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On the Phone: Punctuation for a Parent’s Decline

August 15, 2014
Illustration by Elizabeth Sayles for AJN. All rights reserved.

Illustration by Elizabeth Sayles for AJN. All rights reserved.

“It’s ridiculous. I’m deciding the rest of my mother’s life based on research I did on the Internet,” I tell him.

“You’re really good at that. Research, I mean,” he says, hope in his voice.

I want to scream that I don’t think an undergraduate degree in biology and a long relationship with Google qualify me as a medical professional.

Many of us don’t use the phone as often as we used to, but there are times of strangeness and loss when it may still assume the central role it played in an earlier era. The passage above is from “On the Phone,” the August Reflections essay, which finds a novel way to talk about the strains and strangeness of finding oneself a family caregiver—the gradual withdrawal of a once vibrant parent (or spouse or sibling) from the home that had once seemed to be defined by their presence, the isolation, the learning curve when faced with medical emergencies and the need to make crucial decisions that can’t wait, the reliance on the advice and interventions of nurses and physicians.

All Reflections essays are free and can be read in just a few minutes. This month’s is about an experience, family caregiving, that more and more of us are having in one form or another, whether we find a way to tell about it or not.—Jacob Molyneux, AJN senior editor

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The Gaza Conflict, Through the Lens of Nursing

August 13, 2014

By Jacob Molyneux, AJN senior editor

In 2005, AJN published an article looking at the experiences of nurses in Israel and in the Palestinian territories (free until September 15; choose ‘full text’ or ‘PDF’ in upper-right of the article landing page). Here’s an excerpt:

“[N]urses in the region have many of the same problems American nurses have: disparate educational levels, struggles for professional recognition and workplace representation. The nurses I met came into the profession for diverse reasons and are working in a remarkable variety of settings, carrying on in the face of political, professional, economic, military, and personal difficulties. Yet I was amazed at the things these nurses have in common with each other—and with us. As I listened to them describe their motivations and aspirations and watched them work, the seemingly impenetrable barrier created by the ongoing military and political conflict melted away.”

Photos and captions from 2005 article about Palestinian and Israeli nurse. Courtesy of Constance Romilly.

Photos and captions from 2005 AJN article. Courtesy of Constance Romilly. Click to expand image.

The current conflict between Israel and those living in the Palestinian territories is another chapter in a long story. Our focus at AJN is not on the politics of the situation or the rhetoric of blame coming from supporters of both sides. Most of our readers already have opinions on the topic, and there are other, more appropriate places you can engage that argument.

The stress and suffering, deaths, injuries, and loss of infrastructure have been well documented. We see lots of images of bombed-out concrete buildings that seem always to have been ruins in some nameless place, with little evidence of the lives only recently played out there. Still, one at times stumbles upon photos of people caught in the shelling, the scarred, maimed, or dead lying in rows on stretchers. These are hard to look at or forget.

As has been noted by many international aid groups and the UN, the health care system in Gaza is under great strain and in urgent need of donations, with a number of hospitals destroyed and others without power or basic medical supplies. In shelters where many are seeking refuge from the bombing, the overcrowding and lack of adequate sanitation is giving rise to disease. A number of groups are mobilizing teams of surgeons and nurses to travel to Gaza and treat the wounded. Others are gathering medicines and medical supplies to send. Read the rest of this entry »

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Some Essential AJN Resources on Care of Older Adults, Family Caregivers, More

August 11, 2014

800px-Woman-typing-on-laptopBy Shawn Kennedy, AJN editor-in-chief

August is one of my favorite months. Many people take time off, so the commute into AJN‘s Manhattan office is fairly easy. People’s pace seems to be a little bit slower; there seems to be less immediacy around responses to email. It’s a good time to catch up on reading manuscripts and other work I’ve had piled up.

If you’ve gone through your beach reading, here are a few useful collections on perennially important topics from our back pages:

If you’re just getting started in a nursing career, you might want to read a three-part series of articles, “Protecting Your License,” written by AJN contributing editor Edie Brous, who is a nurse and an attorney and writes on legal matters for the journal. Her series describes common myths about licensure and what steps to take to protect yourself if you are sued or brought up on charges by your state board of nursing. Read the rest of this entry »

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How a Busy Hospital Reduced Its Rate of Hospital-Acquired Pressure Ulcers to Zero

August 8, 2014

By Sylvia Foley, AJN senior editor

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

A skin lesion monitoring form accompanies a patient. Photo courtesy of NHCH.

In 2009, when one of the world’s largest cardiac care hospitals experienced a spike in the number of surgeries performed and a corresponding rise in hospital-acquired pressure ulcers, many people were concerned. The hospital—Narayana Hrudayalaya Cardiac Hospital (NHCH) in Bangalore, India—soon initiated a program to address the problem, and nursing superintendent Rohini Paul was tasked with designing and implementing effective preventive strategies. In this month’s CE feature, “Sustaining Pressure Ulcer Best Practices in a High-Volume Cardiac Care Environment,” Paul and colleagues describe what happened next. Here’s a brief overview.

Baseline data showed that, over the five-month observation period, an average of 6% of all adult and pediatric surgical patients experienced a pressure ulcer while recovering in the NHCH intensive therapy unit (ITU). Phase 1 implementation efforts, which began in January 2010, focused on four areas: raising awareness, increasing education, improving documentation and communication, and implementing various preventive practices. Phase 2 implementation efforts, which began the following month, focused on changing operating room practices. The primary outcome measure was the weekly percentage of ITU patients with pressure ulcers.
By July 2010, that percentage was reduced to zero; as of April 1, 2014, the hospital has maintained this result. Elements that contributed significantly to the program’s success and sustainability include strong leadership, nurse and physician involvement, an emphasis on personal responsibility, improved documentation and communication, ongoing training and support, and a portfolio of low-tech changes to core workflows and behaviors. Many of these elements are applicable to U.S. acute care environments.

The authors emphasize the importance of “absolute transparency and personal accountability” in ensuring the program’s sustained success. As one senior nurse said, “It was the personal responsibility that started making a difference. Now everybody’s aware, everybody’s cooperative and on their toes, and we have no skin ulcers.”

For more details, read the article, which is free online. And please share your experiences and insights with us below.

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Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective

August 6, 2014

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

Ebola virus viron

By CDC microbiologist Cynthia Goldsmith, a colorized transmission electron micrograph (TEM) reveals some of the ultrastructural morphology displayed by an Ebola virus virion. CDC image library.

We humans have a knack for taking any newly reported issue of legitimate concern entirely out of context, foregoing all common sense as we transform it into a danger of galactic proportions.

The current case in point is Ebola viral disease. There has been much ranting and raving about closing our borders to people with Ebola infection (as if that were possible), even some misinformed speculation that the virus has been intentionally released.

To me as a nurse epidemiologist, though, the central questions in this tragic outbreak are the same for Ebola as for any other disease:

  • How is the organism transmitted?
  • What is the risk of protected or unprotected exposure to the infected person?

Ebola is a bloodborne pathogen. It’s spread in the same way as HIV, hepatitis B, or hepatitis C: when blood or other body fluids contaminate another person’s non-intact skin or mucous membranes. None of these diseases is spread by casual contact. And unlike HIV or hep B or C, Ebola is not a chronic condition; transmission occurs during acute infection, after the fever begins and the disease progresses. It is virtually impossible to contract the virus by, say, walking past an infected person in the airport, or sharing a bus ride, or shopping in the same grocery store.

Preventing transmission. Unlike for HIV or hep B or C infection, isolation precautions are implemented to prevent transmission of Ebola. This is because bloody secretions, vomit, and diarrhea are typical symptoms as the disease progresses. Because of the resulting probability of exposure to the patient’s blood or bloody secretions/excretions, both contact and droplet precautions are used (i.e., gown, gloves, mask, and eye protection) in order to place a barrier between the infected person’s secretions and the caregivers.

Airborne transmission has not been documented—however, because of the potential for aerosolization of blood or bloody secretions/excretions, most experts recommend airborne isolation precautions as well (negative pressure room, N95 or greater respirators), if possible. (Here’s a CDC table with recommendations regarding transmission precautions for Ebola in various clinical situations.)

Why the rapid spread in West Africa? News reports of unchecked spread of the virus in West Africa have fueled global fears. However, a closer look at what’s happening makes it clear that two main groups of people have been at particular risk for Ebola infection:

  • close family members of those who are already infected
  • health care workers

There are risk factors unique to these groups in this region that have contributed to transmission.

It has been reported that many family members have continued to provide close personal care to their infected loved ones, without using any kind of protective gear. (Don’t attribute this to ignorance. If your two-year-old child were gravely ill, would you be likely to gown, glove, and mask? And even if you thought about doing so, do you have a large stash of these items at home?) Their repeated exposure to blood and body fluids inevitably leads in some cases to the contamination of mucous membranes or non-intact skin. Read the rest of this entry »

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Much Ado About a Fist Bump Study

August 4, 2014

hands touching illustrates post about fist bump study and germsBy Karen Roush, clinical managing editor

In this world of evidence-based care, is there anything to be said for common sense? Last week a study was published in the American Journal of Infection Control that found that a fist bump transmitted fewer organisms than a handshake.

Really? We know that hands carry untold numbers of organisms. We know that skin-to-skin contact transmits organisms. We know that duration of contact plays a role in how many organisms are transmitted. Did we need a study to tell us that hand-to-hand contact with less surface area for a shorter duration of time would transmit fewer organisms?

With the attention being paid to this study, you might think it was a major discovery. Why? Because it’s fun to talk about fist bumps versus handshakes? (David Letterman seems to think so; he recently opened his monologue with a joke about the study results.) Because we kind of like the visual of everyone, from the staid to the cool, walking around giving fist bumps?

Or perhaps, on a serious note, because we’re still struggling unsuccessfully to get people to simply wash their hands and are ready to jump on anything that mitigates the risk of transmission when they don’t? (Adherence to hand hygiene guidelines among health care workers remains low. Read our March 2013 CE–Original Research feature, in which authors Kate Stenske KuKanich and colleagues describe their evaluation of a hand hygiene campaign in an outpatient oncology clinic and an outpatient gastrointestinal clinic.) Read the rest of this entry »

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AJN’s August Issue: Preventing Pressure Ulcers, Strengths-Based Nursing, Medical Marijuana, More

August 1, 2014

AJN0814.Cover.OnlineAJN’s August issue is now available on our Web site. Here’s a selection of what not to miss.

Toward a new model of nursing. Despite the focus on patient-centered care, medicine continues to rely on a model that emphasizes a patient’s deficits rather than strengths. “Strengths-Based Nursing” describes a holistic approach to care in which eight core nursing values guide action, promoting empowerment, self-efficacy, and hope. This CE feature offers 2.5 CE credits to those who take the test that follows the article.

Decreasing pressure ulcer incidence. Hospital-acquired pressure ulcers take a high toll on patients, clinicians, and health care facilities. “Sustaining Pressure Ulcer Best Practices in a High-Volume Cardiac Care Environment” describes how one of the world’s largest and busiest cardiac hospitals implemented several quality improvement strategies that eventually reduced the percentage of patients with pressure ulcers from 6% to zero. This CE feature offers 2.8 CE credits to those who take the test that follows the article. And don’t miss a podcast interview with the authors (this and other podcasts are accessible via the Behind the Article page on our Web site or, if you’re in our iPad app, by tapping the icon on the first page of the article).

Read our Cultivating Quality column this month for another article on using evidence-based nursing practice to reduce the incidence of hospital-acquired pressure ulcers and promote wound healing. Read the rest of this entry »

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