Posts Tagged ‘patient-centered care’

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At the Intersection of Hospice and Obstetrics, a True Test of Patient-Centered Care

October 22, 2014

By Jacob Molyneux, senior editor

Renee Noble with her newborn daughter, Violet. Photo by Heidi Ricks.

Renee Noble with her newborn daughter, Violet. Photo by Heidi Ricks.

We’d like to draw attention to a particularly frank and thought-provoking article in the October issue of AJN. “A Transformational Journey Through Life and Death,” written by a perinatal nurse specialist who is also a bioethicist, describes a hospital’s experience in meeting the needs of a patient with two very different, potentially conflicting, medical conditions.

It was a sunny afternoon in mid-October when I first met Renee Noble. I had already heard about her from staff who had given Renee and Heidi Ricks, her friend and doula, a tour of the neonatal ICU and were taken aback when they asked to see the Hospice Inn as well. The nurses knew that Renee had been diagnosed with ovarian cancer, but no one had said anything about it being terminal. Heidi had insisted that after Renee delivered she would need hospice inpatient care. Alarmed, the staff had called me, the perinatal clinical nurse specialist, after Renee and Heidi left.

In addition, this is a patient with strong preferences about her own care, preferences that may be at odds with the more conventional approaches to treatment held by many nurses and physicians. Read the rest of this entry ?

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AJN in October: Getting Inpatients Walking, Calciphylaxis, Nurses and Hurricane Sandy, More

September 30, 2014

AJN1014.Cover.OnlineAJN’s October issue is now available on our Web site. Here’s a selection of what not to miss.

Calciphylaxis is most often seen in patients with end-stage renal disease. “Calciphylaxis: An Unusual Case with an Unusual Outcome” describes the rare case of a patient diagnosed with calciphylaxis with normal renal function, and how the nursing staff helped develop and implement an intensive treatment plan that led to the patient’s full recovery. This CE feature offers 2.5 CE credits to those who take the test that follows the article. To further explore the topic, listen to a podcast interview with the author (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).

The adverse effects of bed rest. Prolonged periods of immobility can have adverse effects for patients, such as functional decline and increased risk of falls. “A Mobility Program for an Inpatient Acute Care Medical Unit” describes how an evidence-based quality improvement project devised for and put to use on a general medical unit helped mitigate the adverse effects of bed rest. This CE feature offers 2 CE credits to those who take the test that follows the article. 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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How a Nurse Helped My Health Anxiety

July 1, 2014
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Photo by Sheila Steele, via Flickr.

By Amy M. Collins, editor

As a person who suffers from health anxiety, going to the doctor is always an ordeal. While some hypochondriacs tend to seek medical care with fervor, I am of the variety that avoids it at all costs. Unless it’s necessary.

Recently I had a necessary diagnostic test that involved a contrast agent. Several things about the test worried me. I was told it might hurt; I’d never had a contrast agent before (and on House—a show I should never watch—patients are always allergic to it!); and I was afraid that during the exam I would panic, faint, or cry.

Some people might be thinking: “suck it up!”—and I wouldn’t blame them. But I promise you, this isn’t something I’m proud of. I’d love to be more stoic when it comes to medical procedures/visits. Unfortunately, anxiety is a real thing. It is illogical and it can sometimes take over one’s senses. I spent the days preceding the test sleepless and tense. Read the rest of this entry ?

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‘The Nurse Who Changed My Treatment’

May 29, 2013
By Annalisa Ochoa, for AJN. All rights reserved.

By Annalisa Ochoa, for AJN. All rights reserved.

Two years ago, when I was diagnosed with advanced lung cancer in the ED of a large urban hospital, I asked a nurse if I could borrow her cell phone. Without hesitation, she handed me her Blackberry—this simple gesture was a first indication of the solidarity I’d come to feel with the nurses whose kindnesses have helped me heal.

We think it’s important to sometimes include a patient perspective in our monthly Reflections essay. “The Nurse Who Changed My Treatment,” the June Reflections essay, is by Nila Webster, who writes about the gestures by nurses, the little kindnesses and words of wisdom and encouragement, that helped her during her treatment for lung cancer and made her feel seen and understood. The essay is free, and short, so please click the link and give it a read.—JM, senior editor

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‘Patient Activation': Real Paradigm Shift or Updated Jargon?

February 7, 2013

By Jacob Molyneux, AJN senior editor

I attended a Health Affairs briefing yesterday in Washington, DC. Based on the February issue of the journal, it was called “A New Era of Patient Engagement.” A lot of research money appears to have been flowing to this area in recent years.

Our January article on "Navigating the PSA Screening Dilemma" includes a discussion of 'shared decision making'

Our January article on “Navigating the PSA Screening Dilemma” includes a discussion of ‘shared decision making’

The basic idea isn’t entirely new to anyone who’s been hearing the term “patient-centered care” for a long time: as Susan Dentzer writes in “Rx for the ‘Blockbuster Drug’ of Patient Engagement,” a useful article summarizing the main ideas raised in the Health Affairs issue: “Wherever engagement takes place, the emerging evidence is that patients who are actively involved in their health and health care achieve better health outcomes, and have lower health costs, than those who aren’t.”

One might add to these projected benefits: better experiences as patients.

Something’s got to change, so why not this? If many nurses feel they’ve heard all this before, the sense of a health care system in necessary flux is particularly acute right now, with mounting pressures from an aging Baby Boom generation with its full complement of chronic conditions, not to mention federal budget constraints and the influx of patients expected from the Affordable Care Act. It’s unlikely we’d be talking so much about patient engagement if we weren’t facing, perhaps as never before, the need to do something about the glaring gap between costs and quality in the U.S. health care system.

Patient activation. A term that got a huge amount of use at the briefing was “patient activation.” Hibbard and colleagues define it thus, in an article on the the evidence for cost reductions associated with patient activation: “understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role.” Some examples of patient activation they cite are patients with type 2 diabetes performing regular foot checks and keeping a glucose diary, or patients who regularly exercise and get relevant screenings.

Don’t write off certain type of patients. Many of the presenters emphasized that it’s important to see patient activation as a possibility for every patient, whatever their socioeconomic level, disease severity, or cognitive limitations. As Hibbard put it, “there are more or less activated patients in every demographic.” Providers need to meet patients where they are and, as Marion Danis put it in an article on the ethical justification for getting patient activation right, set goals and have realistic expectations.

The physician problem. Many presenters noted that, without support from the health care system, individual efforts may not make much of a difference. In addition, physician resistance was mentioned repeatedly, whether attributed to their lack of time, their skepticism, or the overly common belief that more expensive care is always better. Bernabeo and colleagues observed that even those physicians who advocate shared decision making may not always engage in it. Their article on necessary competencies posits four crucial elements for true patient engagement: system support, providing patients with decision aids, collaborations and teamwork (can anyone say nurses?), and new reimbursement models.

Lin and colleagues, in looking at efforts to distribute decision aids in primary care practices, also noted physician-based problems with furthering patient activation, discovering that physicians

  • didn’t see a role for patients in their own care.
  • believed they lacked the time to give them decision aids.
  • didn’t see a potential benefit in doing so.

They also found, again unsurprisingly, that clinical support staff embraced the concept far more than the physicians did. Read the rest of this entry ?

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Individualized A1c Targets for Type 2 Diabetes

October 23, 2012

By Jane Seley, DNP, MPH, MSN, BC-ADM, CDE, diabetes nurse practitioner at New York Presbyterian/Weill Cornell Hospital, New York City

On April 19th, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) released a joint position statement online that represented a giant step forward in the care of people with type 2 diabetes. “Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach” is a comprehensive yet easy to read primer in the most up-to-date therapies, one that also emphasizes individualizing care as the key to success.

An example of the patient-centered approach of this position statement is a refinement of the customary across-the-board hemoglobin A1c test target recommendation of less than 7% for most people with type 2 diabetes, with pre-meal blood glucose (BG) targets of less than 130 mg/dL and post-meal targets of less than 180 mg/dL. The position statement suggests “more stringent” targets of 6%–6.5% for “selected” patients who are younger and in good health, but safer targets of 7.5%–8% for older patients who have comorbidities or are prone to hypoglycemia.

When discussing therapeutic options, each medication is ranked according to its potential for lowering A1c, risk of hypoglycemia, effect on weight, adverse effects, and cost. In addition, the clinician is encouraged to individualize the treatment regimen by considering age, weight goal, and comorbidities such as heart disease and kidney function. For example, if losing weight is an important consideration for the patient, then a medication that may assist in weight loss such as metformin (oral agent) or a GLP-1 receptor agonist (injectable) would be good choices. A weight-neutral alternative would be a DPP-IV inhibitor (oral agent).

The position statement reminds us that lifestyle changes are a priority, with a focus on weight optimization, healthy meals, and increased activity levels. My favorite part of this document is the recommendation that treatment decisions be made in partnership with the patient, with a focus on each individual’s preferences, needs, and values.

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