Nursing Notes

December 30, 2009

Success in the Windy City: Hospitals Tackle New-Nurse Turnover

WASHINGTON - OCTOBER 05:  Risa Lavizzo-Mourey,...
Image by Getty Images via Daylife

Since I began serving on the nurse retention committee at my hospital, I have become more aware of costs and of turnover rates.  As this article points out, it is expensive to lose a new nurse for the hospital.  But, I think it is expensive and unnecessary to lose any nurse at all.   While the focus of this article is on the new graduate nurse, I think if we expand the premise and come up with ways to nurture our experienced nurses by validating their concerns and responding to their calls for help.

Please read the article and let me know if you agree or if you disagree.

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By Claire Brocato, contributor

Dec. 18, 2009 – For new nurses entering the profession, a number of challenges and frustrations can lead to high turnover rates, which has become a major issue at many hospitals nationwide.  Two Chicago-area hospitals are investing their time and resources in finding the solution, and helping set the standard for the rest of the nation to follow.

The Nationwide Problem

The median voluntary turnover rate for first-year nurses is 27.1 percent, according to a 2007 report from PricewaterhouseCoopers’ Health Research Institute, while further research shows that the turnover rate for newly graduated nurses jumps to 57 percent in their second year.

This kind of turnover can put a strain on hospital staff, as well as its finances. The estimated cost to replace just one new graduate nurse is $88,000 as reported in the January 2008 issue of the Journal of Nursing Administration.

So why are they leaving? In a 2007 study funded by Robert Wood Johnson Foundation, researchers found that newly licensed RNs often encounter frustration with their new positions, citing workload demands, unexpected situations, a relentless pressure for speed and lack of respect as the most challenging aspects of their new jobs.  While anecdotal evidence indicates that the current recession may have cut the turnover rate temporarily, the underlying problem continues to plague hospitals.

In an effort to ease the transition for new RNs and to prevent these nurses from leaving, an increasing number of hospitals have begun implementing programs aimed at providing new graduate nurses with the support and guidance they need as they enter the workforce.

Two Chicago Success Stories

With a turnover rate hovering near 30 percent for their first-year nurses, Children’s Memorial Hospital in Chicago, Illinois, knew that they could do more to address the needs of their novice nurses. After interviewing their new graduate workforce and incorporating research from other organizations, Children’s Memorial launched their New Nurse Internship Program—and saw their new graduate turnover rate drop to 12.3 percent.

“We’ve had excellent feedback about our internship program from our graduate nurses,” said Barbara Keating, RN, MS, director of clinical learning and innovations at Children’s Memorial Hospital. “Our nurses really appreciate the learning experiences it offers.”

The hospital’s New Nurse Internship Program focuses on five key elements, including: (1) an individualized preceptor orientation that offers a one-on-one relationship with an experienced nurse within the same unit; (2) ongoing classroom instruction that focuses on practical, hands-on situations; (3) transition sessions that offer novice nurses a safe environment to voice their concerns or frustrations; (4) clinical exchange opportunities that allow new RNs to learn about other areas of care within the hospital; and (5) clinical mentors, who serve as counselors and advisors to the new nurse.

“Our internship program has also been very successful as a recruitment tool,” Keating added. “Student nurses hear about the program from our new grad nurses and they want to work at a hospital that offers that kind of support when they enter the workforce.”

Launched in June 2008, Weiss Hospital in Chicago, Illinois, has found similar success with their Nurturing the New Grad Nurse program, a 12-week course that focuses on clinical and professional development.

Once a week, the new nurses meet in the classroom to hear physicians, nurse leaders and other hospital personnel present aspects of their jobs, and gain support in their transition to the hospital workplace.

“The curriculum is based on realities of practice” explained Stella Hatcliffe, RN, MS, vice president of patient care services and professional development at Weiss Hospital. “It provides our new RNs with the tools they need to grow and to build collaborative relationships with other staff.”

During the weekly sessions, the new graduates also have the opportunity to network with each other, to share their experiences from the previous week, to voice any frustrations and to reflect upon what they have learned.

“Providing our new nurses with this kind of peer support has been one of the most successful elements of the program,” said Hatcliffe. “It’s comforting, as a new nurse, to know that others are going through the same experiences as you and that they understand your situation. They have an entire peer group they can turn to for support.”

Other important elements of the new graduate program include partnering the new RN with a senior nurse for the first 12 weeks, and allowing the new nurse to visit other departments for the day and to shadow various hospital personnel—including respiratory therapists, unit clerks and patient care technicians—to learn about workflow and how each department operates.

“We are continually improving the program, based on the feedback we receive from our nurses,” said Hatcliffe, “but most importantly, we know from our high retention rate that it eases the transition and gives our new nurses the confidence they need to practice their skills and to deliver quality patient care.”

The original article can be viewed here

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December 28, 2009

The Virtual Visit May Expand Access to Doctors

Last time I posted something about technology that helps (?) nurses so this time I posted something about technology that makes access to physicians easier for the general public.  I think I like this, but I will have to think about it more.  I can see that this could have a practical application for minor illnesses and would save time and money for most people.  I can also see the doctor’s position–that there is no actual relationship with a patient and that they are reluctant to treat without face-to-face interaction.

However, the future is here with us now and we may all have to rethink our biases and our ideas of what health care is and is not.

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By CLAIRE CAIN MILLER
Published: December 20, 2009


SAN FRANCISCO — Americans could soon be able to see a doctor without getting out of bed, in a modern-day version of the house call that takes place over the Web.

Mark Graham for The New York Times

Dr. Christopher Crow conducting a simulated online exam in Plano, Tex.

Mark Graham for The New York Times

A screen shot of that exam, which is not of an actual patient. Dr. Crow says the NowClinic system allows him to pick up on nonverbal cues, similar to an in-person visit.

OptumHealth, a division of UnitedHealth Group, the nation’s largest health insurer, plans to offer NowClinic, a service that connects patients and doctors using video chat, nationwide next year. It is introducing it state by state, starting with Texas, but not without resistance from state medical associations.

OptumHealth believes NowClinic will improve health care by ameliorating some of the stresses on the system today, like wasted time dealing with appointments and insurance claims, a shortage of primary care physicians and limited access to care for many patients.

But some doctors worry that the quality of care that patients receive will suffer if physicians neglect one of the most basic elements of health care: a physical exam.

“This is a pale imitation of a doctor visit,” said David Himmelstein, a primary care doctor and associate professor at Harvard Medical School. “It’s basically saying, ‘We’re going to give up any pretense of examining the patient and most of the nonverbal clues that doctors use.’ ”

Others, including Rashid Bashshur, director of telemedicine at the University of Michigan Health System, say online medicine is a less expensive way of providing routine care.

“The argument that you need the ‘laying on of hands’ to practice medicine is an old and tired argument that simply has no credibility,” he said. “There are two constants in medicine: change and resistance to change.”

Christopher Crow, a family physician in Plano, Tex., who used the system during its test period, said, “NowClinic gives you the ability to have that gut feel if something is wrong, in tone or facial expression or body language, that you have when you walk in the door with a patient.”

Many patients who do not have primary care physicians nearby use the emergency room for routine problems. Wait times for patients needing immediate attention have increased 40 percent, in part because of overcrowding, according to a study by Harvard Medical School and Cambridge Health Alliance.

In Texas, 180 counties do not have enough physicians, 70 percent of patients cannot obtain a same-day visit with their primary care doctor, and 79 percent of emergency room visits are for routine problems, according to OptumHealth.

“We are, through this technology, replenishing the pool of physicians and making them available to patients,” said Roy Schoenberg, chief executive of American Well, which created the system that OptumHealth is using.

For $45, anyone in Texas can use NowClinic, whether or not they are insured, by visiting NowClinic.com. Doctors hold 10-minute appointments and can file prescriptions, except for controlled substances. Eventually they will be able to view patients’ medical histories if they are available.

The introduction of NowClinic will be the first time that online care has been available nationwide, regardless of insurance coverage.

American Well’s service is also available to patients in Hawaii and Minnesota, through Blue Cross Blue Shield, and to some members of the military seeking mental health care, through TriWest Healthcare Alliance.

Some hospitals and technology companies provide similar services on a smaller scale, including Cisco, the networking equipment maker, which uses its videoconferencing technology to remotely connect employees with doctors. It is working with UnitedHealth Group to offer the service more broadly.

The service has encountered resistance in states where it is already available. Texas law requires that before doctors consult with patients or prescribe medicine online or over the phone, they form a relationship through means like a physical examination.

The Texas Medical Board, which regulates doctors in the state, is evaluating its telemedicine policies in light of new technologies. But Mari Robinson, executive director of the board, said that an online or telephone exam was inadequate if doctors and patients had not met in person and was “not allowed under our rules.”

After American Well’s service began in Hawaii last year, lawmakers passed legislation that allowed doctors and patients to establish a relationship online, though the Hawaii Medical Association opposed the bill.

“From our perspective, we still are a little bit concerned that a relationship can be established online with no prior relationship,” said April Troutman Donahue, the association’s executive director.

American Well and OptumHealth predict that health care professionals will adapt. “This is new technology, so you have a lot of code written that doesn’t take these medical technologies into account,” said Rob Webb, chief executive of OptumHealth Care Solutions.

Many patients seem ready to embrace the new technology. In a recent study, a Harvard research team at Beth Israel Deaconess Medical Center found that patients were comfortable with computers playing a central role in their health care and expected that the Web would substitute for face-to-face doctor visits for routine health problems.

You can view the original article here

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December 26, 2009

I can C U Remote monitoring program at UMC reduces mortality, shortens hospital stay

Infant ventilator
Image via Wikipedia

As a nurse working the floor, I find this article very interesting.  I don’t think I fully comprehend how this eICU is designed to function.  Does this mean that, in addition to the floor staffing, there will be another 10 nurses who will technically be working the ICU?  How can that fly with administration?  Or does this mean that because of the remote 10 nurses, the floor staff will be cut to the bone; leaving only a skeleton crew to deal with critically ill patients during emergencies?  This, I believe, would make administration very happy.

So, please read this article and let me know how you see this issue.  I think I am really confused.  I am all for anything that will enable the floor nurse to better care for her/his patient, but I am adamantly against reducing staffing more due to some remote monitoring process.

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Shanderia K. Posey
sposey@jackson.gannett.com

When it comes to caring for patients in intensive care units, there are not enough doctors and nurses to go around.

About 6,000 intensivists – physicians with advanced critical care certification – currently guide the around-the-clock care for ICU patients. More than 30,000 are needed nationwide.

To improve quality of care, hospitals are utilizing a Philips VISICU eICU remote electronic monitoring program proven to reduce mortality by 25 percent. It also reduces complications and hospital cost and shortens a patient’s hospital stay by 1 1/2 days.

The University of Mississippi Medical Center went live with the program – one it calls Intensiview – at 2 p.m. Dec. 15.

The program allows up to 10 nurses and a physician at a time to work out of a north Jackson office to remotely monitor vital signs, view X-rays, review lab work, talk to nurses and patients and evaluate ICU patients with two-way audio and video cameras.

“The camera is so sensitive that we can look at all the numbers on the monitor,” said Terrie Gillespie, director of operations for Intensiview and an acute-care nurse of 26 years. “We can zoom in and read her (a nurse’s) name tag if need be. We can look at pupillary reaction.”

“It’s like being at the bedside with your hands in your pockets,” said Dr. Doug Campbell, director of pulmonary critical care and sleep medicine at UMC.

Each nurse can monitor 30-40 patients 24 hours a day. A physician works from 7 p.m. to 7 a.m. and will monitor 100.

The technology allows the team of critical care specialists to support the bedside care team and to ensure the dayside doctor’s care plans are followed throughout the night.

“I think this is going to be just so much support for nurses on the floor,” said Belinda Birdwell, a critical care nurse of 18 years and a new UMC employee. She worked her first day in the remote office Dec. 16. “They feel like they have a resource person as a backup if they get into a situation.”

For example, an alarm will ring if a patient’s blood pressure drops. If the ICU nurse is attending to another patient and not in the room, an Intensiview nurse can call the unit to have someone check the patient. The Intensiview physician can send in orders for medications immediately instead of ICU nurses taking extra time to find a physician or contact the on-call physician.

Besides acquiring the system to monitor 83 beds at UMC, the program will expand to monitor 24 ICU beds at Delta Regional Medical Center by June.

“Really the mission of all this is to take health care to under-served areas, particularly the Delta,” said Gillespie. “We would like to include hospitals in every area of the state as well as the long-term acute care facilities.”

The Delta Health Alliance provided financial support so UMC could serve the region.

“UMC stands out as the first health system in the nation to initiate an eICU program in partnership with a nonprofit agency like DHA,” said Deb Dominianni, director of corporate communications for Philips VISICU in an e-mail to The Clarion-Ledger. “This is a ground-breaking initiative to improve the health of Delta citizens in what has historically been a medically underserved rural area.”

From other sites where the system was in place, “families do feel a real sense of peace just knowing that, for instance, if the nurse is taken away to do something with another patient that there’s always someone that’s aware of what’s going on with them,” Gillespie said.

Dr. William Pinkston, Intensiview medical director, notes other benefits.

“Smaller hospitals will get more confidence in treating the not-so-sick, (giving them) better utilization of what they have,” Pinkston said. This will lead to fewer patients being transported to larger hospitals and reduce costs.

Being able to remotely monitor patients also will mean patients who do need to be transferred will be identified quicker.

The system will serve as a teaching tool and also build confidence among the bedside care team.

For example, Pinkston worked the first night the system was in place. When the resident physician on the floor called with questions, Pinkston was able to help the new doctor come up with a plan.

ICU nurses get to bounce concerns off of their more experienced colleagues as well. All Intensiview nurses have to have significant critical care experience, Gillespie said.

Even though they are stationary on their shifts evaluating up to five computer screens at once, “it’s still intense,” Birdwell said.

“When you’ve got the number of patients we’ll be taking care of, it’s gonna be constant.”

You can read the original article by clicking here.

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December 24, 2009

Men in Nursing

Filed under: Nursing — Shirley @ 5:45 am
Tags: , , , ,

Here is a blog post that talks about the issues men have in the nursing profession.  After reading this, I can say that I agree with some of the points but not all.  It has been my experience that male nurses get promoted over female nurses frequently; however, the difference between my experience and the experience of the blog writer is the ethnicity of the male nurse.  I agree that minority nurses, both male and female, are at a disadvantage sometimes in this field.  Why, escapes me.  In a field that professes diversity and understanding, I find those two values lacking when applied to the participating nurses in the work place.

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“Times and rules have changed a lot since I was first in nursing school back in the ’60s,” recalls Eddie Hebert, R.N., B.S.N., director of nurses at Louisiana State University Health Sciences Center in Houma, La. “However, many of the prejudices which males faced back then are still with us today.”

“For example, I was not allowed to enter the delivery room because I was a male student, but had to stand at the door of the room to catch a glimpse of the delivery,” he explains. “I was also not allowed to have a female patient. This all had to do with gender.”

Hebert also remembers studying textbooks that made no mention of the male gender—except as the patient. “All educational materials were oriented to the female gender,” he notes. “Males were seen in nursing texts as the anatomy to be studied—the one in need of female assistance. Every picture seemed to identify the nurse as the ‘caring female individual,’ while the patient was always a ‘male in need of care.’”

However, that was almost 40 years ago, some may argue. Certainly the bias and prejudices toward men in nursing that existed at that time no longer exist. Right?

Wrong, according to Gene Tranbarger, Ed.D., R.N., CNAA, associate professor of nursing at East Carolina University in Greenville, N.C. “Open discrimination against men is fast disappearing from schools of nursing but remains imbedded in the school fabric,” he observes. “The faculty still relies on feminine pronouns when discussing nurses. Male nurses who wish to work in obstetrics/gynecology still face obstacles and often have to resort to legal remedies.”

What about male nurses who happen to be racial/ethnic minorities? Do they face similar issues as non-minority male nurses, or do they experience a whole other array of issues? Though there is no single united viewpoint or experience that speaks for all minority men in nursing, theirs is a voice that is growing in strength and numbers. It is a voice that loudly proclaims the importance of the nursing profession reflecting the diversity of its patient population—including gender.

Lingering Stereotypes
Approximately 5.4% of the 2.1 million R.N.s employed in nursing in the United States are men, according to the National Sample Survey of Registered Nurses conducted in March 1996 by the Health Resources and Services Administration. Of these working male R.N.s, the racial and ethnic breakdown is:

“The last survey showed a progressively aging work force and that we needed to do more to encourage young people from diverse backgrounds to go into nursing,” says Vincent C. Rogers, D.D.S., M.P.H., the HRSA’s associate administrator for health professions. “The 2000 survey results will help us develop policies and programs to strengthen the nurse work force in practice and education.”

The survey also found that roughly 13% of students enrolled in nursing schools are men. Dwight Elliott, a senior in nursing at East Carolina University, is one of two men in his class of approximately 80 students. “I am the only black male in my graduating class,” he notes. “It has been kind of tough being a black male in a predominantly white female profession. I’ve caught some looks like, ‘What is he doing in nursing? He doesn’t look like a nurse.’ I feel like I must work twice as hard as others because one, I’m black, and two, I am a male.”

Elliott is not the only one turning heads as a male nurse. Ifeanyi John Nwokocha, R.N., B.S.N., a staff nurse at La Rabida Children’s Hospital in Chicago, recalls receiving a few strange glances himself while at a previous nursing job. He explains, “When I used to work in med/surg, I got reactions like, ‘Oh—a male nurse?’ I even got questions like, ‘Are you an orderly?’ People do not expect to see a black male nurse.”

Elliott agrees, noting that nursing has traditionally been a white female profession. “I feel that as more men come into nursing, [men as nurses] will become more widely accepted. My family and friends ask, ‘You want to be a nurse? Why not a doctor?’ I guess they feel that traditionally males are doctors and females are nurses.”

Stereotypes of nurses as being female and white have persisted throughout the years but do seem to be lessening as the number of minorities (including men) in the nursing profession has gradually increased.

Francisco Navarro, R.N., a nurse at La Rabida Children’s Hospital, has seen the effects of such stereotypes firsthand. “Some of the kids [I work with] have a hard time dealing with the fact that I am a nurse because they say that only women can be nurses,” he explains. This bothers Navarro, who believes the notion that only women are nurses is an idea the children learned from schoolmates or family. He also notes that society often labels male nurses as being homosexual.

To some extent, male nurses have been viewed as being different or gay due to their close working relationship with women combined with the assumption that nurses are female, believes Hebert. “For many years, nurses were considered the ‘handmaids’ of the physician,” he observes. “Today, things are a little different. Physicians have come to realize that nurses are much smarter than given credit for years ago. Nurses are now moving into higher management roles and are more educated than in the past.”

Hebert also feels that society is slowly becoming more comfortable with men as nurses. “Although people may feel a little uncomfortable at first sight of a male nurse, they will quickly come to trust and respect him for his professionalism.” He also believes that unlike female nurses, male nurses have had to prove themselves before being accepted.

“Because of years of publicity and propaganda, [the image of nurses] is fixed in the mind of the general public as being white and female and trustworthy. Minorities in nursing do not have this image.”

It’s Not Always a Man’s World
So how has the stereotype of the white female nurse affected minority men in nursing? The responses range from “a lot” to “not at all.” For Nwokocha, the stereotype has hurt.

“Right now where I’m working, they treat me with respect,” he says. “But in my experience, when it comes time for promotions, I feel like the male minority nurse lags behind.

“For example, when I worked in psych at another hospital, I was bypassed [for a promotion]. Even though I knew the unit very well, they bypassed me and gave the position to another person. I feel like it was because I’m black and I’m male. All the promotions there were given to females.”

Bernard Smith, R.N., M.S.N., clinical educator and recruiter at Benjamin Rush Hospital in Syracuse, N.Y., observes that it is sometimes more difficult for male nurses to work in certain specialties (e.g., women’s health) than others. He remembers, “There was at least one physician (in obstetrics) who did not want us around his patients. He did not want any male nurses around his patients.”

Navarro agrees that it is harder for a male nurse to work in women’s health than in other areas of nursing. “I could never work in a maternity unit,” he says. “There was one instance while I was in school when I was asked to interpret for a new mother who did not speak English. My instructor was showing the mother how to hold her breast and the newborn so that the baby would latch on to her breast. I could tell that the mother was uncomfortable—she would not feed her baby while I was present. Her feeling uncomfortable made me feel uncomfortable; I felt as if I did not belong in that environment.”

Both minority and non-minority men in nursing face similar issues, believes Hebert. As a board member of the American Assembly for Men in Nursing, an organization for nurses to discuss and influence the issues that affect men in nursing, Hebert hears of the discrimination and harassment experienced by some of AAMN’s members.

“The fact that male nurses are not given equal opportunity to move up in the ranks or are being denied equal employment opportunities is repeatedly heard during our annual conferences by our membership,” he states. “Many male nurses are denied [the opportunity to work in] certain areas in hospitals, such as labor and delivery units, or nursery units. In my 30 years as a nurse, I have seen many unfair practices in which male nurses and minorities were passed up for promotions due to gender. This practice continues today and is slowly surfacing in courts throughout the country.”

Neutralizing the Gender Issue
At the same time, some men in nursing have experienced no repercussions from the “nurses are women” stereotype and have actually received positive treatment because of their gender.

For example, Ramon Lavandero, R.N., M.A., M.S.N., director of the International Leadership Institute of Sigma Theta Tau International, headquartered in Indianapolis, had a very positive experience working in obstetrics. As one of the first men to go through an obstetrics class at Columbia University’s School of Nursing in New York, Lavandero found the faculty to be extremely supportive, contacting him even before the course began to see if he had any questions or concerns about being the first (and only) male in the class.

“Some people might consider that favoritism because it wasn’t done for the women,” Lavandero says. “On the other hand, it was an acknowledgment of a new circumstance, and they were planning ahead.”

In fact, Lavandero was offered three different positions within the women’s health service after graduation. He believes his experience working in obstetrics taught him an important lesson about the role of gender in nursing. As he explains, “I learned that in great part, I had the upper hand depending on how I treated and dealt with other people. If I was comfortable and didn’t see my gender as being a distraction, then there was no issue. If I was assigned a woman as a patient and if I was at all unsure as I interacted with that patient, then it would become a question.

“So I would go in and say to the patient, ‘My name is so-and-so, and I’m the nurse who will be working with you today.’ Ninety-nine percent of the time, there was never any question. There were a few times when, for example, a mother in postpartum requested a female nurse because she felt she would be more comfortable with a woman. But we had set a very comfortable tone. I can’t really say I have problems because of my gender any more than a woman nurse might occasionally have a problem with a male patient.”

Lavandero agrees that there are stereotypes of women in nursing but emphasizes that there are stereotypes attached to many other careers. “There are stereotypes that soldiers in combat duty are men,” he points out. “Well, you know where that can lead in terms of stereotypes. In the same way, there are stereotypes of men in nursing just like there are stereotypes of women in nursing—just like there are stereotypes of women who teach physical education and of men in engineering.”

Finding Strength in Numbers
Given these stereotypes, what can men in nursing do to find camaraderie?

Join organizations that support men in nursing, encourages Hebert. “There is voice in numbers, and you should seek your special interest organization and see if they will stand behind you and support your issues of concern.”

One such organization is the American Assembly of Men in Nursing, of which Tranbarger is president-elect. “We are a small group of male nurses and their supporters and represent a wide diversity of age, educational background, work experience, sexual orientation, ethnicity and almost any other characteristics one can think of,” he says. “I look forward to each meeting so I can interact with others who share my work, my experiences, my concerns and my hopes for the future.

“I must also add that I enjoy greatly our dedicated women members who share our beliefs that nursing is a profession, not a gender-based occupation,” adds Tranbarger. “AAMN is a healthy organization of men and women and is better because of all who join us.”

Each year, AAMN holds a conference, rotating the theme so that one year focuses on men’s health issues and the next focuses on issues of gender in nursing. “Diverse Nurses for a Diverse World” is the theme of this year’s conference, which will be held in Seattle from November 30 to December 2.

Another organization which offers support to nurses is Sigma Theta Tau International, an honor society of nursing with over 120,000 active members. As part of the International Leadership Institute, the Chiron Mentor-Fellow Program was started in January 2000 to provide the opportunity for individualized leadership development to members of Sigma Theta Tau. Although there were not any men involved in the program at the time of this article’s writing, Lavandero states, “We very much would like to have men involved. We really would like it to be a very diverse program.” He encourages potential mentors to identify a potential fellow and to apply to the program as a pair, believing it to be a valuable way for an experienced nurse and mentor to help another person to develop.

Other sources of support can be one’s fellow nurses—both men and women; it is important not to adopt an “us against them” mentality and alienate those of the opposite gender. Smith urges male nurses to develop friendships with their female colleagues.

“By far, [female nurses] are going to be your greatest source of support and strength,” says Smith. “They always have been for me—just by the sheer weight of their numbers, if for no other reason. But it’s more than that. I’ve learned so much from the women who are colleagues of mine.”

Reflecting the Face of Society
In order to encourage other men to enter the nursing profession, Nwokocha speaks with high school students on an informal basis.

“I meet the students through my nephew,” he explains. “He introduces me to his friends: ‘This is my uncle. He’s a nurse.’ And the students come to me and say, ‘Oh, you’re a nurse? How do you like it? What’s it like being a male nurse?’ Some of the students are excited—they want to become nurses, too. But they also want to hear what it’s like from someone who’s a man. So I talk to them, giving them advice and telling them what nursing entails.”

Tranbarger believes the best way to encourage minorities (including men) to consider nursing as a career is first to speak well of nursing as a profession. “No one wants to join a group that dislikes their work,” he says. “We also need to make schools of nursing more welcoming to non-females and non-whites. Language, symbols and policies all need to give each person a full and fair chance at success or failure.

“I do not know a man who wants an advantage in nursing,” he continues. “Every man I know just wants a fair chance. I think that is true for other minorities as well.”

Lavandero offers some additional insight on this issue. “Rather than simply saying, ‘We need more minority nurses,’ I would phrase it as, ‘We need more men and more people from varied ethnic and cultural backgrounds in nursing because that is the composition of our society today.’ In general, what nurses really bring to the table is an ability to help identify the health care needs of the patients and families in our communities. If we are not representative of our [patient population], then it becomes a lot more difficult to identify and meet those needs.”

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December 22, 2009

Job-hunting is a headache even in health care

Below is an interesting article that I have seen repeated numerous times.  New graduate nurses who are not having any luck finding a job due to lack of experience or just the sheer number of applicants for a few jobs.  This is a real problem for someone who just spent years and quite a lot of money to get a degree and a license.  What may be the problem is the fact that certain areas of the nation are saturated or certain specialty areas are saturated.

I know that when I went to nursing school, I had my heart set on a specific specialty; so did most of my classmates.  However, I spoke with several older RN’s about finding jobs after school and they gave me really good advice.  They told me to go where the job takes me, even if that is not my area of interest.  Their reasoning was that any work in the nursing field is useful and helps you build your foundation of knowledge.  Once you are a seasoned nurse, you will then have your pick of specialty areas to move into.

I originally had planned to take this sage advice, but at the very last moment, my dream job simply fell into my lap.  I took it and have never looked back.  Now, 20 years later, I see that I could have done it differently, but I would still have ended up where I am.  So, my advice to all the newly graduated nurses out there is to simply find a job nursing. Once you get experience as a nurse, you can specialize in any field you want.

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By Drew DeSilver

Seattle Times business reporter

During this long, grueling recession, which already has chewed up and spit out 166,500 Washington jobs, the health-care sector has been one of the few bright spots — steadily adding jobs even as the rest of the state’s economy shrank.

Health care did it again last month, according to the monthly report released Tuesday by the state Employment Security Department.

The sector, which includes hospitals, nursing homes and doctors’ offices as well as social assistance, gained 900 jobs in November, even as the state as a whole lost a seasonally adjusted 4,800 jobs.

But even in a relatively strong industry, jobs can be tough to find, as Shawn Saline, of Seattle, has discovered.

After several years out of the work force, Saline, 43, graduated from Shoreline Community College’s registered-nursing program in June. Once her two kids went back to school this fall, she started seriously looking for a nursing job.

The result: a one-day-a-week slot as a fill-in nurse and a bunch of rejected applications.

Saline said that even while she was in nursing school, she’d heard that opportunities for new nurses were tightening, due to the expense of training and the number of experienced nurses either staying in their jobs longer or returning to the work force.

“They don’t have the budget to train new nurses,” she said. “The people who are getting hired are people who’ve worked in that organization, on that floor, during nursing school.”

At one hospital, Saline said, 150 people applied for eight nursing positions. She interviewed at another hospital where she was competing against 100 others for a single job.

Several of the 30-odd new nurses in her graduating class are working temporary jobs this winter at flu-shot clinics.

Not counted

Because she is working part time, Saline is not counted among the 321,280 Washingtonians officially considered unemployed — 105,190 more than in November 2008.

(The jobless data come from a monthly survey of households — not, as is sometimes thought, by counting the number of people getting unemployment benefits.)

The seasonally adjusted unemployment rate for Washington fell to 9.2 percent in November, from 9.3 percent a month earlier, the state reported. The jobless rate in the Seattle metro area also fell, to 8.6 percent from 9.2 percent in October.

Some of that decline was due to people dropping out of the labor force because they went back to school, or are sick or they’re tired of job hunting. Almost 44,000 Washingtonians have left the labor force since September.

Including part-time workers who’d rather have full-time positions, people too discouraged to hunt and other “marginally attached” workers would add about 6.7 percentage points to Washington’s official unemployment rate, according to estimates from the federal Bureau of Labor Statistics.

The recession has taken a heavy toll on working Washington. Since nonfarm payrolls peaked in February 2008, they’ve shrunk by 166,500 jobs — a decline of 5.6 percent.

Although most of the state’s major employment sectors have lost jobs, the hardest-hit have been construction and manufacturing.

Construction, which boomed along with home prices, has cratered since that bubble popped. Since February 2008, 55,800 construction jobs in Washington have evaporated — more than a quarter of the peak payroll.

Durable-goods manufacturing has fallen by 31,500 jobs, or 14.5 percent. And there likely will be more cuts before the sector turns around.

In the summer, furniture maker Herman Miller announced it would close its Brandrud subsidiary in Auburn, which specialized in furnishings for hospital waiting rooms and patient rooms.

Herman Miller is moving the work to a unit in Sheboygan, Wis. The first of what eventually will be 104 layoffs came earlier this month.

Bad news

Joel Gragg, Brandrud’s marketing coordinator, has been with the company since graduating from Washington State University three years ago. Now 25, he’s facing his first layoff; he was told he’ll be let go in February.

Gragg said he’s begun gathering references and updating his résumé but will wait until he’s let go to actively start looking for a new job.

Until then, he said, knowing his termination date has placed him in a kind of limbo.

“I’m at the point where I just want February to be here,” he said. “I just want to be done with it and move on to the next thing.”

Drew DeSilver: 206-464-3145 or ddesilver@seattletimes.com

You can read the original article here

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December 20, 2009

Health Promotion in Nurses: Is There a Healthy Nurse in the House?

This article is a survey summary from Medscape Psychiatry and Mental Health.  I found this interesting and thought you might enjoy it also.  Caregivers, as a rule, do not ever take care of themselves; they are “other” focused and this can lead to burn-out and illness.  As nurses, we are failing at “walking the walk” but we are great at “talking the talk”.  We frequently give our patients education on stress reduction, good diet, exercise, and healthy lifestyles.  This study seems to point out that we nurses must not be listening.

Working in healthcare is very stressful and very demanding, both emotionally and physically.  We should be looking for ways to support and strengthen our nurses to facilitate the ability to continue doing the work they love.

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McElligott D, Siemers S, Thomas L, Kohn N
Appl Nurs Res. 2009;22:211-215

Study Summary

As nurses focus on the health of their patients, families, and communities, are they practicing health-promoting behaviors for themselves? Is there a healthy nurse in the house?

Pender’s Health Promotion Model is a framework often used in nursing research to examine the factors that promote health. This framework integrates nursing and perspectives from behavioral sciences into factors that may influence health behaviors. Health promotion is defined as a behavior that is “motivated by the desire to increase well-being and actualize human health potential.” This actualization is possible through competent self-care, goal-directed behavior, and harmony with the environment, including interpersonal relationships. Health promotion is differentiated from disease prevention as a result of its motivational dynamics. Whereas prevention is disease or injury specific in its approach, health promotion seeks to expand the potential for health.

The model has 2 dynamic and reciprocal phases. The decision-making phase includes the individual perceptions and modifying factors. The action phase includes the barriers and cues that trigger activity. This conceptual framework targets characteristics for assessment and suggests interventions to alter perceptions and improve health-promoting behaviors. Nursing self-care may easily be influenced by several of the model’s propositions: (1) perceived barriers can hinder commitment to action; (2) peers and situational influences in the environment can increase or decrease commitment to participation in health promotion behavior; and (3) commitment is less likely to occur when uncontrollable competing demands require attention.

The purpose of this pilot study was to examine the health-promoting lifestyle behaviors of acute care nurses using the health promotion model.

This study used an anonymous, convenience sample of registered nurses (RNs) working in a tertiary hospital. The sample included the nursing staff working in the cardiac and neuroscience services in medical, telemetry, and critical care units. Surveys were available to 500 RNs working on the cardiac and neuroscience services. In 1 month, 149 surveys were returned (a 30% return rate).

Statistical analysis of 149 returned Health-Promoting Lifestyle Profile II surveys indicates areas of weakness in stress management and physical activity. No significant differences were found in unit, demographic factors, and subscale scores at the .01 level of significance, but medical-surgical nurses consistently scored better than the critical care nurses on health promotion.

These findings support the need for the development of holistic nursing interventions to promote self-care in the identified areas. Strategies include educational/experiential classes in holistic nursing; individualized unit-based activities that foster stress management, such as massage, reflexology, and imagery; and development of an employee wellness program.

Holistic caring and nurturing of self support a healthy balance and increase productivity and a fuller participation in the life experience. Support of this paradigm shift to an emphasis on self-care provides the energy for nurses to enhance their care of patients, families, and communities.

Viewpoint

This article tackles directly the question of whether nurses do as they teach. It is nurses who talk to patients about “taking care of themselves” and how to manage stress, and reduce risk factors by exercising and losing weight. This article documents what nurses themselves have often said: “We need to do the same things we are telling our patients.”

Why don’t nurses exercise and manage stress better? For the same reason that patients don’t do it — a lack of time. Everyone seems to be stressed in life; no one seems to have enough time to exercise and do the things that mean we are taking care of ourselves. How can we get our patients to be motivated and make the commitment when we ourselves do not?

First, nurses have got to take a good look at themselves. This study takes the first, small step by saying that we have to change. Too often nurses act as though the statistics don’t apply to them, nor do the protocols and guidelines that we expect patients to follow. Too often we are too busy caring for others to care for ourselves.

No one else is going to take care of the caregiver. It is a fundamental lesson, long overdue.

The original article can be found here.

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December 18, 2009

Changing diets on nine-inch plates

Filed under: Nursing — Shirley @ 3:51 am
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The article below I included because it shows a nurse who “thinks outside of the box” and who was able to take her idea and make it profitable and productive.  I have always felt that nurses are the perfect entrepreneurial pool because nurses frequently are faced with having to “make do” or “make it work” in daily dealings with patient needs.

Here is a fine example of a nurse who took a problem and pushed it through to an acceptable outcome, both for herself and others.  How many other nurses out there do you think are doing the same thing?  I think the number would be surprising.  Nurses are very creative and willing to think critically about problems.

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   Christine Bromley with one of her small plates.
Christine Bromley with one of her small plates.

BY TERESA MEARS

tmears@mindspring.com

Christine Bromley of Fort Lauderdale worked for many years as a nurse, teaching her recovering cardiac and diabetes patients how to eat right. But she didn’t always take those lessons home, and she struggled with her weight for years.

A desire to run her own business led her to create One Helping Helps Many (OneHelp

ingHelpsMany.com), which sells nine-inch dinner plates designed to maintain portion control.

The products are part of what is called the Small Plate Movement, which advocates that both families and restaurants downsize their plate sizes. The movement, which includes numerous books and products, cites studies that show that people eat less when the food is served on smaller plates.

Bromley’s plates are imprinted with the words “One Helping Helps Many,” and she donates 15 percent of her process to three charities: Commit 2B Fit, a South Florida organization that combats childhood obesity; House of the Children, which helps provide sustainable water around the world; and Feed My Starving Children, which packs and ships meals to children in more than 60 countries.

Q: What prompted you to create a small plate?

A: I did home health nursing for the last 15 years and that was mainly teaching patients. I taught them how to change their lifestyles, and a big part of that was their diet. Though they were taught that you had to cut down their portions, they fought it all the way. They didn’t know how to change a lifestyle.

It all began with the plate. We had tools that showed where the vegetable goes, where the protein goes, and it was much smaller than the average 12- or 14-inch plate.

I wanted to have a plate that the whole family could eat on. I had battled the bulge my whole adult life. I had gone to every diet center and did great, and then when it came time for maintenance and returning back to normal food, I blew it because I was going back to the big plates.

Q: Why do people find portion control so difficult?

A: When you have a large plate in front of you, and you’re told as a child to clean your plate, you cannot really put it together. We were not taught portion control. When I went on diets I would go to these diet centers and they would have their little bits of food in the Tupperware, and I would do OK with it, and I was satisfied. I knew that’s what I had to eat at each meal. When I was given back my regular-size plate, I just couldn’t do it.

Q: How did using the small plates change your approach to grocery shopping and cooking?

A: Mealtime was always an important part of our day. I came from a big Italian family, always had big family gatherings, and eating was a big part of my life. To make my kids happy, I would buy a lot of food at the grocery store. If my kids were happy eating, we ate. And we put on the weight. When my plates came off the production line, I started with my family. We loved eating off the plates because we could eat a small amount that satisfied us. But I was still putting on the table the amount of food I did before (and people went back for seconds). I realized I had to include portion control at the grocery store, and that’s when things began to change. Since July I have lost 17 pounds. Even my grocery bill has declined. I went from $200 to $250 at the grocery store weekly to $150 to $175. Now I plan my grocery list according to my plate and I visualize what I am going to put on that plate. When we’re done eating, when the food is gone, you’ve gotten what’s healthy for you and we’re done.

Q: What other tips do you have for people to avoid weight gain, especially over the holidays?

A: Eating three meals a day is the best defense against overeating.

Q: Did you start out as a participant in the Small Plate Movement?

A: I came upon the small plate movement about a year after I decided to do my business. I looked for portion control plates, but I was amazed I really didn’t find anything mainstream. I found plates that were juvenile, that showed pictures of food.

Our plates have increased in size since the ’60s to 36 percent bigger. They said just by cutting down a plate two inches, from 12 inches to 10 inches, you cut calories 22 percent. If you eat like that for one year, you’ll lose 15 to 20 pounds. I know from nursing that just a 15-pound weight loss in someone who’s overweight improves their health dramatically.

There also was the book, The Nine-inch Diet, and it was a fun take on how our plates have grown over the years and how important it is to go back to the nine-inch plate. But, again, there was no actual plate.

Q: Do you have any advice for people who can’t afford new plates?

A: I guess it would be to eat on smaller nine-inch salad plates. Even if people don’t choose to buy the One Helping Helps Many plate, it’s going to be stuck in their head that nine-inch plates have a purpose.

To read the original article>>click here

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December 16, 2009

Patient Photos Help Reduce Hospital’s Medication Errors

Okay, now this article bothers me.  As a psychiatric nurse of 20 years, I can tell you that I have never worked anywhere in psych without  a picture of my patients.  I don’t understand this article.   The reason for a photograph on a psych unit is not just for medication, although that is the main focus.  These are patients who are ambulatory and who behave erratically at best.  Yes we place armband identifications on each patient, but they usually remove them as soon as they can.  We find we need the pictures so we can put names and faces together, period.  With staffing and scheduling the way it is, we frequently find a totally new group of patients on the unit after having a few days off.  Imagine trying to assess and treat your assigned patients when they are all sitting in a day room playing cards or watching television and you have yet to meet them.  Having pictures simply helps to prevent any confusion and to prevent errors of any type.

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Sarah Kearns, for HealthLeaders Media, December 14, 2009

When a new patient enters a hospital, staff members generally follow the same routine. The admitting nurse asks the patient’s name, date of birth, symptoms, and any allergies to medications. From this information, a medical record is created and the patient may be admitted and is taken to a room.

However, at JPS Health Network in Fort Worth, TX, there is one extra step for admitting nurses in the Department of Psychiatry: photographing new patients.

This extra step was implemented in early 2006 when Allison Mason, RN, BS, MHA, program manager in the Department of Psychiatry at JPS, attended a monthly performance improvement review regarding medication errors.

After a medication error occurred on the adult inpatient unit resulting from the misidentification of a patient, Mason and the committee reviewed other patient identification practices on various units within the hospital’s psychiatry department.

They found that the adolescent inpatient unit used patient photographs as a second identifier during medication administration and had only two recorded medication errors because of misidentification in the five years after implementing this process.

The committee rolled out this process on the adult inpatient units after hearing of its success on the adolescent unit. In the four years since photos have been used, there have been only a handful of medication errors in the JPS adult inpatient unit. When later addressed, these errors were found to have occurred because nurses had failed to use the patient photograph as a second identifier. These nurses were educated further about the process using a root-cause analysis and examining the occurrence step-by-step, says Mason.

Medication errors because of patient misidentification are especially challenging in psychiatry because patients are frequently noncompliant with wearing identification bands, are unable to answer identifying questions, or intentionally answer incorrectly, says Mason.

“In psychiatry, patients sometimes are not able to answer identification questions,” says Mason. “The patient may be psychotic or unwilling to answer questions correctly, which presents the department with unique challenges.”

Although patient photographs may raise a red flag for many working in healthcare and hospital settings as a possible violation of HIPAA laws, Mason says it is different for psychiatric units. HIPAA laws protect the privacy of patient health information.

“Our state laws and other regulatory standards we have to abide by are actually more strict,” says Mason. “We explain to the patient what the picture is used for and how it improves their safety and quality of care.”

When a patient is admitted, the admitting nurse takes a picture of the patient, which goes on his or her chart as well as a 3×5-inch index card.

Along with the picture, the patient’s name, date of birth, and medical record number—unique to each patient—are all included on the card.

“Each patient card is handed down, shift to shift, by nurses and is used for identification during medication administration,” says Mason.

In addition, patients wear an identification bracelet, which has a bar code that matches the one on the index card and is unique to each patient, says Mason.

Easy implementation
JPS purchased a digital camera so nurses could print patient pictures immediately.

“We wanted to make the process as easy as possible because we did not want to slow down the admission process or make it a burden,” says Mason. “[Our] information technology [department] installed the camera program on one of the computers in the nurses’ station, and now, taking a patient’s picture during admission has just become part of the process.”

The key to the process is to have a camera on each unit so all nurses have access to one, she says.

Another important factor in the success of this process was the support provided by upper management, says Mason.

“Everyone here is always ready to do something that will improve patient safety and quality of care,” says Mason.

To read more about this program, please see the January 2010 issue of Briefings on Patient Safety, a product of Patient Safety Monitor.


Sarah Kearns is an editor for HCPro in the Quality and Patient Safety Group. Contact Sarah at skearns@hcpro.com

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December 11, 2009

Critical nursing scarcity looming

Public domain image from cancer.gov http://vis...
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This is an exceptional article about the coming nursing scarcity.  We all know that we have a major nursing shortage right now, even though we turn out new nurses rapidly and the economy is keeping older nurses working longer.  We all are aware that there is a shortage of nursing educators and nursing leaders.  We all have been considering what the solution is to these problems.  Now, let’s begin to factor in the surge of newly insured when the healthcare reform passes.  Not only will we be short on nurses and physicians, but we may also find ourselves short on the availability of hospital beds.
Read the article, please, and visit the original site to read the numerous comments.  Some of them really made me stop to think.  We all need to put our thinking caps on to resolve what may become a problem of gargantuan measure.
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Health reforms may create big need for nurses

Sunday,  December 6, 2009 3:35 AM

THE COLUMBUS DISPATCH

<p>Registered nurse Shirley Cooley, right, helps nursing student Anna Hung-Chan give a vaccine to a newborn at Mount Carmel East hospital on the Far East Side.</p>

CHRIS RUSSELLDISPATCH

Registered nurse Shirley Cooley, right, helps nursing student Anna Hung-Chan give a vaccine to a newborn at Mount Carmel East hospital on the Far East Side.

The bad economy might make it seem as if there’s no shortage of nurses in central Ohio, but experts say the situation is temporary.

“We are seeing nurses who might have been considering leaving the profession, ready to retire, and they’re not doing that,” said Janice Lanier, deputy executive officer of the Ohio Nurses Association.A recent report from the Health Policy Institute of Ohio projects that Ohio is one of three states, along with Texas and California, that will have the greatest need for nurses in a decade.

Researchers expect Ohio to be short 32,000 nurses by 2020.

Besides an aging population with more chronic medical conditions, impending health reform could mean that 1.3 million uninsured Ohioans will have insurance.

“They can start coming into (medical) practices, and what’s that going to do to the demand on getting in?” said William Hayes, president of the policy institute. “We have to be ready for the need.”

Advanced-practice nurses, including nurse practitioners, could provide newly insured people with primary medical care.

“Just because we don’t have the shortage hitting us over the head every day now, we should not take it off the policy plate,” Lanier said.

There are more than 2.4 million registered nurses in the United States, making it the largest health profession. The average age of an Ohio nurse is 47, and the median age of a nursing faculty member is 51.

Nursing schools still have waiting lists, but that’s because there are not enough faculty members to train future nurses, experts say.

Plus, some local hospitals aren’t hiring nurses the way they did a few years ago because of the economy.

Sarah Strohminger, a junior at MedCentral College of Nursing in Mansfield, said she knows of nursing graduates who could not find work in Mansfield or Columbus.

Strohminger, president of the Ohio Nursing Students’ Association, said she plans to work as a patient care assistant at MedCentral to get her foot in the door at the hospital.

Ann Schiele, president of the Mount Carmel College of Nursing, said all 160 nurses who graduated from there in May have found jobs.

“It may not have been their first position of choice … but by August every student that I was aware of had a position,” she said.

Ohio State University Medical Center, which hasn’t made the cutbacks that other local hospital systems have, continues to hire nurses, including at least 140 new graduates every year.

“There is not a shortage in central Ohio of new grads, but there will always be a shortage of specialized nurses,” said Karen Bryer, director of medical-center recruitment at Ohio State.

Specialized nurses include those trained to work in intensive-care and neonatal units, and advanced-practice nurses such as nurse anesthetists.

Schiele expects the local hiring lull to end in about three years, and then there will be an immediate need for nurses. By then, aging faculty members will be retiring.

“It’s all very important that we get the funding to educate the faculty in the master’s and doctoral programs,” she said.

That’s where state officials could come in. The state could help pay off student loans or provide grants, tuition assistance for nurses who want to teach, or a refundable tax credit for nursing faculty members.

There have been some state policy moves to address the shortage.

These include changing the Nurse Education Assistance Loan Program in the state’s budget bill this year to forgive student loans of nursing master’s students who teach nursing at an Ohio school, Allison Kolodziej, Gov. Ted Strickland’s spokeswoman wrote in an e-mail.

Lanier said policymakers shouldn’t wait until hospitals complain that there aren’t enough nurses.

“There’s nothing worse from a patient-safety perspective than having an entire floor staffed with brand-new nurses,” Lanier said. “You need to have that mix.”

shoholik@dispatch.com

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December 10, 2009

ANA Smartbrief: Editor’s Viewpoint

WASHINGTON - SEPTEMBER 18:  New Jersey Governo...
Image by Getty Images via Daylife

Here is a recap of the advances and challenges nursing has faced during the year 2009.  Also is a list of links to some of the most viewed stories of 2009 (some have been featured here before).  As the year ends, it is always a good thing to reflect on what has transpired during the year to prepare you for setting new goals for the coming year.

Enjoy!  May the year 2010 be a wonderful adventure full of challenges and triumphs!

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Looking back at 2009

Rebecca M. Patton, MSN, RN, CNOR ANA President

2009 has been a year of change and challenges for nurses, and through it all, ANA has worked diligently to be a unifying force for the nursing community. Today, as in days past, it is our members who guide ANA as it works to be the voice of nursing.

Health care reform has been at the forefront of America’s political and policy discussion this year. I am proud that ANA played and continues to play a significant role in representing the interests of nurses and the patients we serve.

ANA has a long-standing commitment to promoting nursing quality as a means of improving patient safety. In 2009 we renewed that commitment by launching the “Handle with Care Recognition Program” to award health care facilities with comprehensive safe patient handling programs.

ANA was gratified to see another quality measure, NDNQI®, reach the milestone of 1,500 participating U.S. hospitals, a number which represents 25% of the all the nation’s hospitals. This unique database continues to experience steady growth, and is a proven, invaluable resource for nurses.

I would like to thank our members for their hard work and their support and to wish them continued success in the New Year.

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The Year’s Top Ten

Top 10 news stories clicked by SmartBrief readers in the past year.

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Favorite Quotes:

It is our responsibilities, not ourselves, that we should take seriously.”

Peter Ustinov,
British actor and writer

There is a real difference between managing and leading. … Managing winds up being the allocation of resources against tasks. Leadership focuses on people. My definition of a leader is someone who helps people succeed.”

Carol Bartz, Yahoo! CEO

If you don’t go after what you want, you’ll never have it. If you don’t ask, the answer is always no. If you don’t step forward, you’re always in the same place.”

Nora Roberts,
American author

If you’re walking down the right path and you’re willing to keep walking, eventually you’ll make progress.”


He who has the fastest golf cart never has a bad lie.”

Mickey Mantle,
National Baseball Hall of Famer
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