August 3rd, 2012
By Jennifer Olin, BSN, RN
Electronic medical records (EMRs), electronic health records (EHRs), personal health records (PHRs), electronic charting, databases, and texting, the Blackberry versus the iPhone—what do all these things have in common? These are the ways healthcare professionals (including nurses) communicate these days.
The electronic age is amazing. However, a recent study shows that it is printed paper that is most effective and most used when communicating with our patients.
The healthcare communications agency HealthEd Group recently released a report on the most effective ways healthcare providers—other than doctors—communicate with their patients. The results showed 55% of health professionals polled said they rely on paper-based communications when talking with their patients. That’s right, we still prefer paper to electronics.
So why are we still relying on printouts and written information to educate our patients when this is the electronic age? One of the first reasons cited by healthcare providers as to why so many print out paper information for their charges was straightforward: 61% said they didn't pull out laptops and smartphones during appointments because educational technology was just too expensive. Others said regulations lessen their own ability to be creative when presenting information.
Another reason is that those doing the educating view themselves as “the de facto search engine or curator of health information for patients and care partners,” said HealthEd’s Susan Collins, SVP, health education R&D. The healthcare educators winnow down the tremendous amount of healthcare resources available, and steering clients away from misinformation towards more reputable sites,” she added.
Also cited in the study was that educational tools often don't take into account health literacy. Healthy People 2010 defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
According to the study only 12% of patients qualify as health literate. That means most folks don’t necessarily understand what's online, let alone know if they are finding their information from reliable sources.
That makes the digital world less valuable for them (and even a little dangerous), and it's an area respondents cited as being forgotten in the educational technology effort.
Those patients who do go online to track down information pose an educational challenge of their own: the survey showed that while 30% of educators said patients are unable to distinguish between credible and unreliable sources for health information and nearly 59% said patients are bringing in downloaded materials to discuss in their clinical visits. I think we all have been confronted by patients who come in telling us what is wrong with them, how they should be treated, and they need to be prescribed some certain medication as part of their treatment process.
This is often a case of a little information can be dangerous. It also brings us back around the healthcare provider being a human search engine and being able to edit out the bad information. Printed materials of our own in hand give us teaching tools that are concrete, can be personalized for each patient concerned, highlighted for important issues, and easily referred to without having to carry around a computer.
The surveyed educators included nurse practitioners, registered dietitians, diabetes educators, and social workers; the people who, in many instances, take the physician’s diagnoses and make them understandable, workable situations for the patient’s everyday life. “This is the group doing the translation…in terms of how to cope with a diagnosis or how to translate what treatment recommendations doctors made into adherence,” explained Collins.
“We actually go deeper and broader in our discussions than most MDs,” said Mindy Nichols, a certified diabetes educator and registered dietician. “The MD usually gives the diagnosis and suggestions to maintain control of the disease, and the certified diabetes educator assists with personal understanding of that diagnosis and prescription.”
I can think of many reasons to forgo my laptop or tablet in exchange for paper or printed teaching materials. For example, particularly when you are talking about a geriatric population, they may not be electronically literate. Much of our current senior citizen population doesn’t use computers. They prefer handouts they can refer back to repeatedly and carry around with them.
Also, when you are dealing with older patients you are often dealing with vision deficiencies. Presbyopia and cataracts make everything hard to see and computer screens are particularly difficult. With printed materials you can effectively make the words larger or change their color. Plus with many computer screens you have to be very specific about where you sit to see the screen clearly or at all. With paper the patient can move it to wherever they can best see.
Another reason behind our tendency to resort to print is that even today, as you are reading this on a computer, not everyone actually has computer and internet access. They may not be able to afford it or in the case of some people I know, their rural location hasn’t allowed for it. Paper is pretty universal.
I know from my own perspective (and I love the electronic universe) most of us can’t hang our computers on the wall, or the mirror in the bathroom to refer to our individual healthcare instructions. Paper fits the bill. You can copy it, you can tape it up, use a magnet to hold it on the fridge, fold it and put in your wallet or purse and always have the instructions you need quite literally, at hand.
August 2nd, 2012
By Jennifer Olin, BSN, RN
In past posts I have written about how infections take hold and the nurse’s responsibility in preventing them. I just recently posted a piece about methods for avoiding nurse burnout, a problem affecting thousands of nurses nationwide. Now it seems, researchers have found a correlation between the two—nursing burnout and higher patient infection rates.
A study recently published in the American Journal of Infection Control concludes that not only does nurse burnout lead to higher healthcare-associated infections (HAIs) but it ultimately cost hospitals millions of additional dollars annually.
Researchers from the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing analyzed data from the Pennsylvania Health Care Cost Containment Council, the American Hospital Association Annual Survey, and a 2006 survey of more than 7,000 registered nurses from 161 hospitals in Pennsylvania. They were specifically looking to study the effect of nurse staffing and burnout on catheter-associated urinary tract infections (CAUTI) and surgical site infections (SSI), two of the most common HAIs.
To measure job-related burnout the research team used the nurse survey responses and the Maslach Burnout Inventory (MBI). The MBI has been recognized for more than a decade as the leading measure of burnout. It incorporates extensive research conducted over more than 25 years and addresses three general scales:
The MBI filters 22 items on job-related attitudes against the three scales, identifying emotional exhaustion as the key component to burnout syndrome. More than one-third of the survey respondents received an emotional exhaustion score of 27 or greater, the MBI definition for healthcare personnel burnout.
Comparing CAUTI rates with nurses' patient loads (5.7 patients on average), the researchers found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population). Additionally, each 10 percent increase in a hospital's high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually.
This is all very scientific and having facts to back up assertions makes for a better argument. However, this research study is hardly news to the millions of nurses out there working with patients.
”I believe burnout, chronic understaffing, wasted resources, workplace violence, and workplace injuries, are inter-related phenomenon that impact all sentinel events,” said Beth Boynton, RN, MSN and author of "Confident Voices: The Nurses' Guide to Improving Communication & Creating Positive Workplaces." “We need work environments that support our work…enough staff, enough time, enough training are key as well as respectful communication at all levels. If you look at the sentinel event data re: root causes on TJC (The Joint Commission) website with a focus on human behavior you'll see profound links.”
So, research supports what we know as common sense. We all know, when you get tired, when you are angry or depressed, when you are physically exhausted or emotionally drained you may show up at the job but you often are just going through the motions.
Tired people make mistakes. Overworked people make mistakes. Unhappy people make mistakes. Cutting staff to save money ultimately seems to cost more money. When will our healthcare institutions learn?
It’s been about 10 years since California mandated minimum nurse-to-patient ratios and the outcomes have been controversial and continue to raise questions. However, we do know that nurse turnover rates and nurse burnout rates have declined while the number of qualified nurses willing to work has gone up, as has nursing morale according to the California Nurses Association.
Other advocates claim there is improved patient satisfaction and reduced medical errors, including medication mistakes and falls in high-traffic, high-intensity areas like emergency services.
Opponents of the mandated staffing legislation say it is very hard for the hospitals to meet all qualifiers of the legislation and to keep the staffing numbers consistent. They also say the mandated staffing actually slows down care in areas like emergency rooms where patients have longer wait times even getting to an exam room much less being seen due to the staffing issues.
Of course, staffing is only one part of the equation when it comes to burnout and quality of care, specifically higher infections rates. As reported in the Philadelphia Inquirer, “when there also is a lack of teamwork and support from the top, and an inability to act independently, 'stress builds up and builds up and builds up until the giver of care just detaches,' said lead author Jeannie P. Cimiotti, and ‘all of a sudden they are doing work, but they are not even cognizant of what they are doing, they are so stressed.’”
With that stress, the nurse may forget to wash her hands between patients, or may not clean the patient as thoroughly before inserting a Foley urinary catheter or prepping the patient for surgery. These actions do not happen with intent, nor is it the goal of the nurse (or other care providers for that matter) to make the patient sicker but when we are tired and overextended mistakes happen.
Researchers on this study determined that if nurse burnout rates could be reduced to 10 percent from an average of 30 percent, Pennsylvania hospitals could prevent an estimated 4,160 infections annually with an associated savings of $41 million. These findings were based on the average cost per-patient associated with CAUTIs ($749 to $832 each) and SSIs ($11,087 to $29,443 each).
"Health care facilities can improve nurse staffing and other elements of the care environment and alleviate job-related burnout in nurses at a much lower cost than those associated with health care-associated infections," Cimiotti and colleagues concluded. "By reducing nurse burnout, we can improve the well-being of nurses while improving the quality of patient care."
While the study uncovered an association between nursing staff burnout and infections among patients, it did not prove a cause-and-effect relationship. However, it sounds like plain, old-fashioned common sense—if the nursing staff is pushed beyond its limits because of an unpleasant work environment or low staffing ratios, more mistakes can happen and patient care and safety can be jeopardized. We just need our healthcare facility administrators to embrace the message and work toward better outcomes for both the staff and the clients.
August 1st, 2012
By Jennifer Olin, BSN, RN
Opportunities to train as an Advanced Practice Registered Nurse (APRN) multiplied this week as U.S. Secretary of Health and Human Services Kathleen Sebelius announced the recipients of a $200 million grant.
"With this important initiative, we are putting more advanced practice nurses on the front lines of our health care system and further strengthening and growing our primary care workforce," Sebelius said in a statement.
Sebelius announced the Graduate Nurse Education Demonstration at Duke University Hospital in Durham, one of five hospitals across the country selected to receive the funding.
The other four hospitals are: Hospital of the University of Pennsylvania in Philadelphia; Scottsdale Healthcare Medical Center in Scottsdale, Arizona; Memorial Hermann-Texas Medical Center Hospital in Houston, and Rush University Medical Center in Chicago.
The five hospitals will share the estimated $200 million in federal funding to help train additional APRNs the Department of Health and Human Services (HHS) announced on Monday. The money will be spread over four years and is provided under the Affordable Care Act (ACA).
This announcement comes amid growing concern that the demands of healthcare reform and the Affordable Care Act (ACA) will exceed the ability of primary care practitioners to meet those needs.
Hospitals in the program must partner with accredited schools of nursing in their area. As a condition of participation each hospital has committed to support nurse training in nonhospital settings such as community health centers and rural health clinics. "This program will bring talented nursing students into five communities that have a real need for additional primary care and healthcare access," Sebelius said.
Duke Medicine expects to double the number of advanced practice nurses it trains under the initiative. By 2016, 216 additional students are projected for enrollment.
"The complexity of the challenge to make care more accessible and affordable, while enhancing quality, is exacerbated by the continuing decline in the number of primary care physicians and the expected influx of patients into the healthcare system as a result of health care reform," said Victor J. Dzau, M.D., president and chief executive officer of Duke University Health System, in a news release. "We are proud to be a part of this important effort to help solve this problem."
The funding will cover as many as 400 additional over the next four years, said Nancy Busen, assistant dean of the University of Texas Health Science Center at Houston’s School of Nursing.
UTHSC-SON, along with nursing schools at the University of Texas Medical Branch in Galveston, Texas Woman's University in Houston, and Prairie View A&M University, will handle the academic component, while Memorial Hermann provides clinical training.
APRN Areas of Practice
"Having more of these kinds of skilled nurses will increase access to essential healthcare services," Sebelius said during the press conference.
There are four different specialties associated with APRNs:
APRNs can diagnose illnesses, prescribe medications and treatment regimens, and perform procedures consistent with their scopes of practice.
According to the program description, the Centers for Medicare & Medicaid Services will provide reimbursement for the "reasonable cost of providing clinical training to APRN students added as a result of the demonstration." Payments will be linked directly to the number of additional APRNs trained and will be calculated on a per-student basis, comparing previous enrollment levels in APRN training programs with enrollment under the demonstration.
It is hoped that the program will relieve some of the barriers experienced by hospitals and colleges in providing APRN training. Last year nursing schools were forced to turn away more than 14,000 qualified APRN applicants, according to Polly Bednash, PhD and RN, CEO and executive director of the American Association of Colleges of Nursing, who attended the program announcement.
The primary reasons were the lack of clinical sites and budget cuts, explained Bednash, who added that the demonstration program addresses those specific concerns.
that the Obama administration has earmarked for nurse training, education, and job placement.
The academic portion of the program will begin this fall.
July 31st, 2012
By Jennifer Olin, BSN, RN
Being a registered nurse (RN) is the best! And apparently it’s going to stay that way according to the folks at to U.S. News & World Report. In their annual rankings of the best career choices in 2012, nursing topped the magazine’s list.
Using measures such as projected job growth, average salary, and predicted job prospects, healthcare-related occupations filled five of the top ten picks. Number one, of course, was nursing with pharmacist, medical assistant, physical therapist, and occupational therapist filling other high- ranking spots.
If you are a student trying to decide on a career path, clearly nursing could be a good choice. If you are looking for a career that offers many opportunities for growth and advancement, nursing is a good choice. And if you worry about getting bored, nursing is a great choice because there are so many different fields in nursing.
Home Health Nursing
Some areas of nursing are wide open as soon as you pass your licensing exam. Other areas require some experience before you can move into that specialty. If you are looking for a job in healthcare that isn’t necessarily 9-to-5 with lots of independence, home health nursing just might be for you.
Now, before you can embrace a career in home health you do need a couple of years experience in med/surg or ICU nursing or even the emergency room. You need to cement your day-to-day nursing skills. But once that is done, you are probably ready to get out and meet the public.
The focus of home healthcare nursing is individuals and their families. According to the American Nurses Association (ANA) home health nursing is a “synthesis of community health nursing and selected technical skills from other nursing specialties,” including medical/surgical nursing, psychiatric/mental health nursing, gerontology, parent/child nursing, and community health.
History of Home Health Nursing
Home care has been an organized system of nursing in the United States for over 100 years. It developed in response to the needs and preferences of families to care for family members at home and because of the limitations and costs associated with institutional care.
Lillian Wald is widely regarded as the founder of visiting nursing or home healthcare in the U.S. and Canada. She is described as a nurse, social worker, public health official, teacher, author, editor, publisher, women's rights activist, and the founder of American community nursing.
In 1893 she started teaching home classes on nursing for women living in the tenements on the Lower East Side of New York City. Not long after that she began to provide care for the ill and infirm residents of the same area.
Along with another nurse, Mary Brewster, she was the founder of the Henry Street Settlement, dedicated to bringing nursing care, and eventually education to the immigrant poor on Manhattan’s Lower East Side. By 1906 she had expanded her services so much she had 27 nurses working by her side. The Henry Street Settlement is still in business today.
Home Health Care Today
Home health nurses will tell you there are significant advantages to caring for individuals and families in their own homes. The home setting is intimate. It helps foster familiarity, sharing, connections, and caring between clients, families, and their nurses. Behavior in the home setting is more natural, cultural beliefs and practices are more visible and there is often exposure to multiple generations of family.
When working in the home environment all the rules of the nursing process apply but some of the processes are a little different or expanded. For example, you don’t just assess the client, you assess their living space.
The home health nurse obtains a health history for the client, reviews documentation, examines the client, observes the interaction between the client and the caregivers and assesses the environment. Parameters can include client and caregiver mobility, client’s ability to perform self-care, the cleanliness of the environment, the availability of caregiver support, safety, food preparation, financial supports, and the emotional status of both the client and the caregivers. Now you see why you need a wide range of experience before stepping into a home health career.
The home healthcare nurse is not just a care provider but also a teacher and an advocate for the client and their family. The nurse may have to intervene to mobilize resources of the community or a hospital to provide patient appropriate care.
Home health nurses have first-hand knowledge of the burdens of caregiving. There are many costs involved. Sometimes the caregiving demands can go on for months or years, placing the caregivers themselves at risk. Facing reality too, home health nurses must often enter homes where the living conditions and support systems are inadequate. When additional support or improved care cannot be obtained the home health nurse faces difficult decisions.
Doing the Job
There are some great benefits to working in home health. If you are tired of literally punching a time clock and being inside a hospital or clinic all the home health gives you frequent changes of setting. Want to be more your own boss? Home health offers lots of autonomy and less office or desk time than many jobs.
You have the opportunity to create your own schedule when you are a home health nurse and working part-time is always an option. There are literally dozens of agencies in every city that provide home health care nurses. Of course, you have to keep in mind that home health care is not usually a quick visit, patients and families take more time, and you should probably enjoy driving and working out of your car.
The most common patient base in home health is the elderly or the disabled young. You will look at a lot of decubitus ulcers, check a lot of urinary catheters and you should have good blood draw skills.
According to the home health nurses I know you need to have a good sense of humor, be open minded, and be flexible. Your day will never go the way you plan, whether it’s traffic slowing you down or the need to jury-rig an IV pole out of a broomstick and vacuum cleaner for a rolling base, it’s probably not what you had planned when you first got in the car.
Home health is a big industry, and it is unlikely to get smaller since shorter hospitalizations are the rule of the day and people are becoming more demanding about their healthcare options. If you truly like your patients and their families and often get talked to at work for spending too much time talking to your clients home health nursing just might be for you.
July 30th, 2012
By Jennifer Olin, BSN, RN
Here at RNCentral.com we are fascinated with all the inroads the electronic age is making in healthcare. I mean, come on, we are all about online education opportunities for nurses, keeping up your continuing education responsibilities with online CEU courses, and we stand behind the move towards EMRs, EHRs, and PNRs.
On a more personal level I love all this cool technology. Talking to Connie Barden, RN, a tele-ICU educator, was fascinating. It is truly amazing how computers and the internet can help us up our game in providing on-the-spot, real-time, quality healthcare.
Now, it seems, tele-health is moving into home health. This story was first brought to my attention by Kevin Ross, RN over at Innovative Nurse. Ross is, among other things, a great advocate of advancing healthcare and using technology to do so. A little article on a visiting nurse association starting to use tele-health to reach more patient captured his attention, and then mine.
The Visiting Nurse and Hospice of Vermont and New Hampshire (VNAVNH), and VGo Communications, the leader in robotic tele-presence, are announcing their agreement to be the first home health agency in New England to deploy tele-presence robots to help deliver care in New Hampshire and Vermont clients’ homes.
Now, if you know anything about Vermont and New Hampshire you know urban settings are not their strong suit. Both of these states are made up of beautiful mountains, rivers and ponds, and moose—and not a lot of people. It is beautiful country with lots of picturesque hamlets and usually big snows in the winter. Much of the population lives scattered about these two small states and depending on the season getting in and out can be very difficult. That means being a visiting nurse can be a real challenge.
“We are continually looking for ways to increase levels of care, independence and safety in the home,” said Jeanne A. McLaughlin MSN, MSEd, and President/CEO of VNAVNH. “VGo is the first affordable solution that enables us to expand client engagement without a dramatic increase in cost, while still preserving a person to person interaction.
”People often need more care and attention, not less, but that’s hard to do in rural areas without an army of staff. VGo’s lightweight and ease of deployment means that nurses and doctors can now visit with select patients more frequently, McLaughlin said. “By eliminating the need to travel for each visit, professional staff can better utilize their time and respond to client’s needs and unforeseen problems that arise much quicker.”
The VNAVNH serves nearly 113 towns in Vermont and New Hampshire and provides healthcare coverage over 4,000 square miles along the Connecticut River Valley. They care for more than 5,000 people each year, making over 132,000 home visits to people of all ages and at all stages of life.
The VGo robots give nurses the freedom to move around a patient as if they were physically there. With VGo, you can see, hear, talk, interact, and go anywhere. VGo is not a traditional videoconferencing/tele-presence solution where two or more people meet using specially equipped rooms or PCs in their offices. With VGo, you are completely independent of the people in the distant location – it’s 100% remote controlled.
VNAVNH will initially use its fleet of VGo robots in four ways:
“VNAVNH’s visionary approach to improving healthcare at home is a perfect match with our goals of replicating a person in a distant location at a very affordable cost,” said Peter N. Vicars, CEO of VGo. “For about $10 a day, healthcare professionals can visit more clients, spending more time with each one and less time on the road. Researchers have proven that patients enjoy interacting with their caregivers using VGo and look forward to each visit.”
The VGo even, sort of, looks like you have a new friend or nurse in the house. VGo stands 4-foot-6 inches tall, weighs 17-pounds, has two wheels and video monitor face. The robot is even dressed in white, like the nurses of old.
With cameras, advanced audio gear, and a video screen on its “face,’’ the robot allows the patient and their caregivers to talk with nurses and doctors anywhere in the country. They can see and communicate back-and-forth, take close-up photos of surgical sites and scars, wounds or any other body part or anomaly, and doctors and nurses can review, and help determine what type of care or medications are needed.
While it seems that the national nursing shortage is somewhat contained for the moment in rural areas and some small states like Vermont and New Hampshire it can be hard to recruit enough nurses to provide all the states’ healthcare needs. There is competition from big nearby cities and major medical centers for the limited nursing personnel available for employment. With a tele-presence a single nurse can literally cover two or three times as much territory without leaving an office and see two or three times as many patients.
It seems to me there are other benefits to systems like VGo. As a home health care provider it is certainly more “green” if you aren’t out driving around all the time. And, how about a time and money saver? For patients being able to talk to their nurse or doctor without leaving the house means no, often long, trips into a hospital or clinic and for the healthcare provider if you don’t have to spend your time driving around you have more time to actually spend with your patients. It’s like getting the personal touch back without being there in person.
I look forward to seeing how this system works out. It seems like a win-win situation for difficult healthcare settings.
July 27th, 2012
By Jennifer Olin, BSN, RN
When I started thinking about this article I was actually watching a cooking show on television. I’m addicted to “Chopped” on the Food Network. That got me thinking, do real working chefs watch this?
I got more curious as I continued to watch so I picked up the phone and called my friend Marene Gustin. She's a food writer. I asked her my question and she said she didn’t know, but she’d get right on it. If you want to know what professional foodies watch, check out Gustin’s Culture Map blog and find out.
Now this, of course, led me to think, do nurses bother to watch the medical dramas on TV? I mean over the years there have been so many. One of the first I remember was “Medical Center.” It came to mind just this week when it’s star, Chad Everett passed away. I remember my Mom watched, always saying how handsome he was. I also sort of remember my Dad making fun. I always thought that was because she was star struck. Looking back now, it was probably because he was a medical student at the time and he couldn’t believe what he was seeing.
In my teen years, like almost every young woman in the country I was addicted to the trials and tribulations of Luke and Laura on “General Hospital.” The VCR had been invented and I could record it and watch whenever I wanted. More snorts of derision from my now surgeon father when he would pass through the room. “M*A*S*H” is the only show with any medical integrity,” he would say.
Now, I must admit, since I became a nurse I can barely tolerate doctor/nurse/hospital shows. I tried to watch “Grey’s Anatomy” a few times. However, every time one of their surgeons would walk into the OR without a mask I would get disgusted, say something nasty to the TV, and change the channel.
With these thoughts in mind, I started a totally unscientific survey of nurses I know, or meet around the hospital. Here’s some of what they had to say:
Terri Polick, RN – “I don’t own a television anymore. But, when I did I think the closest one to reality was ‘St. Elsewhere.’ I remember episodes where there would be crazy patients and the call lights would be flashing and the nurse would say, “Oh hell, that light again.” That’s reality.
”They were one of the first shows to talk about the AIDS epidemic. They captured the back door drama and the drama in the lounges. I remember when Nurse Rosenthal had breast cancer and how she dealt with that. Back then it was death sentence.”
Nora Lawton, RN – “Most of them are so ridiculous. ‘ER’—please. And, you ever watch ‘House?’ He’s an a__ and he’s crazy.
”’China Beach’ I used to watch. She had a mission. They really cared about those boys over there (Vietnam) and I knew that was right. No one had a lot of coping mechanisms there. She worked as a nurse and she drank. We knew that really happened when people came home. Plus, I liked that they didn’t just save a life, you got follow-up. You found out what happened to them afterwards.
”And I liked ‘Marcus Welby, MD.’ He was ethical and practical and useful. One of those old Docs who still made house calls.”
Audrey Orlino, RN – “Ok, I like ‘House.’ You know, he does all those diagnoses. He looks at all those signs and symptoms, narrows it down, and then figures it out. It’s fun.”
Now of course while Orlino was talking and telling me this, one of her friends and coworkers was yelling, “Oh my gosh, are you kidding. He’s ridiculous, no one does that. And, where are all the nurses at that hospital. You never see any.”
Erik Martinez, RN – “ I used to watch ‘M*A*S*H. I loved that one. But now, I don’t really watch any of them. I tried to watch ‘ER’ when it first came out. But then, in the first season, they had this ridiculous moment.
”There was a medical student alone in an ER triage room with a patient. The guy throws a ruptured AAA. There just happens to be a tray of instruments in the room, she grabs a knife, then a clamp and fixes him up—in just five minutes.
”I never watched again.”
This avoidance or disregard for medical dramas on television carries over to other media when it comes to healthcare professionals. The current national obsession with the novel “Fifty Shades of Grey” elicited a tirade that had me in stitches when I was talking with an OB nurse one day.
Stephanie Posada, RN – “I started reading the book and I got the fascination. It’s romantic, he’s everything you look for in a perfect man. And then came the love scenes. Oh My God! The things they do. I just can’t help thinking, this woman will never have any bladder control again. Her pelvic floor is totally gonna be dropping. They’re doing what?
"Then, I flash on all the emergency procedures I’ve seen. I hear women talking about how erotic this book is and all I can see is the stuff we have removed from people in the emergency room. I don’t know how any OB nurse could read this and find it fun.”
So, clearly it’s not just TV that makes those of us in healthcare grimace sometimes. I know these shows are escapism. I know lots of people really enjoy them and I’m glad. But folks, you must remember they are fiction. Nurses, or even more likely techs, take blood. Nursing assistants change beds, walk patients, and collect vital signs. Docs never have that much time to hang around in patient’s rooms and I can’t remember the last time I saw a hospital administrator on the unit.
What are your thoughts? Are there some medical shows you’ve loved? Have I been too harsh? Tell us. We would love to hear your thoughts on state of medical entertainment in the year 2012.
July 26th, 2012
By Jennifer Olin, BSN, RN
To some extent all nurses in direct patient care are psych nurses. We may work on a med/surg floor, or in the operating room, or in a community clinic. We may deal with people facing end of life issues or pregnant women facing new life issues. No matter the problem or experience at hand there is stress. Helping patients deal with stress makes us all mental healthcare providers.
In nursing school we are all given some instruction on dealing with anxious or angry patients and their families. Hospitals employ social workers, clergy, full customer service departments to help clients and families cope with the stressors of hospitalization and illness. However, none of those folks show up until the nurse calls. What that means is you, as the RN, are first on the scene.
Stress can have physical, emotional, intellectual, social, and spiritual consequences. Usually you find some combination of these traits since stress affects the whole person. It is often the job of the nurse at the bedside to determine if a patient is suffering from a stress related symptom and if so the nurse must employ the nursing process to help alleviate those symptoms.
The psychologic manifestations of stress include:
Some of these coping patters are actually helpful; others, not so much. In fact, anxiety is often considered a response to a stressful situation rather than a coping mechanism, since it may impeded action to remove the stressor.
How can anxiety be a coping mechanism? Well, all people experience some degree of anxiety at some time in their lives. Mild or moderate anxiety is needed to accomplish developmental tasks and motivate goal directed behavior. In this sense, mild anxiety is an effective coping strategy. For example, mild anxiety motivates students to study. It is excessive anxiety that has destructive effects.
Although coping behavior may not always seem appropriate, the nurse needs to remember that coping is always purposeful. Short-term coping strategies can reduce stress to a tolerable limit temporarily but in the long run are ineffective ways to deal with reality.
Helping Clients Overcome Anxiety and Other Stress Symptoms
Nurses can help clients recognize stress and support effective coping strategies or teach the client new and more effective ways of handling stress. To be able to turn the patient’s coping strategies into an effective, safe tool the nurse must first assess what is a normal coping pattern for the patient. This will include questioning the patient and members of their support system.
There are several NANDA-I diagnoses relating specifically to clients experiencing stress including: Anxiety and Ineffective Individual Coping. It is now up to the nurse to develop a plan (in collaboration with the patient and significant support persons) for ways to change the existing responses to the stressors.
This is where we get to implementing the plan, which is of course the best part. This is the time where with skill and a little bit of luck the nurse will actually help the patient feel (emotionally at least) better.
The list is long with suggestions on how to do this. Start with orienting the patient to the facility and how it works, that includes everything from visiting hours and meal times to who is in charge and when they are there. Make sure to repeat information when the client has difficulty remembering. Take a minute to listen to the patient express their feelings and thoughts on their current situation. When listening make sure you are communicating competence, understanding, and empathy rather tan stress and anxiety. It’s the difference between taking a seat and standing in the doorway repeatedly looking at your watch.
Finally keep a smile on your face and maybe a few jokes in your pocket. Humor is a great means of coping with stress.
Progressive relaxation requires the client to tense and then relax successive muscle groups, usually working your way up or down the body. This technique can result in decreased body oxygen consumption, metabolism, respiratory rate, cardiac rate, muscle tension, and even the lowering of blood pressure.
The client’s religious and/or spiritual beliefs should be considered when determining helpful images. Images of religious or spiritual bliss can produce physical relaxation and mental peace.
When we are new nurses dealing with a patient’s anxiety, our lack of experience may actually provoke anxiety. This passes. With time, we all find the ways that work with our own skill sets and personalities. Ultimately it is better for the patient and improves the quality of the care we give.
In the pre-operative holding area I often have patients who are really worried about their surgery. They often express this as “they just don’t know what they are going to do.” If they seem approachable with humor I almost always tell them the same thing. “There’s nothing for you to do, you are going to sleep through the most important stuff. Worry about if I am going to get my lunch.”
Not only do they usually laugh but we change the focus of their stress from having surgery to how soon will they get to eat when they are done. A much more pleasant thing to focus on.
July 25th, 2012
By Jennifer Olin, BSN, RN
When I was in nursing school, most of my classmates dreaded our clinical rotation in mental health nursing. They were disinterested, or nervous, or flat out scared. I didn’t get it. I loved my rotation at the county mental health facility—in fact I liked it so much psych nursing was my second choice if I couldn’t get a job in the OR.
Ten years down the road I still wonder what it would be like to work in psych nursing. With all that’s been in the news the last few days I found myself thinking about it again. So, I called up Terri Polick, a psych nurse with more than 20 years in the field, and asked her how she got there and what it takes to really find success in the field of mental health nursing.
”I was a history and poly sci major at Iowa State, focusing on middle eastern history and languages,” Polick told me. “A friend of mine went to China as one of the first American students to visit China right after Nixon (1972). She came back and couldn’t get a job. I thought I had to be nuts studying this. We didn’t even see the Middle East a major player then.
”I didn’t know what I wanted to do and I didn’t want to waste my parents’ money so I quit school. All the factories in my area were closing, there were no jobs. Every day I would look in the paper and the only jobs I could find were for certified nursing assistants. I went to my Dad and asked if I could borrow $40 to get my certification.
”After the 12 week course I was working in a nursing home and I loved it. I asked my boss if she would write me a recommendation for nursing school. Then I went and told my Dad I had found what I wanted to do. He said, “you won’t be rich, but you will always have a roof over your head and be able to find a job. “
Polick has been a nurse ever since.
Did you go straight into psych nursing?
”Oh, gosh, no! You remember “One Flew Over the Cuckoo’s Nest?” That came out in my junior year of nursing school. In my clinical for psych my first day on the unit was like that. Someone actually tried to choke me. You have to fast-forward 10 years before I came back to psych. I worked as a med/surg nurse, a neuro nurse, did a little of everything. I never worked in the OR and I never birthed a baby. I had done it all but never found my niche.
”One day my supervisor says I should try psych. My time management skills were awful and she said it was because I spent all my time talking to my patients, 'you are trying to solve everyone’s problems.' I was a square peg trying to fit in a round hole. I finally found my square hole."
In most areas of nursing we learn our job by learning a set of concrete skills, how to draw blood, how to place a catheter…how did you train for something like psych?
”I got attached to a nurse who had been in psych since Florence Nightingale was a little girl. On my first day on the unit I felt so odd. In med/surg you start your day by getting your patient’s vitals, checking IVs, checking wounds—physical stuff. On a psych floor you feel for the vibe. You check moods, put up your antennae. You have to get the vibe of the floor.
”You talk to people. How they speak tells you a lot about what’s going on: what is their volume, their cadence—you assess. You ask the night nurse if they slept, were they agitated last night, did they need meds? You need to know if they had visitors and who and how’d that go? In med/surg it’s a physical assessment. In psych it’s emotional.”
But, I hear those med/surg skills come in handy with some populations, or patients. How’s that?
”I worked with street people in Chicago, you know the people in tin hats living under the bridge. And, you know how winter in the Midwest can be. When they would get brought in the very first thing I would do was make them take off their shoes to check their feet for frostbite. And the people who live in camps or shelters, you have to check for TB. You do need those med/surg skills.”
These days Polick works for the Department of Defense providing psych services to active duty military and their families.
”The military has really changed, from the top down. They are being encouraged to seek help. There used to be a huge stigma in the military about mental health problems, people believed they wouldn’t get promoted if anyone knew they were having troubles. However, that has really changed. The military is learning from its own history and the leadership is really stepping up."
If a nurse or nursing student is interested in a career in mental health, what qualities do you think they need to have to be successful?
”You cannot be judgmental. You cannot be narrow-minded when you see someone struggling with their sexual orientation. Sometimes you will have patients who have abused children or done other things along those lines. You have to have a very big, open mind.
”You have to be open to different cultures, too. What may be very macabre or different to you may be healing to someone else. You have to be open to it."
How do you stay culturally competent with everyone? The U.S. is such a mixed bag.
”At least in metropolitan hospitals they try to hire nurses who reflect their population. In a lot of my hospitals I have been the only white American on the unit. You really have to be in touch with who your patients are.”
There are many who would say the military is it’s own culture, how did you learn about that area?
”I was mentored by my head nurse, a Lt. Col. in the Army and a Midwestern girl like me. She gave me a pamphlet on military culture, sort of “Military Officers for Dummies.” I learned about rank and protocol. “I have to say here, the military nurses I have worked with are the best educated nurses in the world. They have to be proficient in more than one specialty. I have worked with a lot of nurses over the years, I am old and jaded, and these are some of the best nurses I have ever met. I am always learning stuff working with them."
What other qualities make for a good psych nurse?”
"You’ve got to have a good sense of humor. You have to find some sort of humor in the intensity. You have to see the insanity for what it is."
I’ve heard a lot of psych nurses are as “crazy” as their patients. Is this true?
"Everyone has their issues. There really is no one in this world that doesn’t have some kind of problem. A lot of times patients want to make it you versus them. The difference between us, and I’ve said this, is ‘I have learned to run my craziness, I don’t let it run me.'"
“You can be as crazy as you want in this country, I tell them. As long as you pay your bills, don’t break any laws, and don’t make too much noise.”
Do you encourage nurses or students to go into mental health nursing?
”I have on occasion said, I’ve seen how you handled that patient or situation, you used the nursing process, you were empathetic, you should consider working in psych.
"You know, psych has been until very recently the redheaded stepchild of nursing. We’re told we aren’t real nurses, you know, no bandages. But, now we are gaining legitimacy. In the military recently they ran a survey to see what skill their nurses have and what they need. Psych is where there is huge need. I think there will be many more jobs opening up in psych."
So, I’m guessing psych nursing is what you will do until you stop nursing?
"I will die with my Nursemates on—or I will be a no call/no show and I told my boss he will need to send the sheriff to break down my door. I have an aunt in her 80s who is still a working hospice nurse.”
Polick brings her insights into healthcare, and nursing in particular, to her blog site, Nurse Ratched’s Place. Polick isn’t crazy, she just plays a psych nurse in real life.
July 24th, 2012
By Jennifer Olin, BSN, RN
The events in Colorado last week have us all wondering, what would lead someone to go from quiet neuroscience student to an alleged gun-toting killer? Why didn’t someone see it? Weren’t there any obvious signs that young man was on a dangerous edge?
These are all questions that will be addressed by healthcare professionals over the coming weeks; healthcare professionals who focus on mental health concerns and psychiatric diagnoses.
Psychiatric mental health nursing (PHMN) is a specialty area within the nursing realm. Like other areas it has its own language and its own special characteristics. Psychiatric mental health registered nurses work with individuals, families, groups, and communities, assessing their mental health needs. Like every other area of nursing, the psychiatric mental health nurse develops nursing diagnoses and plans of care, implements the nursing process, and evaluates it for effectiveness.
History of Psych Nursing
Care for the emotionally and mentally ill goes back centuries, but the formal recognition of psychiatry as a modern study really came to being in the early 1800s. One of the early advocates for mental health nurses to help psychiatrists proposed giving the “keepers of the insane” better pay and training so more respectable, intelligent people would be attracted to the profession.
In 1836, Dr. William Ellis said that an established nursing practice calmed depressed patients and gave hope to the hopeless.
Psychiatric nursing as a study was not really recognized in the United States until 1882 when Linda Richards opened Boston City College. This was the first school specifically designed to train nurses in psychiatric care. In 1913, Johns Hopkins University, in Baltimore, was the first college of nursing to offer psychiatric nursing as part of its general nursing curriculum.
The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey was published in 1920. It was not until 1950 that the National League for Nursing required all nursing schools to include a clinical experience in psychiatry to receive national accreditation.
One nurse was a major player in the development of PHMN. Hildegard Peplau is universally regarded as the “mother of psychiatric nursing.” Her seminal book Interpersonal Relations In Nursing has been widely credited with the transformation of nursing from a group of skilled workers to a full-fledged profession.
Her model of “Psychodynamic Nursing Theory” was first published in 1952 and is still used today by clinicians when working with people who have psychological problems. The book was republished in 1991. It emphasizes the significance of the relationship between the patient and the nurse as a treatment modality.
What’s It Take To Be a Psych Nurse?
The A-number one attribute of a good psychiatric mental health nurse is the ability to communicate. And that often means asking simple, open-ended questions then sitting back and listening. Getting to know what is in the client’s mind and helping that client back to a place of mental wellness is the job of the mental health nurse.
A psych nurse must also be non-judgmental. You cannot bring your own prejudices and biases to the table. The patient must feel that you are open to anything they have to say and will provide a safe, accepting environment for them to work through their problems.
During the nurse-patient relationship, nurses assume many roles: stranger, teacher, resource person, surrogate, leader, and counselor. A large part of psych nurse work involves close observation.
Psych nursing calls for expert assessment skills. The general survey of appearance and behavior will tell the nurse much about the client’s emotional state. When further assessment is required psych nurses focus five major areas:
Nonverbal communication such as eye movements, gestures, use of touch, and posture can reveal much of what the client is actually feeling. The nurse, must in particular, note when the nonverbal behaviors and the verbal expression are not in synch.
Besides strong communication and assessment skills, psych nurses need to be real. A good psych nurses is patient, empathetic and has a genuine attitude of caring. Confidence, patience, and a sense of humor come in handy too.
Where Will You Work?
Psych nurses are found in acute care hospitals, psychiatric facilities, community clinics, halfway houses, and rehabs, to name just a few places. There are state, county, and even city psych hospitals and there are private clinics. Specialty areas range from adults to children, addicts, veterans, or the homeless to name a few.
Being a psych nurse is a special calling. When I was in nursing school I had several different clinical instructors in my hospital rotations who were psych nurses. Even then, when I was completely absorbed in trying to figure out how to make a bed with a patient in it or changing a colostomy bag for the first time, I recognized the value of my instructors having focused their training in psych.
They were the nurses who, to this day, stand out in my educational experience. They taught all of the nursing skills, but they may have contributed more in our post clinical breakout sessions when they helped us all understand what in our day was intimidating or scary and built our confidence that we too would one day be comfortable in the role of healthcare providers. So, I guess there’s a place for psych nurses in education, too.
July 23rd, 2012
By Jennifer Olin, BSN, RN
By the time you are reading this blog the events of Friday morning, July 20, 2012 in Aurora, Colorado have played out on every news outlet imaginable. But, what happened at that movie screening will, like many other mass casualty disasters, have repercussions for some time to come.
This country has had more than its share of mass tragedies, some on a national scale such as September 11, 2001. For the people of Colorado, despite the fact that the Columbine school shooting disaster was in 1999 (13 years ago,) what happened just up the road in Aurora last week will bring back many unwelcome memories. And, people across the country, from Oakland, CA and the Oikos University campus, to Oklahoma City, to Blacksburg, VA and the students of Virginia Tech, will relive their own private nightmares.
When you work in the news business or in healthcare, events like these stand out immeasurably. I have had careers in both, been involved in covering these events from the standpoint of the media and as a nurse, and it is hard to explain the obsession that comes with being even tangentially involved.
I watched a nurse give press conference about the movie shooting from the parking lot of one of the hospitals where the injured victims were being treated. I saw a doctor from another facility do the same. Both mentioned that as soon as they received calls their hospital’s “disaster protocol” was put into play.
What that means, is phone trees are lit up, everyone from physicians and nurses, to OR and ER support staff and custodians are called in to work immediately. If the disaster drills have been practiced, what happens is almost seamless. ERs gather gurneys and supplies, ORs are opened and instruments readied, ICUs prepare vents and pumps, and all staff are on alert. It is an adrenaline rush at the beginning and exhausting at the end.
Many medical facilities run mock disaster drills in order to prepare for just such an emergency as the shooting in Colorado. All hospitals are required by The Joint Commission (JCAHO) to have disaster preparedness plans in play.
Standards of care developed by JCAHO have evolved from studying previous significant public disasters. JCAHO guidance centers on managing consequences to; provide safe and effective patient care during an emergency, clearly defining staff roles, training those roles and responsibilities; and sustaining staff competencies over time.
There are six focus areas that hospitals must address to demonstrate they have proper plans and response mechanisms to a disaster. During planned exercises, the organization monitors, at a minimum, the following six critical areas:
The protocols for each facility’s disaster preparedness plan and how each individual department will ready should be found at a central location on each unit, usually the nurses’ station or front desk.
The Centers for Disease Control and Prevention (CDC) also are a great source for understanding what a healthcare facility and its providers need to be ready for in case of such an emergency as happened in Colorado. Through studying previous disastrous events the CDC even offers formulas for estimating how many casualties hospitals in the area can expect.
When trying to determine how many casualties a hospital can expect after a mass casualty event, it is important to remember that casualties present quickly and that approximately half of all casualties will arrive at the hospital within a one-hour window. That window opens when the first casualty arrives at the hospital. To predict the total number of casualties a facility can expect, you simply double the number of injured who arrived in that first hour.
When All Is Said and Done
Once the initial disaster has passed, the hospital is running at normal again and extra personnel have gone home or back to their regular shifts you would think you were done. But dealing with the aftereffects of such a community tragedy as happened at the movie theater takes its own toll on the healthcare providers.
To say that caregivers sometimes need counseling almost as much as the victims and their families is an understatement. Anyone who works in a hospital setting, or happens to be a healthcare provider on the scene of the events carries what they see and do with them for a lifetime.
There have been research studies and even the CDC addresses caregiver needs, not just victims’ needs, following public tragedies. Often, we as caregivers are not prepared for the post trauma stress. I know post traumatic stress disorder (PTSD) seems like a major term for people who are trained to deal with just such happenings but it can affect us too.
It is always good for a hospital or at least a department to have a post-disaster briefing. It is a good way to address problems that may not have been anticipated, to make plans for future emergencies, and to let everyone who worked blow off a little steam, take a deep a breath, and really face what happened, not just at work, but also in the neighborhood where you live.
None of us ever really want to have events like what happened in Aurora happen in our community. However, it is part of the package we sign up for when we come into healthcare. The paramedics, techs, nurses, doctors, and the rest of the staffs of the Colorado hospitals who cared for these victims are returning to normal now. But, what happened in their hospitals could just as easily happen in yours.