Nursing Notes

October 26, 2010

Brother, Can You Spare an RN?

Filed under: Nursing — Shirley @ 8:02 pm
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A friend recently sent me this article in an email.  I read it and I have to say I was appalled by the thought of this type of teaching for new nurses.  Nursing is all about touch and connection as well as knowledge.  What this type of training might turn out are simply nursing technicians–those capable of doing the tasks but without the underlying understanding and without the judgement factored in.  Please let me know what you think after reading this article.  Maybe I am just too old fashioned, but I want a nurse who knows all about me and what is best for me at that moment, not a nurse who is proficient in the tasks but hasn’t a clue how to deal with anything else.

This article is from Governing.com, which in and of itself is kind of creepy.

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There aren’t enough nurses to go around, and there’s no cure in sight.

Ellen Perlman | May 2004

 

Coming soon to the state of Colorado–if the Colorado Department of Labor and Employment has its way–is a computer simulator that will train nurses on virtual patients programmed to have emergent symptoms of a variety of conditions and diseases. With a shortage of clinical training sites and qualified nursing instructors throughout Colorado, the virtual teacher is one way the state plans to pitch in to help get more nurses trained.

Colorado is not the only jurisdiction that needs to take action to ease a nursing shortage. At the present time, at least 30 states are grappling with a shortage of registered nurses and that number is expected to grow to 44 states by 2020. The lack of nurses is felt in all sectors: private hospitals, nursing homes and doctor offices as well as facilities run by states and localities–clinics, public hospitals and the like.

While there are limits to how much an individual government can do to boost a profession’s ranks, several states and localities are trying to figure out how to solve the nursing riddle in their jurisdiction. And it is a complex riddle because the shortage problem is two-fold. There is a dearth of nursing teachers to teach the next generation of nurses, thereby cutting down on the number of people who, even if they want to become a nurse, can find an open slot in a nursing program. Beyond that, there are not enough young people being drawn to the profession to replace retiring nurses and meet escalating needs.

The current nursing shortage didn’t materialize overnight. It’s been happening, off and on, since the 1960s. Each time a crisis has arisen, it has taken a year or two to resolve it. The current shortage, however, breaks with the past: It began in 1998, and there’s no end in sight.

Lifestyle and demographics are part of the reason. In the early ’60s, nursing was one of the few careers open to women. Opportunities are, obviously, greater now, and the supply of students has gone down. As the nurse workforce ages, no baby boom of high schoolers is rising up to replace the old order. The employment growth in various age cohorts tells an alarming story. From 1994 to 2002, the number of employed nurses 50 years old or older grew by 60 percent; for those younger than 35, growth was inverse: -17 percent.

Given those numbers, it is not surprising that many nurses are likely to retire within the next 15 years. Unfortunately, those retirements will come just as the need for their services increases. “Demand,” as Peter Buerhaus, associate dean at Vanderbilt University School of Nursing, points out, “is going to accelerate with the wave of boomers turning 65.”

Throw state budget problems into the mix and the picture darkens further. Many state schools and community colleges that offer programs to train nurses have been devastated by funding cuts, and early retirement packages to reduce the workforce attracted a healthy share of nursing teachers. “We’re almost at a public health crisis on this issue,” says G. Rumay Alexander, a director at the School of Nursing, University of North Carolina at Chapel Hill. “Many of the schools don’t have the capacity to handle the numbers applying.”

A WEAK PULSE

Last fall, schools of nursing turned down at least 15,000 applicants. A big piece of the problem is the lack of nursing instructors. “The faculty shortage is the choke point right now,” says Jo Ann Webb, senior director of federal relations and policy for the American Organization of Nurse Executives. Clearly, without a sufficient number of nursing instructors, there’s no way to educate enough nurses to ease the shortage.

Low pay relative to nursing positions makes it difficult for schools to attract and keep teachers. “Why would I want to teach when I could be a nurse practitioner and make a heck of a lot more money,” asks Peggy Welch, a state representative from Indiana and a registered nurse in oncology. “We’re all scratching our heads over this. We know there’s a shortage. How do we address that?”

Colorado is trying. It is tapping public and private funds to develop an e-learning portal aimed at expanding classroom space and the availability of instructors. Simulation software will allow nursing students to take part of their clinical instruction in a virtual situation. Once in place, the portal could provide other curricula so students could complete some coursework over the Internet.

The state submitted a proposal for $250,000 in grant money from the U.S. Department of Labor and expects a public-private partnership to fund the rest of the $1.3 million to $2.2 million needed to design and launch a system and develop training modules. “We’ve all known the problem is there,” says Tom Looft, director of workforce development programs for Colorado’s labor and employment department. “It’s just gotten to the point where it’s become very critical.”

THE RACE TO RECRUIT

If the teaching shortage were solved, that would still leave states with the problem of attracting people to the nursing profession, and particularly to areas of health care where the shortages are most acute. In fiscal year 2001, when state budgets were flush, many legislatures passed measures creating nursing scholarships or loan- forgiveness programs for nursing students who agreed to serve in health professions that faced nursing shortages. The next year, as budgets shrank, legislatures focused on setting up nursing workforce commissions and data centers to analyze statistics on the nursing situation.

Some big states have persevered in efforts to bring more people into the profession. New York passed a health care reform act in 2002 that provides $1.8 billion over a three-and-a-half-year period for health care workforce recruitment, training and retention in hospitals, nursing homes and home health care settings. That same year, California announced a $60 million, three-year nurse workforce initiative to recruit, train and retain nurses for employment in hospitals and other health facilities. About $36 million of that money had been allocated by the time Governor Gray Davis was recalled.

Still, there are problems. There is a waiting list of one to two years to get into nursing schools. “The California pipeline for nurses is not big enough,” says Joanne Spetz, assistant professor at the University of California at San Francisco. “And it’s a leaky pipeline.” Anywhere from 10 percent to 50 percent of nursing students don’t complete their schooling. An average of 20 percent to 35 percent of students either don’t graduate or don’t pass the board exam.

Other states are rounding up public and private organizations to attract and train nurses. In Georgia a $4.5 million initiative pairs the state university and health care providers in an effort to turn out 500 new nurses, pharmacists and medical technologists within two years. The state pays $2 million for instruction and expenses. Health care providers contribute money and also donate equipment, staff time and lab space.

Agencies in neighboring Florida have teamed up with private partners to provide eligible nurses with affordable home mortgages, including up to 100 percent financing. The partners also offer low-interest student loans to those who work full time in health care after graduating from Florida colleges and universities.

The Colorado Department of Labor and Employment teamed up with representatives from federal and state agencies, community colleges and private health care groups to develop scholarships for nursing students. Small projects around the state have community colleges working with workforce investment boards and hospitals to increase capacity for nursing students in select community colleges and to speed up the training track.

Some legislators are studying working conditions to see how they can be improved to attract more people to nursing. In particular, they have looked at minimum nurse-to-patient ratios so nurses aren’t overburdened. California passed a law, sponsored by the California Nurses Association, that calls for clearly defined nurse-to-patient ratios. There must be, for instance, at least one nurse for every four patients in the emergency room and one for every six on medical- surgical wards.

Hospitals are not happy with the law, particularly since it doesn’t provide money to pay nurses or to train them. “Hospitals,” says Jan Emerson, spokeswoman for the California Healthcare Association, “are in a bind.”

Some hospitals have been trying to staff up by hiring nurses through traveler agencies–companies that get nurses from out of state. But Emerson says that’s just stealing nurses who are needed in other states, and it doubles a hospital’s nursing costs. “You can’t pass a law mandating new nurses when the nurses don’t exist. That requirement is posing serious problems.”

Emerson says the association has been doing a weekly survey of 450 acute-care hospitals and the responses from nine out of 10 of them is that they cannot comply with the state law. Their options, they say, are to break the law and continue to provide care or comply and shut down beds, make people wait longer in the emergency room and delay surgeries.

Meanwhile, hospitals have taken steps to increase the base of nurses available. Sutter Health, a not-for-profit community-based hospital system, is underwriting a program that enables Sacramento Community College to hire more faculty members and expand space to admit more nursing students. “It’s wonderful that hospitals are stepping up to the plate and partnering, but it’s not the solution,” says Emerson. “We need a statewide policy solution.”

The problems caused by a nursing shortage are repeated all over the country. The annual need for nurses is at least three times above and beyond normal levels of enrollment, says Vanderbilt’s Buerhaus. If schools don’t produce the required number of nurses, “the alternative is watching health care facilities turn off their lights. Access will go down, quality will go down. States will have to deal with the issue in a different way.”

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October 22, 2010

FL nursing shortage will grow | Jacksonville Business Journal

Filed under: Nursing — Shirley @ 8:38 am
Tags: , , , , , ,

This is one of the few articles I have found about the nursing shortage that actually includes the economic slowdown as well as the impending changes from the new health care bill.  Although many states say they “have no nursing shortage”, my opinion is that either they are unaware of the projected needs of the state or their nurses are so overworked that they don’t have a second to voice an opinion.

In Austin, I am frequently told that there is no nursing shortage here.  Great!  Explain to me then why I work with more than 5 acutely psychotic patients at a time.  There are some hospitals that staff 12:1 on some shifts, even.  I guess there is no shortage if the nurses working now are able to do more and more for less and less.

Don’t get me wrong, I work hard and make a decent living.  I don’t want to be anything except a nurse.  What I do want to be, however, is a nurse with a voice and some control over my workplace/workload.  I want to be a nurse that gives excellent nursing care and takes great care of my clients.  What I find is I am struggling just to get the minimum done each shift.  I don’t like this.

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New projections from the Florida Center for Nursing show that the implementation of health care reform, along with a slowly recovering economy, may cause the nursing shortage to grow.

The Orlando-based Florida Center for Nursing, which studies the state’s nurse workforce needs, said the shortage will grow to more than 50,300 full-time registered nurses by the year 2025.

The center said it expects an increase in retirements and a reduction in the workforce participation of nurses — which is at historic highs due to the recession. Combined with a lack of faculty and clinical space, the result will be very slow growth in the number of working nurses.

“We have been urging stakeholders all along not to be lulled into complacency by the temporary reduction in the nursing shortage,” said Mary Lou Brunell, the center’s executive director. “With these new forecasts, we’re now able to put a timeline on the reemergence of the nursing shortage and quantify its severity.”

The center projects a continuing tight labor market for RNs over the next three years, owing to a sluggish economy. Once the major provisions expanding coverage within health care reform are enacted in 2014, the shortage is expected to increase rapidly. By 2015, the shortage may top 11,000 nurses, and by 2020 it may reach more than 37,500.

Read more: Report: FL nursing shortage will grow | Jacksonville Business Journal

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October 21, 2010

Technology Monitors Nursing Performance

BALTIMORE - JANUARY 15:  Beds are prepared in ...
Image by Getty Images via @daylife

I read this article with much interest.  I guess things really are terribly different between med-surg and psych in that I was lost pretty soon after I started reading this.  At a psych hospital, no one considers your expertise or training when making assignments.  You are simply a cog in the wheel and you get your patients assigned for whatever reason the charge nurse wants to use.  In my experience, the rationale for assignments usually goes like this–I like you, so you can have so-and-so; I don’t like you, so you can have the SOB in room ???; I don’t feel like working too hard today, so I won’t take many patients today; I’ll give you all the difficult patients because you made me look bad last week; etc.  Where in this process is my expertise taken into account?  I did complete the reading of this article and I have to say that this hospital in Midland, TX seems to be very forward thinking and modern in its approach to nursing care.  What do you think?

You can find this and other great nursing articles here.

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HCPro’s Advisor to the ANCC Magnet Recognition Program® , October 19, 2010

Midland Memorial Hospital in Midland, TX, recently changed its process for tracking not only online training but demonstrated proficiencies among its nurses. The change has resulted in a real-time information tracking program that has helped not only with tracking training, but documenting growth of its employees for its ANCC Magnet Recognition Program ® (MRP) journey.

Jenny Delk-Fikes, BSN, RN-BC, clinical excellence manager with Midland Memorial, explains that previously, e-learning was tracked online, while checklists for demonstrated proficiencies were tracked in paper format—leading managers to have to look in multiple locations, in multiple formats, just to figure out what their staff knew and how well they knew it.

This has been much improved with an all-electronic system.

“The first thing we did was get a system that met our needs,” says Delk-Fikes.

They needed a centralized component that gave the hospital real-time access to knowledge skills and critical thinking skills of the nursing staff.

“We need to know when something is new and when it has changed. We need to be able to communicate those changes in real-time,” says Delk-Fikes.

The previous system had a delay, because the learning management system, while it was a good program, did not have all the necessary components in one place.

“We needed an integrated competency system that could support the practice model,” she says.

With the new system, managers could look at their staff as a whole to determine who the right person is for the right patient. Previously, managers would literally have to look in three locations to assess staff competency.

Midland Memorial went with a system called Decision Critical, a 360-degree learning and evaluation system.

This new system actually allows them to track input from the staff as well, at times tracking downward trends early.

“Our staff knows performance is low before our data even shows it,” says Delk-Fikes. “We want them to be able to communicate that with us.”

The facility also wanted a system that could demonstrate skills in practice—are the lessons being taught then put into practice?

Finally, they needed a system that could capture professional development inside and outside the organization.

“We have a lot of people who are very active in their professional organizations,” says Delk-Fikes. “They’re attending conferences, doing training certification classes, things that are not deliverable through a computer system that you want to track. We want to know if you are an ED-trained nurse working on the oncology floor, because if a head trauma is transferred to our unit, you’re the best provider to work with that patient. It’s all in the individual portfolios.”

The first delivers the knowledge component of nurse education.

“Here’s the content, now take the test,” says Delk-Fikes. This is the basic component of demonstrating that information has been given and taught, but does not yet demonstrate competency in the field.

Communicating comfort level

Next up: a check list going over everything in a given area of practice that is important for nurses to know to drive up performance, adhere to standards of care, and provide safer and more beneficial healthcare.

“This is essentially your peer evaluation,” she says. “We need you to work on X proficiency, but you did Y efficiently. The individual can communicate what they feel they need to work on in the self-assessment component, and there is also an annual needs assessment.”

This one-two punch of assessment is key to success of the program. A nurse can identify their own strengths and weaknesses and ask for additional training or help in the latter.

“They might tell you, I’m good at IVs, at foley catheters, and at restraints., but this list includes tracheostomy care, and I haven’t taken care of a tracheostomy patient in three years, so I’m going to say I’m average,” says Delk-Fikes. “I have the knowledge but not the skill.”

The program pulls in everything the nurse has accomplished, needs to work on, and has not done yet, she says.

This level of communication also helps design methods for training. If the nurse needs help learning or re-learning tracheostomy care, why not send them down to the cardio-pulmonary unit to shadow a more experienced nurse to pick up those skills? When managers are going through nurses’ files, they aren’t bouncing from source to source—the educators and managers can see each nurse’s self assessment, their annual assessment, and all of this can be used to plan upcoming education events.

It also means that educators can identify how great a need certain training requires. How many nurses identify themselves as not proficient in a given task? How many have been identified by their peers as needing additional training?

“If one nurse says she’s not comfortable with tracheostomy care but the majority of her peers are, I’m going to loop her through cardio-pulmonary to increase her knowledge,” says Delk-Fikes. “But if the whole unit says it’s a problem, rather than looping them I’m going to bring the education to them on that floor.”

Midland Memorial has shared governance with a multidisciplinary team they turn to for when they encounter practice issues. For example, if they were to discover they are not hitting their benchmarks for Foley catheters based on CMS guidelines, they bring this issue to the council to update how this information is going to be rolled out to staff.

“In our old system, I worked with every council, key departments  like quality management, infection control, human resources, and said, we are doing 32 annual training modules,” says Delk-Fikes.

These were just testing knowledge. That’s a significant amount of time, she says.

“Our employees were spending four to nine hours completing each of these,” says Delk-Fikes.

They needed to find a more efficient way of handling training. Non-clinical roles now have 22 training modules required, and clinical still have 32 on hire, but 24 annually.

“When we reevaluated we looked at more effective learning,” says Delk-Fikes. “We moved things off the checklist or added depending on need.”

Regulatory requirements

They also pulled in the requirements for NIAHO (National Integrated Accreditation for Healthcare Organization) standards in order to align their required training with the standards (the organization is DNV accredited). But they also looked beyond their own standards for best practices.

“We still look at The Joint Commission because they also have wonderful practices. We put everything we were doing under the appropriate categories,” says Delk-Fikes. “If a regulatory agency says okay, you need to provide training on, for example, confidentiality and ethics, we need to know how to demonstrate that.”

To show all the components they engage in annually is great, but how does it align with the standards? You need to be able to demonstrate that.

Nursing excellence documentation

Midland Memorial is seeking ANCC Magnet Recognition Program® (MRP) status. They need to be able to track and trend their nursing education to show progress. With the new system, they are able to drill down, whether it’s an organizational problem they want to fix, or a performance issue they want to improve.

“If our scores are stagnating at 88 or 89% and we want to do better, we can do that,” says Delk-Fikes.

The way a critical care unit nurse is trained is completely different from a pediatric nurse. Under the new system the organization can document the progression of each nurse in accordance to their unit’s requirements.

“One of the things about this system that we’re using is that, for MRP’s requirements in the area of innovation and technology and nurse organization-wise performance, this actually is your Source of Evidence,” says Delk-Fikes. “If you want to show nurses are growing professionally, you can pull it from this program.”

Previously, it was a challenge to simply show how many certified nurses were on staff at a given time. Now, a nurse manager just has to look at a given nurse’s portfolio to see whether they have been CPR recertified, for example. Is the nurse a certified medical interpreter? That is in the portfolio as well.

Nursing levels

Midland Memorial Hospital uses “levels” to describe each nurse’s skills and training: beginner, novice, and expert.

At orientation they are given the on hire checklist. Evaluations are done six months to a year out, allowing time to acclimate and grow into the culture of the facility. By the end of the first year, nurses begin their competency-based assessment.

After reaching the expert level, nurses start getting into individualized growth plans. They enter preceptor roles, take on mentoring tasks, and help train skilled nurses in areas where there is a knowledge gap.

But before reaching that level, there is quite a climb—and that climb is ever changing. Expert level nurses cannot stagnate—there are always new things to learn. If, for example, 10 new requirements arise for experta, they must become proficient in all of those requirements before being considered an expert/level 3 nurse again.

In fact, most of the time, nurses are considered advanced beginners. Nurses are paired in training with the appropriate trainer—a beginner is not handed over to an expert to shadow at first, but instead are paired up with a novice/level 2 nurse who can bring them up to their level of training first.

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This article was adapted from one that originally appeared in the November 2010 issue of HCPro’s Advisor to the ANCC Magnet Recognition Program®, an HCPro, Inc. publication.

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October 15, 2010

Hospital launches new telemedicine program for stroke and child trauma Neurologists and child trauma experts can now view patients at suburban Seton Hospitals through a webcam.

HELP Telemedicine clinic 1
Image via Wikipedia

Here’s an article in the Austin American Statesman that shows the benefit of developing technology for better patient outcomes.  At Seton Hospitals here in Austin and the surrounding areas, this one technological change is saving lives.

Telehealth is a trend that will not only continue but will expand as the need for services outgrows the available service providers in any given area.  Hospitals that cannot or will not expand their use of technology will not be able to compete with those who do.

Won’t you tell me how your hospital is meeting this challenge?

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By Claire Osborn
AMERICAN-STATESMAN STAFF
Friday, September 04, 2009

ROUND ROCK — A woman lying in a hospital bed at Seton Medical Center Williamson in Round Rock on Thursday was listening to a series of questions Thursday from an Austin doctor on a 27-inch LCD television monitor.

“Can you open your eyes please and face the camera?” said Dr. Darryl Camp, medical director of neurology for the Seton Brain and Spine Institute in Austin.

“Elevate your right leg and then elevate your left leg. Can you say your name?” Camp said.

He was demonstrating new technology that will allow doctors at Seton hospitals in Round Rock, Burnet and Kyle to more quickly consult with neurologists in Austin about stroke patients and pediatric trauma patients.

The $250,000 program, based at Dell Children’s Medical Center in Austin, starts this week.

Instead of having to describe symptoms over the phone to neurologists, physicians can wheel their patients in front of a television monitor with a camera that allows a specialist to see the patients.

The program also allows the Austin neurologists to read CT scans on their laptops. Seton hospitals have handled 1,200 stroke cases in the past year and hope to double that number with the new technology, Camp said.

Time is precious when a person suffers a stroke because brain cells can die by the minute, Camp said. He is one of seven stroke specialists who will participate in the program.

Neurologists can advise doctors whether clot-busting drugs are needed immediately or whether a patient should simply be observed, said Dr. Brian Aldred, medical director for the emergency department at Seton Medical Center Williamson.

Neurologists can also catch subtleties in a CT scan that other physicians might miss, he said.

Children with traumatic injuries will also benefit from telemedicine, said Dr. Pat Crocker, emergency department medical director for Dell Children’s Medical Center of Central Texas.

A neurologist in Austin might need to tell a doctor in another county whether a child who comes into a hospital with a chest injury and a collapsed lung needs to be intubated before being transferred to Dell Children’s Medical Center of Central Texas, Crocker said.

Fifty-four pediatric specialists from Dell Children’s will participate in the child trauma part of the telemedicine program, said Emily Schmitz, a spokeswoman for the Seton Brain and Spine Institute.

The five Seton facilities that will be using the technology include University Medical Center Brackenridge, Dell Children’s, Seton Highland Lakes Hospital and Seton Medical Center Hays, which is scheduled to open in October in Kyle.

cosborn@statesman.com; 445-3871

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October 13, 2010

How do so many journalists miss it?

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This article originally appeared in The Washington Post, but I found it on one of my favorite websites, The Truth About Nursing.  This article is stunning in that a nurse was able to use common sense and experience to help a patient after numerous specialists were stumped.  I wondered, after reading the article, if any of these physicians ever really looked at the patient or asked him any questions about his life and locale.

I simply saw the picture and knew he had Lyme’s Disease, but I live in an area where ticks and deer are plentiful.  Maybe, in the defense of the doctors, they had never been in an area where either of these two organisms are found and therefore knew nothing about them.

Please read the entire article and leave them a comment if you feel like it.  There are many wonderful articles and stories to be read on that site.  I hope you enjoy.

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bulls-eye rashSeptember 27, 2010 —  Today The Washington Post published a lengthy entry in its “Medical Mysteries” series headlined “Nurse solves mysterious ailment that puzzled orthopedists, oncologist.” Sandra G. Boodman’s piece describes a local man who spent more than a year consulting various specialist physicians, enduring “two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars,” before “a nurse” at an infectious disease specialist’s office suggested that he might have Lyme disease. He did. You might think, then, that the article would be a tribute to nursing expertise, but instead the central fact of the story is overwhelmed by disrespect for nursing. It’s not just that the piece repeatedly dismisses what the nurse did by calling it “simple” and “obvious,” “a basic query by a nurse, not the acumen of five specialists.” No, the most striking thing is that in this 1,300 word story describing all the erroneous thinking of the “specialists,” the nurse who actually solved the problem is never named, quoted, or further described. It’s true that none of the specialists are named or quoted directly either, which certainly protects them from embarrassment. And it seems that the approach of these pieces is to rely mainly on the patient’s account; perhaps this patient never actually met the nurse, though he says he “remains grateful” to the nurse. But the piece does name and quote an infectious-disease expert the patient consulted after the diagnosis, so it might have done more with the nurse, even if could not give the nurse’s real name. The net effect of what we do have here is to suggest that the nurse solved the problem by being so simple and limited, with a mind uncluttered by real expertise. Needless to say, there is no suggestion that maybe the nurse solved the problem because of her own expertise, or the nature of nursing, including the profession’s holistic and flexible approach, which is no less “expert” for being broad. The piece pokes fun at the specialist physicians, but it still reinforces the idea that they are the main source of health knowledge–the same idea that seems to have gotten this patient in so much trouble.

This is the story of John Gordon, the 54-year-old president of a commercial real estate firm. Gordon thinks he might have been better off “had his office not been located in a Montgomery County high-rise that also houses many medical offices,” which made it convenient for him to see all the specialists there. Gordon, “whose father and father-in-law were doctors,” says he did not ask enough questions, and was “too good a patient,” which must mean accepting whatever physicians say–hardly surprising for a person with that background. The result, apparently, was “two unnecessary knee surgeries and dozens of physical therapy sessions, as well as acupuncture and other useless and sometimes painful treatments that cost thousands of dollars.” This part of the article hints that we should not be so trusting of specialist physicians. But then we get this:

In the end, it was a basic query by a nurse, not the acumen of five specialists, that led to the correct diagnosis of a common malady. “If you don’t ask simple questions, you screw up,” Gordon said. “I see that in my business all the time.”

The piece traces the history of Gordon’s problem, which appeared in 2007, when he first noticed that his knee was swollen. He consulted an orthopedist, who recommended physical therapy. That did not help. The orthopedist drained the knee and gave Gordon cortisone shots. That did not help for long. An MRI showed no torn ligaments or cartilage, so the orthopedist recommended exploratory surgery. A surgeon operated, “told Gordon he had a partially torn meniscus, a common injury involving cartilage,” and then “repaired the cartilage.” That did not help.  Gordon consulted a physiatrist, who specializes in rehabilitation and pain management. This physician considered whether it might be an infection, but assumed that had been ruled out, and suggested acupuncture. That did not help. Gordon got a second MRI, and his orthopedist suggested surgery for “pigmented villonodular synovitis, which causes an overgrowth of tissue for no apparent reason.” Gordon switched orthopedists but had the surgery. It did not help. The surgeon suggested that the abnormal tissue in the knee pointed to cancer, and referred Gordon to an orthopedic oncologist and an infectious-disease specialist. But the tissue biopsy was negative.

The infectious-disease specialist confidently suggested that Gordon had contracted “valley fever,” a serious fungal infection, from a recent trip to the Southwest. Gordon took “the maximum dose of a potent antifungal drug” for two weeks. It did not help, but it did make Gordon “feel weak and very nauseated.” The infectious disease specialist was stumped, though that did not stop him from prescribing an antibiotic.

But a week later, in June 2008, the doctor called back. Gordon said he reported that during a staff meeting at which his case was being discussed, a nurse asked whether Gordon had ever been tested for Lyme disease.

nurse-physician discussionGordon said he had not, and that “no one had mentioned it.” We’re actually impressed that the physician admitted that this was the nurse’s idea. Physicians often receive credit for life-saving nursing ideas and observations, whether because physicians present the ideas to patients as their own, patients assume they must have been the physician’s idea, or nurses hide their own role. Of course, it’s also impressive that this specialist’s office had meetings in which a nurse’s professional opinion was considered. Physicians routinely leave nurses out of discussions of diagnosis and treatment, even though nurses’ input can mean the difference between life and death. Nurses must often use complicated social dances to have their views considered. Naturally, the Post article explores none of this, though it certainly would be worth discussion in a major newspaper.

In any case, the infectious-disease physician faxed an “order” for the test, which was positive. The disease was responsible for Gordon’s knee problems. The piece gives some basic information about Lyme disease, which is “a bacterial infection caused by a deer tick bite.” Lyme arthritis is “sometimes permanent.” Gordon was “stunned,” and wondered how this could have been “missed by so many specialists.”

For some answers, the piece turns to “Adriana Marques, an infectious-disease expert at the National Institute of Allergy and Infectious Diseases who is studying the natural course of Lyme…[read the rest of this article]

October 11, 2010

Commentary: To Improve Health Care, Broaden the Role of Nurses

Here is an interesting article about the future of nursing.  I believe this study caused an immediate response from the AMA to point out quite clearly that nurses are not doctors.   I, for one, don’t have any desire to be a doctor.  I don’t want to diagnose or prescribe.  All I have ever wanted to do was help my patients get better by giving them good care and assisting them to do for themselves so they could return to their own lives and live unencumbered by an illness.

I get tired of the misconception that nurses are simply frustrated doctors.  NOT!  Nurses deal with patients totally different from doctors.  Nurses know more about their patients than most doctors do.  Nurses are trained to observe and to intervene only when necessary.  Nurses don’t believe that they know everything and can do anything.

Okay, enough of my soap-box.  Please read the article and then let me know what you think.  Be sure to click over and read any of the other thought provoking articles to be found at Health News Digest.  Leave them a comment or leave me one, please.

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From HealthNewsDigest.com
By David Goodman, M.D.
Oct 9, 2010 – 4:41:18 PM

DMS faculty member David Goodman, M.D., was a member of a committee asked by the Institute of Medicine to study the role of nurses in the health-care workforce.

(HealthNewsDigest.com) – Lebanon, N.H.—In a rapidly changing health care environment, the nation’s 3 million-plus nurses can and should play a much greater role in delivering care, according to a new Institute of Medicine report. David C. Goodman, MD, MS, of The Dartmouth Institute for Health Policy and Clinical Practice, a researcher known for his expertise on issues involving the health care workforce, is a member of the Committee that authored the report.

“Nurses already are central to high quality care. Of any member of the health care team, they have the most enduring relationship with patients and are the most trusted professionals in health care.” said Dr. Goodman, who is also a Professor of Pediatrics and of Community and Family Medicine at Dartmouth Medical School and a practicing physician at the Children’s Hospital at Dartmouth-Hitchcock Medical Center.

The report, The Future of Nursing: Leading Change, Advancing Health, was authored by the 18-member Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Over two years of analysis and deliberation, including five meetings, workshops, three public forums, and numerous site visits, the Committee considered its charge to “examine the capacity of the nursing workforce to meet the demands of a reformed health care and public health system.”

Among its recommendations, the Committee concluded that to fully take advantage of the skills and commitment of nurses, they must have expanded educational opportunities, and be freed from “scope of practice” regulations that limit the care they can provide. Further, it recommends that nurses be given a greater role in health care redesign and improvement efforts.

“We believe the search for an expanded workforce to serve the millions who will now have access to health insurance for the first time will require changes in nursing scopes of practice, advances in the education of nurses across all levels, improvements in the practice of nursing across the continuum of care, transformation in the utilization of nurses across settings, and leadership at all levels so nurses can be deployed effectively and appropriately as partners in the health care team,” write the authors.

The nursing population represents the largest portion of the U.S. health care workforce. Yet, it faces many challenges to being integrated as fully as it could be in the provision of care, according to the report. Among these are a lack of diversity in race, ethnicity, gender and age; insufficient education and preparation to adopt new roles; restrictions on scope of practice, limitations by insurance companies, and in some cases “professional tensions” that make it difficult or impossible to practice to their full potential.

“Producing a health care system that delivers the right care–quality care that is patient-centered, accessible, evidence based, and sustainable–at the right time will require transforming the work environment, scope of practice, education, and numbers of America’s nurses,” the report states.

“This report will advance the nursing profession to the center of leading change and improvement in health care systems as the nation seeks higher value in patient care,” said Dr. Goodman.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education.

The Robert Wood Johnson Foundation is a non-profit philanthropic institution, founded in 1936, whose mission is to improve the health and health care of all Americans.

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October 8, 2010

Linking Medical Errors, Nurses’ 12-Hour Shifts

As a 12 hour shift worker myself, I read this with concern.  I love working three days and being off 4 days.  It may be the only way I can stay working as a nurse until I retire.  However, that said, I have to agree that those last 4 hours of the shift are usually a nightmare and occur at a time when I am exhausted.  So, there is something to be said for the reduction of shift hours.  I like the idea of 4 hour shifts, but don’t see how they could work.

Please read this article and let me know what you think, won’t you?  This article is from HealthLeadersMedia and I hope you read the entire article which include many interesting comments on the original site.

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Rebecca Hendren, for HealthLeaders Media, October 5, 2010

It’s well known that caregiver fatigue is a huge cause of medical errors, whether the caregiver involved is a new resident coming off a marathon week or an overworked nurse pulling back-to-back shifts.

A few months ago, the Accreditation Council for Graduate Medical Education placed new restrictions on the hours residents can work and the supervision they receive. This follows years of research into new physicians’ training and the effect long hours and tiredness play in performance and contribute to poor quality care. A 2004 study found that first-year residents working all night were responsible for more than half of preventable adverse events.

Nurses don’t have the same extraordinarily-long work requirements as residents—and they clearly perform very different tasks—but like residents, they work long shifts and suffer from fatigue. Studies have linked nurse fatigue with medical errors, poor quality care, stress, and burnout.There are many reasons for nurse fatigue, but one stands out as pretty easy to fix: shift length. It’s no wonder that nurses are fatigued when 12-hour shifts are the norm. Despite the fact the Institute of Medicine has recommended limiting use of 12-hour shifts, it’s standard practice throughout the profession. Nurses routinely work back-to-back-to-back 12-hour shifts.

At the recent Nursing Management Congress in Grapevine, TX, held September 23-25, I attended a presentation by Cole Edmonson, CNO/vice president of patient care services at Texas Health Presbyterian Hospital in Dallas. Edmonson noted that research is helping us understand the dangers nurse fatigue presents to patients and to nurses themselves. He called 12-hours shifts a dead idea whose time has passed and suggested they may cause more problems than they solve. He asked attendees whether it is time to declare the end of 12-hour shifts.

I can’t imagine working a 12-hour day as a nurse. Nursing is a professional job, requiring college education and high-level thinking. But it’s also manual labor. Nurses are on their feet all day, running everywhere, lifting patients, changing dressings, inserting IVs, and all the other direct patient care responsibilities.

It’s no wonder that nurses are fatigued. Shifts include mountains of paperwork, difficult patients and families, and hundreds of tasks. Somewhere in all this nurses make time to connect with their patients, expressing compassion and empathy. Let’s not forget that 12-hour shifts also frequently run into overtime, when the nightmare shift means they have to stay late to complete their charting.

Over the next few years, more studies will be published that show the danger of nurse fatigue. What if hospitals preempted the public outcry and started reducing 12-hour shifts now? Let’s focus on shifts that are best for patients, nurses, and hospitals alike. This means ending rigidity and allowing greater flexibility.

Senior leadership can embrace creative staffing and scheduling options that increase satisfaction for nurses and improve efficiency. For example: <…click here to continue…>

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October 6, 2010

Hospital bed transfers put thousands of patients at risk of infection

Here is an article I found on Nursing Times that comes from across the ocean.  It seems that our sisters over in the British Isles struggle with many, if not all, of the same issues we struggle with daily.  This particular article caught my attention because it seems that JCAHO or TJC, whichever you are familiar with, is always looking for a new issue to deal with and I think this should be one.

At my facility, patients are moved from one unit to another, from one floor to another, etc. with little concern for what is best for the patient.  I have always felt that we should look at the needs of the patient and place them in the correct unit from the very first minute.  This article is talking about infection control issues in medical hospitals, but in a psych hospital there are many other issues involved as well.  Mixing depressed people with actively psychotic people or bringing active detoxing patients into a unit with 30 or more patients should be contraindicated.  When we transfer patients to the correct units, staff are tied up, patient belongings get lost or left behind, and the patient experiences increased anxiety about the unknown on a new unit.  This cannot be good customer service and I know is detrimental to good patient care.

It was interesting to see that other nurses are also having these worries.  I also worry about the infection control issue of moving my patients around.  In today’s hospital settings, you have to be concerned about this.

Anyway, I hope you enjoy the article.  Won’t you leave me a comment to tell me what you think?

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Hundreds of thousands of hospital patients are being moved from one hospital ward to another with no clinical justification and risking the spread of infection, evidence collected by Nursing Times suggests.

The bed moves often happen because wards are too full and so patients are admitted into inappropriate wards and then moved.  If you are transferring patients lots of times you are moving bugs around the hospital

Patient transfers between wards are a well known cause of infection outbreaks as they reduce the ability of hospitals to contain infections. The transfers can also result in a disruption in patient care as notes are misplaced and observations missed.

Despite the risks only a small number of hospitals monitor their non-clinical patient transfers.

Nursing Times has analysed the data from those hospitals. It suggests that nationally there are around 1.3 million patient bed moves made each year for non-clinical reasons.

The figures suggest nearly one in 10 hospital patients could be affected, although a proportion of patients will have been moved more than once during their hospital stay so the precise number affected is not clear.

Eighty-eight trusts responded to a Nursing Times freedom of information request asking for data about patient transfers. Among the 42 that collected information about the number of patients being transferred from one ward to another, monthly transfers ranged from 9 per cent of inpatients in one trust to 88 per cent in another.

It is impossible to compare the trusts and judge which have the biggest problem as they measure performance in different ways.

Only six trusts were able to distinguish between transfers that were clinically justified – such as when a patient needed to be moved to a lower dependency unit or a different specialty – and those that were not.

Their rates ranged from 0.4 per cent of inpatients transferred without clinical justification at Frimley Park Hospital Foundation Trust to 15 per cent at Imperial College Healthcare Trust in London.

At Southampton for example, an average 5,922 patients were admitted each month between July 2008 and July 2010, and there were 703 non-clinically justified transfers – 12 per cent of admissions.

At Taunton and Somerset Foundation Trust, another which collects detailed information, there were an average of 6,301 inpatients a month and 735 non-clinical transfers in the same period -11.7 per cent of admissions.

Across the six trusts the average monthly rate of non-clinical transfers was 8.8 per cent of total inpatients.

Scaled up across the 13.6 million hospital admissions in England last year, the data suggests there are around 1.3 million clinically unjustified patient transfers each year.

Royal College of Nursing emergency care adviser Alan Dobson told Nursing Times hospitals were struggling to admit patients to the appropriate ward as the bed occupancy rate in hospitals was higher than ever, meaning fewer beds were left vacant to cope with surges in demand.

Mr Dobson said: “Bed occupancy should be about 85 per cent to enable good patient care. Most hospitals are running at about 95 per cent and sometimes it is at over 100 per cent.

“Patients are often moved around the hospital for non-clinical reasons and it’s unacceptable. If you are transferring patients lots of times you are moving bugs around the hospital.”

Frimley Park Hospital Foundation Trust nursing director Mary Dunne said the trust had changed its arrangement of wards to reduce non-clinical transfers.

She told Nursing Times that senior nurses frequently intervened to prevent patients being moved several times.

She said: “We began looking at it as a patient safety issue, but being moved can also be upsetting. Patients like to get to know their team, and just as they are settling they can be moved to another new team.”

However, she said increasing beds and staff would not help because more patients would be admitted to fill them, rather than the flexibility used to reduce transfers. She said: “The more beds you open the more beds are filled. We should be looking to supporting patients back into their own homes.”

Earlier this year a Nursing Times investigation revealed that patients were regularly being placed in areas not designed for care – including wards that were already full, store rooms and mop cupboards – because appropriate wards were full.

The National Audit Office’s report on hospital infection in 2000 highlighted transfers as a risk factor. Accommodating patients in the wrong area – away from the team that is meant to be caring for them – also means they get less attention and are less likely to get the treatment they need, and more likely to deteriorate.

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October 5, 2010

Three steps to ensure new charge nurses are successful

Filed under: Nursing — Shirley @ 4:06 am
Tags: , , , ,

As a charge nurse on my unit and having been a charge nurse many times during my career, I read this article with interest.  I have always wondered why, with all the push on nurses to educate patients, we fail so miserably to educate our own?  This is a good article, but I believe it only scratches the surface of the problem we seem to have.

Although all three steps are good and will help a new charge nurse to grow and develop, I feel that we still need to address the bigger problem of why an article like this is even necessary.  Unfortunately, we still seem to want to “eat our young” no matter how many times we have been told to stop.

This article is from Strategies for Nurse Managers and I have found many really great articles at that site.  Please visit and see if you agree that the information there is good and useful.

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Rebecca Hendren, for HealthLeaders Media, September 28th, 2010

Leadership development is an oft-overlooked issue in nursing, so it’s no surprise that charge nurses rarely receive the training they need. Many organizations promote nurses into the charge position simply because they are good nurses and no one else wants to do it. But the charge nurse is crucial to the smooth operation of a patient care unit, and spending time on training and development can reap dividends in organizational efficiency.

At the basic level, charge nurses manage the operations of patient care units during a particular shift. They assign tasks, workloads, and oversee the care provided to patients. But they also provide support, mentorship, and guidance to bedside nurses. For those reasons, it’s important to train charge nurses so they are up to the job.

Tammy Berbarie is an accreditation coordinator at Baylor Jack and Jane Hamilton Heart and Vascular Hospital in Dallas, and a former director of education, who created a charge nurse orientation program for her hospital. Berbarie believes charge nurses are an organization’s untapped resource. She says these frontline leaders—the eyes and ears of the patient care operation—are vital to ensuring patient safety, quality, and satisfaction, and staff retention.

“I believe that most organizations are in an infant stage when it comes to developing their charge nurses,” says Berbarie. “It is important to develop a robust orientation program to give them the confidence to manage the patient units.”

Berbarie recommends organizations provide all charge nurses with an orientation program, which includes a preceptor and leadership development training.

1. Charge nurse orientation. To be effective, charge nurses must know their responsibilities. The best way to outline expectations and ensure competency is to spend time orienting them to their new role.

Orientation can be accomplished in a one day workshop or through a series of training sessions. This is the time to cover the charge nurse role, regulatory requirements, coordination and delivery of patient care, patient safety, quality improvement, and leadership topics.

2. Charge nurse preceptors. Following the workshop, new charge nurses should be assigned a preceptor. Preceptors are routine for newly hired nurses and it’s a technique that works well for any new role. Preceptors not only show new charge nurses the ropes, they also serve as mentors who can support them in their new role.

Berbarie advises the precepted time should last two- to three-weeks and that senior leadership should be active participants and strive to present the preceptees with as many experiences as possible.

3. Leadership development. The third part of the orientation program as a whole is the development of leadership skills. At a minimum, Berbarie says charge nurses should receive training on:

  • Leadership
  • Team building
  • Conflict resolution
  • Communication
  • Developing talent

Organizations that do not invest in leadership skills for charge nurses will not get the most from them. The best charge nurses mesh administrative, clinical, and educational expertise with the ability to solve conflicts, reduce nurse-to-nurse hostility, improve communication, and ensure the unit is a collaborative, collegial place to work.

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October 1, 2010

Here are more Friday Videos

Filed under: Nursing — Shirley @ 3:55 am
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