Johns Hopkins School of Nurses, spoke of how ethical practice is critical for improving health care, especially with the move to person-centered care. She reminded us of the moral imperative to address entrenched health disparities, including access to care, and urged each of us to summon our own courageous leadership as we advocate for patients and families and question “entrenched beliefs.”

ANA President Pam Cipriano gave an overview of the Code of Ethics for Nurses, which articulates the ethical obligations and duties of every nurse. The Code binds us together, according to President Cipriano, no matter what practice setting we work in, or job title we hold. It is our nonnegotiable ethical standard, expressing our profession’s understanding of our commitment to society. There is no “opt-out” from the Code—no exceptions, no days when it just doesn’t apply.

The fundamentals are unchanged. The nine provisions of the Code of Ethics will be familiar, because they did not change with this newest revision.

  • Provisions 1–3 are about the “fundamental values and commitments” of the nurse, and include concepts of compassion, respect, advocacy, protection and safety.
  • Provisions 4–6 describe the “boundaries of duty and loyalty,” and include concepts of authority, accountability, responsibility, self, and ethical environment(s).
  • Provisions 7–9 describe “duties beyond patient encounters,” including research, scholarly inquiry, human rights, health disparities, social justice and the integrity of the profession.

What’s new? While the provisions didn’t change, there is new language about nursing leadership, social and health policy, and global health, as well as updated language and concepts. There is also, for the first time, a helpful glossary of terms. These revisions occurred after an inclusive process including 7,800 responses from nurses to the initial inquiry about what should be updates, and 3,000 comments after the draft document was sent out for field review.

Call to action. After the overview, Diana Mason, president of the American Academy of Nursing, returned us to the concept of the Code of Ethics as a call to action, as she highlighted “action” words and phrases located in the nine provisions, including:

  • Promotes, advocates for, and protects
  • The obligation to promote health and provide optimum care
  • Applies to the nurse, in all roles and settings
  • Protect human rights, promote health diplomacy, and reduce health disparities

Was nursing’s current focus, she went on to ask, really on promoting the health of people? What might we do to change the focus of health care from one that is based on health rather than illness? She reminded us that, as nurses, we have an ethical responsibility to work towards the health of communities and all people. Read the rest of this entry ?

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