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Editing a Journal: Not Bedside Nursing, But Still an Urgency to Get Things Right

August 14, 2015

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

‘Nurses practice based on what’s in the literature; we need editors who will draw lines and stand firm against publishing biased and inaccurate papers.’

Niklas Bildhauer/ Wikimedia Commons

Niklas Bildhauer/ Wikimedia Commons

I recently returned from a meeting in Las Vegas, the land of lights and bells and six-story marquees—and heat (it hit 109 when I was there, but “a dry heat”). The long flight home gave me time to reflect on the meeting I’d attended (of editors of nursing journals) and on what I do.

When I began my nursing career, I always thought I would stay in the acute care setting. I found the fast pace of the ER challenging and never boring. When I moved into a clinical specialist position and then an administrative one, I could still get involved in challenging situations, from dealing with problems that occurred on clinical units or with staff to navigating the politics of hospital committees and community liaisons.

But time passes and paths twist and turn, and here I am the editor of AJN—and it’s the most challenging and professionally fulfilling job I’ve had.

The International Academy of Nursing Editors (INANE for short) meets annually. It’s a loose networking group, mainly held together through a Web site, blog, and listserv. There are no officers or bylaws, no dues. Each year someone volunteers to host the annual meeting and whoever would like to help joins in. Anyone can propose a project, and those who want to work on it volunteer. We pass the hat to raise funds to support the Web site and incidental expenses and to help new editors attend the INANE meeting.

But don’t accuse this laid-back group of being inactive or frivolous—serious issues are tackled on an ongoing basis. True, they are not as exciting as the situations one might encounter in the clinical arena, but they have an effect on what many nurses do and think and implement in practice.

In Las Vegas, sessions focused on some important topics, including

  • the retraction of articles, i.e., when a publisher basically admits that an article is flawed and should not have been published.
  • the ethics of authorship and what to do when authors don’t want to disclose who actually wrote the paper, thus leaving room for conflicts of interest, bias, and skewed results and conclusions.
  • when and how much to fact-check authors’ references.
  • how to ensure students are getting the correct information about scholarly writing and publishing.
  • how to help new authors get their articles published.

Read the rest of this entry »

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Legionnaires’ Outbreak in New York City: Some Basics for Nurses

August 12, 2015

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

11148_loresIn the largest U.S. outbreak of Legionella infection since 1976, when there were 221 cases and 34 related deaths in an outbreak at a Philadelphia American Legion convention, more than 113 cases of the disease have been diagnosed in New York City since mid-July. Twelve people have died.

Legionnaires’ disease is neither rare nor exotic; it is a type of community-acquired pneumonia (it can also be hospital acquired). Symptoms include fever, cough, and progressive respiratory distress. Legionella can also cause a milder, flulike illness known as Pontiac fever that generally resolves without treatment. Because many cases of Legionnaires’ disease are never actually diagnosed, mortality rates are difficult to determine, but the rate currently is estimated at 5% to 30%.

The CDC estimates that 8,000 to 18,000 people are hospitalized with Legionnaires’ disease each year in the U.S., yet only about 3,000 cases are diagnosed and reported. Most cases of Legionnaires’ disease are sporadic, unlinked to any outbreak. The infections often are not recognized as Legionnaires’ disease, for several reasons.

  • Legionella infection is easily treated empirically (that is, without confirmatory lab testing) with common antibiotics, with the patient usually recovering. This is a practical and cost-effective approach to community-acquired pneumonia, but many cases of Legionnaires’ disease are never diagnosed as anything more specific than “pneumonia.”
  • When Legionnaires’ disease is suspected, the most common test ordered—Legionella urinary antigen—tests for only one of more than 46 Legionella species: pneumophila serotype 1. While a significant percentage of cases may be attributable to pneumophila serotype 1, a negative Legionella urinary antigen test does not rule out Legionnaires’ disease.
  • Only a Legionella culture has the potential to identify any Legionella strain, and special culture media is needed. In most labs, a respiratory specimen sent for culture is not routinely tested for Legionella.

Legionella does not spread from person to person. It is transmitted by aerosolized water from sources such as whirlpools, hot tubs, hydrotherapy tubs, showers, indoor waterfalls or decorative fountains, grocery produce misters, or cooling towers on large buildings. Legionella prefers large, complex plumbing systems over natural bodies of water, because plumbing systems provide the temperature range, commensal organisms, and stasis that best support Legionella growth.

Who’s at risk. As with community-acquired pneumonia caused by other organisms, the people most likely to become infected are those with preexisting health problems such as COPD, diabetes, or immunosuppression; smokers; and people over 50. Children are usually not infected with Legionella unless they are immunosuppressed. Read the rest of this entry »

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The Present: What This Visiting Nurse Has to Give

August 10, 2015
Illustration by Barbara Hranilovich for AJN.

Illustration by Barbara Hranilovich for AJN.

It can be daunting for a visiting nurse to enter a patient’s home, especially if the patient seems less than receptive to the nurse’s efforts. In this month’s Reflections essay, “The Present,” Pia Wolcowitz describes one of her first assignments as a visiting nurse. She’s sent to assess a woman newly diagnosed with lung cancer. Here’s an excerpt:

I rang the bell and heard a voice, but couldn’t make out what she said. I rang again. This time I heard her loud and clear. “If you wanna come in, come in! Door’s open!” Entering, I found a woman in her mid-60s sitting hunched at her kitchen table, surrounded by bottles of medication and a bowl of cereal. It was way past noon.

She had cropped blue-black hair with accents of white. She studied me a moment, then her gray eyes examined my ID. “So, you’re the nurse?”

Read the rest of this entry »

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Patient Satisfaction and Nursing: Listening Matters, Whatever the Situation

August 7, 2015

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN. Her last post on nursing and patient satisfaction surveys is here.

by runran/Flickr Creative Commons

by runran/Flickr Creative Commons

During this hospital stay, how often did nurses listen carefully to you?
1. Never
2. Sometimes
3. Usually
4. Always

Listening Carefully About Patients
“Her crit is dropping with each bowel movement, and she just won’t stop bleeding,” said my night shift colleague during the early moments of my shift.

As soon as she finished telling me the rest of my new patient’s care, I got on the phone for the ordered blood. Waiting for the first of many products to be delivered, I went to see her. As I poked around the hanging drips and fluids, checking dosages and orders, setting alarm limits, I heard my patient’s voice:

“Hello, hello? I’m so anxious. I just fell asleep for a moment and now I’ve woken up and I’m terrified. I think I need to be changed again, and I just don’t know what to do, and who are you?”

My colleague, busy with the details of resuscitation, hadn’t said much about my new patient’s anxiety. Anxiety, too often coded as neediness, is clinically important, especially in a patient with questionable stability, and doubly in a patient whose nurse must focus on speedy resuscitation more than handholding. I braced myself for what felt, just then, like an extra factor in an already challenging situation.

“Good morning,” I told her. “I’m Amanda, your nurse. I’ll be caring for you today, and my most important priority is getting blood into your body, because I’ve been told that you’re bleeding quite a bit. We want to stabilize your blood volume and stop your bleeding. We’ll do that with blood products in your IV.”

Listening Carefully To Patients
I start most of my shifts listening first, and then telling, setting a plan of care for the day together with my patients. But I didn’t like the slight bluish tint to this woman’s skin , or her heart’s steadily increasing beat. Her blood pressure was holding, but (applying Maslow’s hierarchy), I believed that she needed blood more urgently than she needed comfort (and antianxiety medication was out of the question—the resident would never agree to anything that might drop her pressure).

As I prepared to help my patient turn in the bed, she sent a million words in response: anxiety, questions, doubts of my actions and capabilities. With an eye constantly on the heart monitor, I gave the tersest of answers, my worries seemingly confirmed when I pulled back the covers and found a pool of bright blood.

Blood products came, and I pumped them into my patient’s flat veins. I was the only one in the room and I worked silently as she talked. And talked. If I had been a more experienced nurse, I would have welcomed her talking as a sign that her blood volume was sufficient enough to carry oxygen to her brain, and I would have engaged her more fully, both as a means of assessment and as a way to relieve her anxiety. But I was entirely wrapped up in the physical realm—stopping the bleeding and resuscitating the volume. Read the rest of this entry »

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A Tech-Savvy Nurse’s Initial Take on Uses for the Apple Watch

August 5, 2015

Megen Duffy, RN, BSN, CEN, is currently working in hospice case management and writes AJN‘s iNurse column, which focuses on technology and nursing.

AppleWatchMegenPhotoBPMI’ve had my Apple Watch for several months now. I ordered it at 12:01 the morning they went on sale, and it arrived the Saturday after its Friday release. I was fairly certain I’d return it or sell it for a profit, but I still have it and keep finding new uses for it. I also have ideas for how it could be handy for a variety of fitness and health care scenarios.

Health tracking. Even at this early stage, though, patients and their families are using Apple Watches to track and enhance their health. The Watch tracks your heartbeat—not every second, but often enough that a useful bank of data results. Rumors say that a mystery port on the back of the watch will allow SpO2 tracking soon. I have already busted out my phone to show my cardiologist my heart rate trends, and it saved me from wearing a Holter monitor. That kind of thing is exciting!

Fitness wearables (e.g., Fitbit) and smart watches (e.g., Pebble) have been around for a few years, with sharply increasing popularity. The (often) colored plastic bands people wear around their wrists are the kind of wearable I mean. Pedometers (included in the wearables category) also come in small clips that attach to pockets or bras, but those typically have fewer features than are relevant medically. These bracelets/watches track some or all of the following: steps taken, calories burned, distance covered, heart rate, and weight.

Wearables have ways of nudging people along in their fitness goals. They tap, send inspirational messages, and even post movement statistics on social media.

Peer pressure works, even in adults. Reaching the daily step goal becomes oddly alluring. Americans are sedentary people, and we like our gadgets and video games. Gamifying fitness could be a winning strategy for getting people up off the couch—both nurses and patients. It is not unusual to see bands of roving nurses in hospitals, walking the halls on break to get their steps in. Every little bit helps.

So far, the Apple Watch does not have any third-party applications, and, though it can do a number of things on its own, its main users for now will be those who already have late-model iPhones (which can pair with the Apple Watch to share data and some functionality). Other devices, such as the Pebble, have a huge library of third-party applications, but they still require proximity to a cell phone. Fitbits do not allow software installation.

Apps for medication tracking, etc., with more likely to come. The Watch has a number of applications that integrate usefully with iPhone applications. Patients and caregivers will have another option for keeping track of medications and treatments because of this integration. An application on your wrist saying “it’s time for your Cardizem” is much more insistent than a phone alarm, for example. An update to the Watch operating system is supposed to occur this fall, and I am excited about what developers will have come up with. Wouldn’t it be fantastic, for example, to have a CPR application on your watch that taps your wrist at the appropriate tempo?

Read the rest of this entry »

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AJN in August: Oral Histories of African Nurses, Opioid Abuse, Misplaced Enteral Tubes, More

August 3, 2015

AJN0815.Cover.OnlineOn this month’s cover, a community nurse practices health education with residents of a small fishing village in rural Uganda. Former AJN clinical managing editor Karen Roush took the photo in a small community center made of dried mud bricks, wood, and straw.

According to Roush, nurses wrote the lessons out on poster-sized sheets of white paper and tacked them to the mud wall as they addressed topics like personal hygiene, sanitation, food safety, communication, and prevention of infectious diseases. The reality of nursing in Africa is explored this month in “‘I Am a Nurse’: Oral Histories of African Nurses,” original research that shares African nurse leaders’ stories so we may better understand nursing from their perspective.

Some other articles of note in the August issue:

CE feature: A major source of diverted opioid prescription medications is from friends and family members with legitimate prescriptions.  “Nurses’ Role in Preventing Prescription Opioid Diversion” describes three potential interventions in which nurses play a critical role to help prevent opioid diversion.

From our Safety Monitor column: More than 1.2 million enteral feeding tubes are placed annually in the United States. While the practice is usually safe, serious complications can occur. “Misplacements of Enteral Feeding Tubes Increase After Hospitals Switch Brands,” a report from the Pennsylvania Patient Safety Authority, reviews cases of misplaced tubes and offers guidance for how nurses can prevent such errors in their own practice.

Clinical feature: It is no surprise that physical activity comes with numerous physical and mental benefits, nor that a majority of Americans do not get enough exercise. “The Evolution of Physical Activity Promotion” updates nurses on physical activity guidelines and provides tips for encouraging patients to improve their physical activity. This feature also highlights the importance of decreasing one’s amount of sedentary and sitting time, even in physically active people. Read the rest of this entry »

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Medicare Turns 50: Familiar Opposition in 1965, Essential and Continuing to Evolve Now

July 30, 2015
President Lyndon B. Johnson signing the Medicare Bill at the Harry S. Truman Library in Independence, Missouri. Former President Harry S. Truman is seated at the table with President Johnson. Photo: National Archives and Records Administration.

President Lyndon B. Johnson signing the Medicare Bill at the Harry S. Truman Library in Independence, Missouri. Former President Harry S. Truman is seated at the table with President Johnson. Photo: National Archives and Records Administration.

On this date in 1965, exactly 50 years ago, Medicare (part of the Social Security Amendments of 1965) was signed into law by President Johnson. The debate over government-sponsored health insurance is not new, and opposition to the creation of Medicare was similar to the opposition to the Affordable Care Act and driven by many of the same organizations and arguments.

According to a timeline at SocialSecurity.gov, Congressional hearings on the topic occurred as early as 1916, with the American Medical Association (AMA) first voicing support for a proposed state health insurance program and then, in 1920, reversing its position. A government health insurance program was a key initiative of President Harry Truman, but, as with the Clinton health initiative several decades later, it didn’t go anywhere because of strong opposition from the AMA and others.

AJN covered the topic in an article in the May 1958 issue after a health insurance bill was introduced in 1957. Yet again, one of the staunchest opponents was the AMA. In the September 1958 issue, “at the request of the American Medical Association,” AJN published an article by the AMA’s general manager explaining the AMA’s opposition. Then (as in recent years we continue to see from opponents of both Medicare and the ACA), the alternative plans proposed by the AMA and others were weak and lacked comprehensiveness. By contrast to the AMA’s position, in 1958 the American Nurses Association (ANA) formally expressed support for federal health insurance for older Americans.

Medicare continues to evolve in numerous ways, and will face unprecedented challenges in the coming years as the number of seniors continues to increase. Medicare has its flaws and waste and inefficiencies, and some of the quality measures it uses to decide compensation rates for hospitals are controversial with nurses and others. There is always room for improvement, always negotiation among competing parties, never enough money.

But some very positive news came out this week about steep reductions in Medicare patients’ mortality and hospitalization rates and in costs for hospitalized “fee-for-service” Medicare patients.

So it’s complicated, as might be expected. But where would be without Medicare? It might not be pretty.—By Shawn Kennedy, editor-in-chief, and Jacob Molyneux, senior editor

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