In London’s Hyde Park, activists laid a carpet of flower petals to represent the lives of children lost each year through malnutrition. Photo by Ismar Badzic via Flickr.

Simultaneously, the Lancet published its second paper in a series on maternal and child nutrition. The authors of the study estimate that poor nutrition is the root cause of 45% of child deaths (3.1 million deaths among children under age five each year). 

The report builds on a similar report from 2008 and highlights the progress achieved since then. For example, the number of the world’s children who never grow to their potential height has dropped steadily over the past two decades, from more than 253 million in 1990 to 167 million in 2010.

But according to the new report, far more can still be done. The authors estimate that close to 15% of all deaths in children under five can be prevented, and at least a fifth of all stunting avoided, if 10 nutrition-specific interventions are scaled up to 90% coverage in the 34 countries most affected by malnutrition.

These evidence-based interventions include

• providing periconceptual folic acid supplements, balanced energy protein supplements, calcium supplements, and micronutrient supplements to pregnant women.
• promoting breastfeeding and delivering appropriate complementary feeding to infants.
• providing vitamin A and zinc supplements to children up to the age of five.
• implementing strategies to manage moderate and severe acute malnutrition.

To read the executive summary of the full report (available to download for free), go to: http://download.thelancet.com/flatcontentassets/pdfs/nutrition-eng.pdf. —Amy M. Collins, editor

Twenty-one days pass. I am a 90-pound bag of skin. Legs like peanut butter drapes thrown over femur bones, no muscle, no pronounced curve. A lover would look past me quickly in the street. I do not want these scars, or this strange body. I want to wear a red bikini. I want a kiss on my belly.

Three weeks felt like spans of small forevers. I didn’t believe my legs and arms were mine. My abdomen sunk to a cave, save for the rustling bag. My aunt hurled the word “unconscionable” on each visit, until the hospital knew her voice. My mother, grandmother, aunts, they stayed in mornings, my little brother stayed through late nights, nodding off once the drugs snatched my eyes to sleep. So many people, one could’ve mistaken my bed for a box. I can’t remember them all, or even all the days.

The nurses were there everyday, same ones. This is their wing. The doctors came in swarms, always hanging heads to pens unless speaking. I wore lipstick when we passed the vomit days, gave laughs to friends. My big sister gave me big twists in my hair.

A disease that had already stolen my youth, at 27 I lost my colon to Crohn’s. When they removed the sick parts, cut away the damaged pieces, they also took the one feeling my body understood. Pain is a tricky thing, illness a confusion of sense. A piercing touch, the sight of blood, a smell can make you puke. A sound can make your head bang. The metallic taste of medication can make you want to quit. I never knew what healthy felt like. It was all so strange.

The functions of me were foreign. I would never work the same.

At first I looked for clothes with ruffles and flares. I cried at the sight of a middriff top I’d purchased the summer before. I would never again wear low-rise jeans, or bikinis, or mesh articles of any kind. I would never undress myself with pride. There were vows to celibacy, thoughts of a hermit life—all sorts of ridiculous ideas. My best friend reminded me I never really wore middriffs much, anyhow. Old pictures reminded me a decade had passed since I’d worn a two-piece swimsuit, then there was the recollection that I couldn’t actually swim. A small step to recovery.

The same Band-aid stuck to my body for a lifetime. This is what permanency feels like. On the right side of belly, I carry the burden of desperation, the things we humans do to stay alive. My caramel skin sticky with adhesive and the color of someone else’s nude. The beige bag flattened under all that I wear, who could ever guess my unbalanced geometry. No one ever had to see the off parts of me, unless there was a man to love me despite, and still, there are ways to hide from the world. Wraps and lace, pockets of all kind. I can never truly be a naked girl. I live in a time warp of constant repair, fixing. Never fixed. My body working its way around the darkness that knows to fill a space.

There are days I long for my missing parts. There are nights I want to rip this flimsy device, this thin plastic velcro glue Band-aid separating me from embarrassment, from fragility. Shame can feel stronger than love tries to be.

My family said it would be okay, that I am a pretty girl, and young, and there are people who would want me even if I am not whole. The little ones pretended not to notice when I walked through the house in sports bras and yoga pants. My son was confused, fearing small plastic grocery bags were my new toilet. Only the girl was bold enough to ask why my body was different. I answered in truthfulness, enough detail to make a small child squirm, but not afraid.

Children need to understand that people sometimes live with holes inside themselves, real holes, or holes that only they can feel. Her brother called me an alien, weird but super cool. I laughed and let my hands tell the story, pointing to skin, making gestures and waving with the scientific words. They all gathered in a circle and listened. They wanted to touch me. I let them touch me.

Then there was awe and question. Searching for shame in the lines of my face, they found none.

They looked at their own bellies. The girl excitedly shouted how we are the same, small brown fingers pointing to tiny nicks in her skin.

I like this new body some days, though not all days, neither is it love or hate. It holds together my bones and blood, and for this I am grateful, for understanding the nature of body through the form of my own, realizing just how much it fights and chooses, how much it wants to live.

Doyle Alphabet by fdecomite, via Flickr

It all started suddenly: weird, creeping sensations in my forehead and between my eyes, especially when I lay on my back or bent my head forward. The expression “my skin is crawling” quickly came to mind. Over the next few days, I began to experience intense pressure in my forehead and a weird sensation on the bridge of my nose—as if a large clothespin had been clipped onto it. Within a few days, it felt like someone had poured a sack of concrete into my head.

My self-diagnosis was sinusitis—a term that covers many etiologies. But most cases of sinusitis begin with head or facial pain and nasal discharge—not the strange sensations my wife and I soon started calling “the aliens.”

Nevertheless, I began an aggressive self-treatment program: decongestants, aspirin, and something called a Neti pot—an ancient form of nasal irrigation using a vessel resembling a small, plastic teapot.

After a couple of days, my symptoms were considerably milder—but by no means gone. I saw my primary care doctor a few days later, and—despite the “alien” sensations—he concurred with my diagnosis. Antibiotics are notoriously overprescribed for sinusitis, and my very conservative PCP was not about to do so. Steroid nasal sprays are also used, and I asked Dr. G. if he’d consider a trial.

“Nope!” he replied, “I’d like you to see an ENT. If you have a nasal polyp, I don’t want to shrink it with steroids and miss the diagnosis.”

I nodded in agreement, but I was disappointed. My doctor was talking the language of science—“Don’t introduce extraneous variables into your investigations”—and I was wagging the tongue of misery.

“OK,” I said glumly, “but my head feels like somebody inflated an inner tube inside it. What should I do in the meantime?”

“Decongestants, pain relievers, liquids, and the Neti pot!” he replied firmly.

Fortunately, I managed to get an appointment with an ENT the following week. But after presenting my history, I could see that he looked subdued and a little pale. What he said next left me with a sinking feeling in the pit of my stomach.

“Your history is very atypical for sinusitis,” he said quietly. “Sounds more like something neurological—maybe some kind of atypical migraine.”

I was stunned. In my entire life, I’d never had a single migraine. Why, at the ripe old age of 59, would migraines start now?

Physicians and nurses are taught that “when you hear hoof beats, don’t think zebras.” Your diagnosis should reflect the most probable causes, not exotic possibilities. But we are also trained to consider worst case scenarios—and so I began to run through some of the “zebra” diagnoses.

One possible if rare cause of abnormal facial sensations is a brain tumor. I knew the likelihood was very small, but I couldn’t dislodge the thought from my mind: maybe the “aliens” were due to a truly alien mass in my head. In the meantime, the ENT didn’t want to prescribe anything, pending a neurologic consultation and maybe some brain imaging. It was back to the Neti pot—and more misery.

The neurologist listened carefully to my history and did a thorough examination, finding nothing out of the ordinary. Nonetheless—“out of an abundance of caution”—he advised an MRI of my head. Naturally, I was relieved by the normal exam. But as a psychiatrist, I knew of many cases in which the neurologic exam was normal, only to have the brain CT or MRI show something really nasty.

Finally the day of the MRI arrived. Some patients describe the MRI’s tubular enclosure as a bit like being inside a coffin. But I relaxed and nearly drifted off to sleep, despite the rhythmic, knocking sounds inside the giant apparatus. The neurologist was extraordinarily kind and told me to call him within 24 hours for the results. The next day, I got the good news: “Your MRI was totally normal,” he said calmly. “Nothing much in the sinuses, either.”

Great news—except that the aliens were still hammering me. Now it was time to “noodge” the ENT. I immediately called his office and informed him of the negative MRI. The next day, he phoned in a prescription for nasal steroids. After I’d used them for less than a week, my symptoms had abated markedly. I still didn’t understand the genesis of my condition, but I was beginning to feel fully human again.

It had taken my doctors nearly two months to start routing the aliens. As a physician, I can’t fault them for their cautious “let’s find out what we’re dealing with” approach. And yet, I sometimes wonder how much discomfort I might have been spared had I received those nasal steroids early on.

Science is wonderful—suffering, not so much. And as for medical self-diagnosis, I am reminded of the lawyer’s adage: someone who represents himself in court has a fool for a client.

March 26, 2010: A poster supporting the Sexual Assault Prevention and Response (SAPR) program. (U.S. Navy photo illustration/Wikimedia Commons)

On June 7, the U.S. Air Force command named Maj. Gen. Margaret H. Woodward director of its Sexual Assault Prevention and Response Office. She replaces her predecessor, Lt. Col. Jeffrey Krusinski, who was charged with sexual assault in early May.

Announcement of his arrest came the day before the Department of Defense was to hold a press briefing to tout changes intended to improve the handling of sexual assaults. Also on June 7, the U.S. Army command suspended Major General Michael T. Harrison, the commanding general of the U.S. Army in Japan for failing to “to report or properly investigate an allegation of sexual assault.”

At the press briefing, Secretary of Defense Chuck Hagel said he was “outraged and disgusted” at the allegations against Krusinki. Hagel also asserted that “[a]ll of our leaders at every level in this institution will be held accountable for preventing and responding to sexual assault in their ranks and under their commands.” But will commanders really be forthcoming? Will they be willing to report crimes that could make them look like they can’t manage troops effectively, thereby potentially endangering their own chances for promotion?

Congress has launched an investigation into how the military is handling sexual assaults. According to the Washington Post, the hearings were precedent setting in that it was the first time the entire Joint Chiefs of Staff had testified together as witnesses; the hearings were also marked by the significant presence of women on the Senate Armed Services Committee—seven in all.

Perhaps we are at the tipping point and having so many women on the committee holding the military accountable will make a difference. Perhaps the only solution is a bipartisan bill proposed by Senator Kirsten Gillibrand (D-NY), a member of the Armed Services Committee, which would remove prosecution of such crimes from the military chain of command. The Washington Post reports that all the military chiefs oppose that idea.

I wonder what nurses in the military think—surely many have had occasion to treat troops who have been injured in sexual assaults.

Illustration © Anne Horst / http://www.i2iart.com

In her poem “Sleep in the Mohave Desert,” Sylvia Plath wrote about not sleeping, feeling comfortless, tormented by the “heat-cracked crickets . . . [that] fiddle the short night away” in “the blue hour before sunup.” Though Plath was writing as an adult, sleeplessness and other sleep difficulties have troubled humans of all ages for centuries. Until recently, we could only guess at the health consequences. Now there is mounting evidence that inadequate or insufficient sleep has many adverse effects. Adolescents appear to be particularly vulnerable—and it’s not simply because they’re rebelling against bedtime. In this month’s CE, “Assessing Sleep in Adolescents Through a Better Understanding of Sleep Physiology,” authors Nancy George and Jean Davis offer an in-depth look.

Overview: Adolescents need about nine hours of sleep per night, yet most teens get far less. Inadequate sleep has consequences not only for academic performance but also for mental and physical health; it has been linked to lowered resilience and an increased risk of cardiovascular and metabolic diseases. It’s imperative that assessment of sleep become a routine part of adolescent health care. An understanding of sleep physiology is essential to helping nurses better assess and manage sleep deprivation in this population. Sleep assessment involves evaluating the three main aspects of sleep: amount, quality, and architecture. The authors provide an overview of sleep physiology, describe sleep changes that occur during adolescence, and discuss the influence of these changes on adolescent health. They also provide simple questions that nurses can use to assess sleep and risk factors for disrupted sleep, and discuss patient education and other interventions.

The authors close with detailed suggestions for nurse–patient education, which include teaching adolescents how to

• unwind from the day’s activities.
• establish bedtime rituals.
• create an environment conducive to sleep.
• avoid activities that might impede sleep.

To learn more, read the article, which is free online. And please share your thoughts and experiences with us in the comments.

Argonauta: The Beach at My Back/ oil stick on paper, 2010 by Julianna Paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

 “Reality is the leading cause of stress among those in touch with it.”—Jane Wagner

By 2014, up to 30 million Americans will have gained access to health care insurance under the Affordable Care Act (ACA). As a nurse human being, I support increased access to health care. However, it is naive to believe it can be accomplished without sacrifice.

My job is a casualty of the ACA.

But let’s backtrack:

It’s more accurate (but less dramatic) to say that our country’s need of better health care delivery significantly affects my job. Most hospital nurses are familiar with Medicare tying reimbursement to patient outcomes. Further, built into the ACA is a requirement that hospitals expecting Medicare reimbursement form accountable care organizations (ACOs):

Under the proposed rule, an ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the patients they serve with Original Medicare (that is, those who are not in a Medicare Advantage private plan). The goal of an ACO is to deliver seamless, high quality care for Medicare beneficiaries. The ACO would be a patient-centered organization where the patient and providers are true partners in care decisions.

In other words, hospitals are expected to stop competing for Medicare dollars and work together to reduce duplication of services, decreasing costs within their communities. This is not an entirely new idea in health care. Trauma and neonatal tertiary care centers existed before I graduated from nursing school. They provide advanced health care technology to communities unable to afford them.

ACOs go beyond this concept, however, mandating “partnerships or joint ventures arrangements between hospitals and ACO professionals.”

For example, one hospital will purchase the most advanced machine for radiology, while its competitor will invest in the latest laser surgery technology. Patients needing either will be referred to the center in their community providing that service, thereby increasing its number of billable Medicare patients, decreasing cost and duplication of services. This is my understanding of some of the changes taking place in accordance with the ACA. May I remind you, I am a staff oncology nurse, not an economist.

Here’s how ACOs affect me: My job as an oncology infusion nurse is being combined with those of another hospital offering similar patient services. The short version: After 20 years of employment, along with my coworkers I will have a new employer.

I know it’s just business. I go to work, and every two weeks receive a paycheck for my hours. Every two weeks, my employer and I are even. Still, it feels a little like how I imagine if, after 20 years of marriage, your spouse informs you he is leaving for no particular reason: “It’s not you, it’s me.”

Initially, I couldn’t help but feel abandoned.

A person’s reaction to such situations is clouded by sentiment. There are concerns about possible changes to regular work routines. There is worry over potentially commuting to other work sites. The funniest one occurred while I perused the hospital gift shop, lamenting to myself about the loss of my employee discount. Then I remembered: “We don’t have an employee discount, you sentimental fool!” Feelings of rejection play tricks on memory.

On the other hand, the new employer presents a very attractive job offer. In fact, some of the benefits are much better. I cannot resist this lover employer. Sometime this fall, just short of 20 years with my current employer, I will have a new employer.

Health care delivery in the United States is not only unjust—it is unsustainable. The ACA is one effort to fix both of these problems, putting the health care industry in flux. The question is not, “Will it change?” but “How?” Collectively, insurers and physicians have known this for a while, and react politically. Nurse leaders attend meetings in Washington, representing nursing’s voice in the conversation. The influencers with the most money have the biggest lobbies, but it’s too soon to call the final product of these discussions.

I continue to support increased access to health care; however, it is naive to believe it can be accomplished without sacrifice.

I am reconciled to the change occurring in my career. In fact, I will go so far as to say I am cautiously optimistic that I will find the change beneficial in some ways. As in any 20-year relationship, it’s not like my old job, while very good, was perfect.

I was recently considering all of this while strolling through the hospital lobby, where I ran into a friend from another department. “Hey, I hear your unit is getting a new employer. How’s that working for you?” he asked. “Oh, fine. No worries,” I replied. “I still have a job. You know, I’m a nurse. We come with the room.”

I could still hear his laughter all the way from the other end of the hall.

from Great Ocean Road in Australia

Here’s a final recap of my trip last week to the 25th quadrennial congress of the International Council of Nurses (ICN). (My previous posts on this year’s ICN events are here and here; there’s also a podcast of my interview with outgoing ICN president Rosemary Bryant.)

My final few days were busy with sessions as well as a meeting with some members of AJN’s International Advisory Board. Here are some highlights:

• Nurses and the Nazis. A session on ethics led by Australian nurse Linda Shields examined nursing in Nazi Germany and discussed how nurses might have rationalized participation in Nazi euthanasia and killing programs. She noted that aside from the usual “just following orders” mantra, obedience was tied to housing and livelihood, as well as to the belief that “the health of the volk (community) was more important than the health of the individual.” (The topic brings to mind our 2009 article, “The Third Reich, Nursing, and AJN” [abstract only], which made the case that “in the interest of promoting international cooperation and an image of nursing unity, AJN shirked its duty to hold German nurses accountable” for complicity in the Holocaust.)
• Nursing visibility. Presentations by Canadian nurse union leaders reminded me of home: they talked about campaigns to make what nurses do more visible, noting that if RNs were invisible and their work not valued, they would be at high risk for job cuts. Debbie Forward, president of the Newfoundland–Labrador Nurses Union, talked about “role clutter” and the loss of an RN identity when one couldn’t distinguish RNs from other health care providers, and she described a union campaign—the Clarity Project—to protect and promote the RN role. Sandi Mowatt from the Manitoba Nurses Association, which represents all levels of nurses, talked about initiatives to protect and support all nurses. Ten years ago, she said, only 26% of their members would recommend nursing as a career because of dissatisfaction with workplace policies and wages; today, 72% of nurses in the union would recommend nursing as a good career.
• Medical tourism keeps growing. Frank Shaffer, CEO of CGFNS, led a session on medical tourism (patients who travel to other countries to seek lower cost medical care and surgery), which has become a big business. According to Shaffer, it’s a $15 billion business, with over 5 million people traveling outside their own countries for medical care in 2011. There is now a Medical Tourism Association, which has begun certification for services and standards. Costa Rica apparently leads the industry—Shaffer reported that it garnered $288 million in revenue from 36,000 international patients. Dentistry and orthopedic procedures are the most popular procedures performed.
• Leadership transition. At the closing session, Rosemary Bryant, whose watchword for her four-year term was “access” (“people’s access to care, nurses’ access to education and support, and governments’ access to nurses’ policy advice”), turned the leadership of ICN over to the new president, Canadian Judith Shamian. Shamian dedicated her presidency to her deceased nursing school roommate, and announced that she chose “impact” as her watchword, as “it embodies action and outcomes, and reminds us of the impact nurses have on the lives of those they care for.”

Monet exhibit, Melbourne

I spent my final two days doing some sightseeing—one day I travelled the Great Ocean Road (along with a New York colleague and a group of Danish nurses) and on the other I visited the National Gallery of Victoria to see the Monet exhibit.

As always, one of the best parts of meetings like this is meeting nurses from all over the world and seeing a bit of another country. In my early nursing years, I really didn’t know about the ICN or that, as a member of the ANA, I could attend the ICN meetings. It’s a great experience and I encourage all nurses to attend at least one international meeting during their careers.

My father started us on M*A*S*H soon after his return from Korea in 1973. The Vietnam War was nearing its end, although we did not know it at the time. A combat medic during his tour of duty in Vietnam early in the war, on this most recent tour my father had been stationed in Korea for a year at a hospital that received the grievously injured. “Spaghetti and meatball surgery,” he called it.

Our family had moved to Maud, Oklahoma, in 1972 to be near my mother’s family while my dad was in Korea. The endless countryside around our small town, combined with the local dump, gave us more than enough adventures to keep our minds off the war in a country of which we knew little.

M*A*S*H, the legendary television show featuring Alan Alda as the sarcastic antihero, started the year my father left for Korea. We were not a television-watching family, as such. My mother’s Pentecostal background instilled a deep-rooted distrust for the medium, unless Oral Roberts or Rex Humbard was preaching.

However, on my father’s return, that changed. I was nine years old when he got back, so I know I wasn’t aware of the political statement Larry Gelbart, the program’s creator, was making. My father would later explain to a 12-year-old me that it was only ostensibly about Korea; really, it was about Vietnam.

Every week, the family gathered around to watch. Many of the laughs required no intricate knowledge of the military or war or medicine, but my father, whose experience as a medic in Vietnam and doing triage in Korea lent him special insight, functioned like an expert annotator, dispensing information that opened up new vistas of meaning in the politics of war, gender, sex, death, and dying.

We were used to the motions of life required of a military family: relocation orders, moving without notice, upended friendships, new schools, new housing, new temporary friends. We had suffered all of it with aplomb, so my father’s newfound cynicism about war was disturbing to our routine.

I am almost certain he decided to be a nurse in the wake of Vietnam. Discontented with the calculus by which countries go to war and horrified to the point of nightmare by what he’d seen, he looked instead for a way to heal rather than harm.

My family did not survive the 1980s intact. The diagnosis later known as PTSD was unheard of at the time, but my father had it. An attempt to view Apocalypse Now led to a near breakdown; he shouted and cried out in the middle of the night for days afterward. Except for his U.S. Army work in the hospital, he couldn’t keep any of the two dozen side jobs he attempted. His attempt to help us understand M*A*S*H was his way of trying to help us understand what it had really been like, but like any war virgins, we were dealing with abstractions, not spaghetti and meatballs.

After my parents’ divorce, my father devoured nursing school. An early pregnancy and enlistment in the Army had delayed the application of his intelligence to academic work. Once exposed to it, he thrived. He used his retirement benefits to live on—he’d completed 20 years in service—while the old G.I. Bill helped pay for his education. He retired from the military at 37, and achieved his BSN before 40.

The next step was also difficult. His experience with medicine had been limited to two milieus: U.S. Army hospitals and war. What do you choose when the choices aren’t limited to what your commander tells you you must do?

It took nearly 10 years for my father to work through the options: coronary care, intensive care, post-critical care, ER, oncology, pediatrics, OB-GYN, and every other floor available at every hospital he worked. He even worked a stint at a state mental health facility, back when such things existed. Four broken ribs and a superstitious fear of full moon night pushed him out of mental health care, but that’s another story.

Serendipitously, he found his niche. He was scheduled to work a shift on a drug and alcohol rehabilitation unit in Norman, Oklahoma, in 1987. I was a freshman at the University of Oklahoma at the time, following my stint in the United States Air Force—he’d threatened an “ass-kicking” if I joined the Army. My father had secured me employment on the hospital switchboard at the same hospital to help pay for school.

He worked his shift, which, as I recall, was to help a friend who needed off. While on the floor, he discovered that many of the patients were military veterans. Their experience had driven them to abuse alcohol, cocaine, heroin, pills, as well as other types of escapism. Alway a nurturer, my father found in those men and women the opportunity to apply an ancient principle—redemption, to bring something good and whole out of something ugly and broken.

From then on, my father never worked another unit. He was a drug and alcohol rehab nurse until he retired 25 years later.

Using evidence-based practice to . . .

Fill in the blank. There’s something on your unit that could be improved—the rate of ventilator-associated pneumonia (VAP), the engagement of family in care, the readmission rate of patients with heart failure, patient satisfaction with pain management. Whatever it may be, you have the ability to improve it. This month we have a CE article (link is below) about an evidence-based practice (EBP) project to reduce catheter-associated urinary tract infections (CAUTIs).

Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm/ CDC

The really interesting thing about this article, and what makes it especially helpful for beginner quality improvers out there, is that it doesn’t just describe an effective project to reduce CAUTIs. It also describes how to do an EBP project, step-by-step. The author, Tina Magers, a novice EBP mentor, followed the seven steps outlined in AJN’s Evidence-Based Practice series and describes the actions involved in each step. It’s a great how-to on applying evidence to practice. Here’s the overview/abstract of this useful June CE article, “Using Evidence-Based Practice to Reduce Catheter-Associated Urinary Tract Infections”:

Overview: In November 2009, AJN launched a 12-part series, Evidence-Based Practice, Step by Step, authored by nursing leaders from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Through hypothetical scenarios, based on the authors’ collective clinical experience, the series illustrated the seven steps of evidence-based practice (EBP), defined as “a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values.” This article reports on an EBP project in which the seven-step approach to EBP described in the AJN series was used to reduce the incidence of catheter-associated urinary tract infection among adult patients in a long-term acute care hospital by reducing the duration of catheterization.

Keywords: catheter-associated urinary tract infection, evidence-based practice, hospital-acquired infection, nurse protocol, quality improvement, urethral catheterization

by ashraful kadir/ flickr

I caught an airing of The Shawshank Redemption the other day. It’s one of my favorite movies—full of irony and rich with messages of hope and perseverance.

There’s one line from the movie, in particular, that I love:

“Get busy living, or get busy dying.”

It’s one of my favorite movie quotes, and one that plagued me at work recently as I took care of a woman who’d suffered such a high-level fracture to her cervical spine that her injury was compared to an internal decapitation.

Her doctors had talked with her and her family at length about her injuries and prognosis, and although she’d initially indicated that she wanted to withdraw aggressive care, as time passed her directives became inconsistent—she’d tell her husband one thing, her medical team something else. On the day I was her nurse, she looked at me and very clearly mouthed the words “I don’t want to die,” then shut her eyes tight, ending our brief conversation as effectively as if she’d stood and left the room.

I think that most of the time, at least in the ICU where I work, people aren’t “getting busy” living or dying, but instead are taking very small steps in one direction or another, having been forced by illness or injury into a stillness that looks like limbo.

The more I considered exactly what my patient had said, the more significant it seemed that she hadn’t actually said she wanted to live, but that she didn’t want to die. I’ve come to interpret her words as an acknowledgment that the life terms she’d been left with were unacceptable—but that she’d take them, nonetheless.

She didn’t die. She’s been in our unit for some time, and neither she nor her family members discuss her directives anymore. I wonder if she’s at peace with her decision, although it may be too early to say. It’s not something I want to ask.

We pull her into the cardiac chair and position her in front of the windows. As I look past her I see the birds fly by and the summer clouds building into beautiful lofty thunderheads. I watch her devoted children tend to her during their visits; they bring her paintings and read her lips with ease.

And I know that if I were in her shoes, I’d grasp just as tightly to this life.