Posts Tagged ‘nurse practitioner’

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If She Yells ‘Help Me’ – Poster Therapy to Convey the Needs, Identity of an Ailing Parent

July 23, 2014

Joan Melton, MSN, lives in Indiana.

Photo by Ann Gordon, via Flickr

Photo by Ann Gordon, via Flickr

I am a geriatric nurse practitioner and have also been the daughter to an ill, aging parent. I felt well trained for my professional role but struggled with the latter.

I joked that, despite my logical understanding of what was going on with my mother, it could be hard to accept her physical and functional changes, which sometimes seemed to fly in the face of logic. There were days Mom’s hospice nurses spent more time with me than with my mother. They’d sit and allow me to vent my frustration at watching my mother slowly leave me, at feeling overwhelmed and “losing my cool” with her, at not being able to practice the advice I’d so readily handed out to so many other families over the years, not being able to “fix it” and successfully comfort all of Mom’s fears and ailments 24 hours a day, seven days a week.

Yes, I know how unrealistic that last statement sounds. Thank goodness for hospice nurses, who reminded me that I was “the daughter” and did not need to be “the nurse practitioner.” They reminded me that as the daughter I had amazing insight no one else had.

So, when Mom spent a week in the nursing home to give my family some long-overdue respite time, her hospice nurses suggested I share all of my rich, personal, daughterly insight.

Their idea was brilliant. It made me feel useful and allowed me to feel less guilty about taking Mom to the nursing home. Most of all, it reminded me of who my Mom really was behind the mask of her dementia.

Mom’s health issues had begun with chronic, recurrent atrial fibrillation. Placed on Coumadin for stroke prevention, she fell, hit her head, and had a cerebral bleed. She was taken off Coumadin, and during her recovery had another episode of atrial fibrillation, this time suffering a thrombotic stroke that left her with memory problems and expressive aphasia. In addition, Mom was blind from the effects of glaucoma and macular degeneration.

In summary, Mom was unable to walk by herself, couldn’t find words to say what she wanted to say, and could only see shadows. Naturally, she became fearful and frustrated as her world closed in on her. Confusion and anxiety were side effects of her condition(s). At times, she was so anxious that she became short of breath. Her oxygen levels would drop, and her confusion would get worse. In addition, her appetite changed. She lost weight, and like many elderly patients, she had recurrent urinary tract infections from not drinking enough fluids.

Two posters. Before it was time to take Mom to the nursing home, the hospice nurses suggested I make two posters to display in her room. They suggested that on the first I list who my Mom was behind the mask of her dementia. What did Mom love to do before she became ill? They also suggested I put photographs of Mom on the poster to show what she’d been like before she became so frail.

On the second poster they suggested I write things to help the staff at the nursing home take better care of Mom, tips that only I knew from my past experiences as her caregiver and her daughter. Seeing these things written on a poster and displayed in her room would serve as a reminder for the staff, and would provide an easy way to share important information about her to all the different staff members who would be involved with Mom’s care.

I took the nurses’ excellent advice and began making the two posters. The entire family helped. Mom’s posters were the talk of the nursing home. People would come into her room just to read them. Here are a few examples of what we wrote:

Poster #1
Mom loves flowers, especially zinnias.
Mom’s was married to Dad (name) for 51 years. Dad went to heaven eight years ago.
Mom had five children (we listed their names). Mom calls out for her oldest son.
He and his wife took care of Mom at home.
Mom loves to waltz and old-time country music.
Mom loves to talk to her sister (name) on the phone every day. Mom is extremely close to her sister. Their mother died when they were only four and six years old.
Mom loves cooking for her family. She makes the best fried chicken.
She loves listening to the Catholic mass on TV or praying the rosary.
Mom loves going to the country, raising cows and bottle feeding the baby calves. She would give the cows names like pets.
Mom loves having her hair fixed and putting on make-up and looking nice every day. 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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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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A Focus on Meaning and Attitude: This Week’s Nursing Blog Post Suggestions

November 13, 2013

By Jacob Molyneux, AJN senior editor

'Autumn Washed Away,' Diane Hammond/ via Flickr

‘Autumn Washed Away,’ Diane Hammond/ via Flickr

Here are a few recent posts by nurses that you might find of interest. As I put this together, a theme emerged, so it seemed fair to just go with it. Maybe the approach of these bloggers has to do with the time of year, the shorter days and colder weather as we approach the winter holidays . . .

At the intriguingly titled Nursing Notes of Discord blog, there’s a short reminder post with a fairly straightforward descriptive title: “Anyone Can Make a Positive Difference.” And, the author points out, you “don’t even have to be a nurse” to do so.

At Digital Doorway, Nurse Keith has a recent post that also focuses on positivity, this time about one’s profession: “For Nurses, ‘Just’ Is a Four-Letter Word.”

At HospiceDiary.org, in the lovely post “Leaves, Geese and Other Ramblings”—as the below quote may suggest—we find another angle on this theme of being present and focusing on the good in the midst of sometimes constant, poignant awareness of change, loss, dying, and rebirth:

Fall moves into winter. Unequivocal  fact. The furrowed fields and leftover husks are what remains of a harvest of work . . .

Read the rest of this entry ?

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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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Old Friends Among the Devastation: A Red Cross Volunteer in the Oklahoma Tornado Zone

June 19, 2013

In 2011, after devastating tornadoes struck Alabama, we ran a series of blog posts, “Dispatches from the Alabama Tornado Zone,” by Susan Hassmiller, the senior adviser for nursing at the Robert Wood Johnson Foundation. Hassmiller went to Alabama as a Red Cross volunteer, and reported back to us with a number of moving and inspiring posts and photos. The recent tornadoes in Oklahoma are the occasion for a new series we are initiating today.


Eleanor Guzik, NP, RN, a volunteer disaster health services manager with the Red Cross, describes herself as a 74-year-old wife, mother, grandmother, great-grandmother, traveler, serial volunteer, and a late-in-life RN who worked in critical care for 10 years, was an NP for 10, and retired in 1995. This piece by Eleanor Guzik describes her deployment and arrival in Oklahoma; subsequent posts by Guzik and other Red Cross volunteer nurses will give us glimpses of the day to day work of volunteers in Oklahoma and the people and situations they encounter.

Deployment and Arrival

May 25, 2013. Oklahoma City, Oklahoma. An American Red Cross emergency response vehicle tours through an Oklahoma City neighborhood to ensure that each residence is provided with resources. Photo by Talia Frenkel/American Red Cross

May 25, 2013. Oklahoma City, Oklahoma. An American Red Cross emergency response vehicle tours through an Oklahoma City neighborhood to ensure that each residence is provided with resources. Photo by Talia Frenkel/American Red Cross

I am proud to say that I am a Red Cross Nurse. My history with the Red Cross goes back to Hurricane Katrina. I have since fallen down the rabbit hole of volunteerism and am having the time of my life, working harder than I ever did for a paycheck.

In May I was in beautiful southern California, retired, without a worry, counting my blessings and trying to keep my head above water in my busy volunteer schedule with my favorite hospice and the American Red Cross.

I’d made myself available during the month of May to deploy to any national disaster for the Red Cross, if needed, but I wasn’t summoned into action until May 21. “Can you come?” they asked. “Yes, for 10 days,” I answered. “I’ll get a flight out tonight.” Read the rest of this entry ?

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Some Recent Notable Posts from Nursing Blogs

January 25, 2013

Some posts of interest from the nursing blogs (those that are currently active; a fair number of familiar bloggers seem to be taking breaks, having kids, starting new jobs):

“Certified Medical Assistants Calling Themselves Nurses” can be found at The Nurse Practitioner’s Place. It’s not just inaccurate to do so, says the author. It’s often illegal.

Photo from otisarchives4, via Flickr.

Photo from otisarchives4, via Flickr.

At My Strong Medicine, a short post about men, women, USPSTF guidelines, becoming an NP, and reaching a certain age, called “Heard While Studying: Everything Falls Apart at Age 40.”

One blogger, among others, who has been pretty quiet for some months (and who used to organize a regular “blog carnival” that helped create a community among nurse bloggers) is Kim McCallister at Emergiblog. She popped back up several weeks ago with a post called “The Voice,” which is about exactly that—how a nurse blogger lost the sense of freedom she started with as a staff nurse jotting down experiences, and instead internalized a “Sister Superego” that cautioned her to be “prim and proper,” rapping her knuckles until she just fell silent instead. Frustration with computerized charting and the general state of health care seems to be part of it as well. We hope the spirit moves her to write more soon.

Lastly, there’s a nice post by Megen Duffy (who often writes AJN‘s iNurse column, and who writes some pretty funny tweets as well) at her blog (Not Nurse Ratched). It’s called “Gratitude: Lessons from Patients,” and I was glad I read it on a Friday, because it’s about the possibility of change, and is actually pretty hopeful.—Jacob Molyneux, senior editor

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ECRI Conference Notes: Creating and Replicating ‘Systemness’ within Health Care Delivery

December 5, 2012

By Joyce Pulcini, PhD, RN, FAAN, Policy and Politics contributing editor, AJN

The ECRI Institute’s 19th annual conference (November 28–29) looked at system-level innovation and quality in the health care system. It brought together experts from many fields, including medicine, nursing, hospital or health system administration, informatics, health care quality, policy makers, journalists, and academics. ECRI Institute is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care. The goals of the conference were to address the following:

  1. What is “systemness”?
  2. Which elements within mature health care systems result in the best clinical outcomes?
  3. Are approaches taken by long-established systems transferable to smaller, newer, or less integrated systems?
  4. Are financial incentives enough to drive change?
  5. How can electronic health records (EHRs) help improve “systemness”?
  6. Do transformation units within health care systems produce results?

The conference essentially tried to attack in a creative way the issues around the creation of systems that function optimally. Truly changing culture and providing optimal care delivery should always result in putting the patient at the center of care. The conversation was open and the conference succeeded in fostering important dialogue among the speakers and the audience.  A major focus was on creating systems, looking at technological or financial solutions, and measuring outcomes.

The session on team care (“Creating teams to improve inter- and intra-health care systems: Does evidence show a benefit?”)  highlighted the vexing issues around how to truly foster optimal teams. Lisa Schilling, RN, MPH, VP National HC Performance Improvement, Director, Center for Health Care Systems Performance, was one of the speakers. She started in her role in 2008 and by 2010 published the results of her efforts, which led to a 30-day readmission rate after hospitalization reduction of 9% (Schilling et al, 2010) and a dramatic reduction of mortality from severe sepsis, which saved 1,100 lives. The solution, she says, was to focus on culture, with leaders and teams working together from the ground up to create learning organizations with clearly measured outcomes. She emphasized that while leaders manage variation, change culture, and manage team-based improvement, change begins at the front lines and alignment in health systems is a key factor in systemness.

Patient perspective. Another speaker, Jesse Gruman, a patient and consumer advocate, asked some heartfelt questions about who teams benefit. She answered quite honestly that patients do not really understand how teams will benefit them. Patients want to have a relationship with their “doctors,” not with teams. They are not really interested in being the leader of the teams either, as some of the rhetoric suggests. When they are sick, patients need people who can help them get better and the patient cannot lead this aspect of care.

She challenged us to think about what happens when teams do not work together well. She was concerned about the large “cast of characters” patients must often face while hospitalized. One solution, which was proposed by Children’s Hospital Boston, was a patient app called “My Passport App,” which had pictures of staff who were on their team (as an alternative to the old whiteboard solution). Family as well as patients could see who was on the care team, know what to do at home, and actually see their own plan of care.

Who really benefits from teams? One speaker asked who teams really benefit. In the end, the perception of the value of teams did not always reach the consumer. If the patient does not see the value of team care, we have a long way to go if this concept is to succeed. Patients should not have to receive the mixed messages and experience the poor communication often inherent in modern health care. Read the rest of this entry ?

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Evidence Contradicts AAFP: NPs Ideal for Leading Patient-Centered Medical Homes

October 3, 2012

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

What will it take to end the turf war physicians are waging  against nurse practitioners? The latest foray is over who should lead patient-centered medical homes (PCMH). According to the American Academy of Family Physicians (AAFP), only physicians should. They insist that nurse practitioners do not have the knowledge or skills to do so and that expanding the NP’s role in primary care would create a “two-tiered health system,” with patients who are cared for by an NP receiving a lower level of care.

That’s not what the evidence says. Or patients for that matter. Studies consistently find that when care provided by NPs is compared to care provided by physicians, the care is similar as far as prescriptions ordered and referrals made—most important, outcomes are the same.

Well, there is one area where differences keep showing up: patient satisfaction. Patients consistently say that they are more satisfied with care provided by nurse practitioners. They say that nurse practitioners listen better, spend more time with them, and provide them with more information.

Not only are nurse practitioners capable of leading medical homes, their education and skills make them ideal for this role. Whereas physicians focus on pathology and have the depth of knowledge and skill to manage highly complex patients, NPs focus on the “human response to disease” and take a more holistic approach to patient care. Nurses coordinate care all the time, identifying the need for and arranging home care, rehabilitative care, nutritional support, and so on. Combine this with an NP’s well-documented diagnostic and patient management skills, and their qualification for this role is obvious.

There already exists a two-tiered health system in this country—but not the one AAFP is imagining. It’s between those who have access to care and those who do not. Expanding the role of nurse practitioners in primary care is one of our best hopes for alleviating that. We know it, the Institute of Medicine (IOM) knows it, and patients know it. It’s time for physicians to accept it.

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Web Roundup: Changing Specialties, Measuring Quality, Caring and Freeloading, More

September 19, 2012

by Ramon Peco/via Flickr

Here are a few things worth noting on the Web today. At Code Blog, “Rookie Mistake” is illuminating on the subject of switching nursing specialties. Here’s a short excerpt:

My new hospice job is going pretty well.  I really like it.  It’s been an adjustment, but worth the stress of change.

Overall, I’ve been pretty surprised at how little I know/knew about how people die naturally.

In ICU, if you are actively dying, you look terrible.  In most cases, people dying in the ICU are there because we were or are trying to save their life.  This requires some treatments that cause other problems. . . . That is what dying looked like to me for 14 years.  Turns out it’s a pretty exaggerated version of how it is when people naturally die without life-saving interventions.

Also notable: a short post that many may relate to about paperwork and burnout, at The Nurse Practitioner’s Place.

In other news, Kaiser Health News reports that the Joint Commission is releasing its annual list of hospitals that have done well in following certain crucial procedures and protocols:

The commission is recognizing 620 hospitals (download list as PDF or .xls file) – 18 percent of those it accredits — as “top performers” for following recommended protocols at least 95 percent of the time.

Congrats to those who made the list. But a caveat: The article does note that there’s “an ongoing debate” about whether process measures or outcome measures better reflect quality of care. And in truth, we’ve heard complaints from many nurses about process measures and their potential unfairness/inaccuracy. What’s your take?

Note also this article on the retirement of a “nursing legend,” and a fantastic piece at the Health Affairs blog called “Caring, Freeloading, and the Fate of the Affordable Care Act,” which makes this observation:

At the heart of the case for medical coverage for all isn’t the public’s health; it’s private tragedy.  Serious illness plunges people into a realm of Dickensian choice.

And if you haven’t, check out the CE articles in this month’s AJN: “Postoperative Delirium in Elderly Patients” and “Outcomes and Complications After Bariatric Surgery.”

Lastly, “At the Eye of the Storm,” this month’s AJN Reflections essay, is by a nurse who describes the struggle to make the right decision, along with siblings, about her gravely ill father’s care. Wanting to avoid overly aggressive measures, she nevertheless does her best to respect what her father would have wanted.
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