By Benjamin Evans, DD, DNP, RN, APN
Two score and 3 years ago (hmm, that would be 43), I graduated from my pre-licensure associate degree nursing program. I was 20-years-old and full of excitement about starting my career. Now, looking in the rear-view mirror at the other end of my nursing journey, I can say that while I am older, wider, wiser and experienced, it has been the correct path.
At age 20, I wanted to join the pediatric nursing staff. However, I was placed on a 50-bed, primarily male and geriatric unit because, as the director of nursing stated, "How would I justify the presence of a male nurse to the parents of young females?"
Of course, in my naiveté I responded that she could respond the same way she would to explain female nurses for young male patients. It wasn't accepted. A bit earlier, I remember being called aside by my orthopedic nursing instructor and told apologetically that I was not welcome in the nurses' lounge according to the Head Nurse. I was to use the orderly lounge two floors down in the hospital.
If only I were as savvy then as I am today about sexism and discrimination!
Of course, the other side of the coin was always this question from patients: "Are you my doctor?"
When I responded that I was the RN, the next question(s) invariably were, "When are you starting medical school?" or "Weren't you smart enough to go to medical school?" Of course, there were also the frequent under the breath, but loud enough for me to hear, comments as I left some of the men's rooms -"***," "faggot."
I would never have envisioned that 43 years later I would have been an advanced practice nurse (NP certificate in 1979), an occupational health nurse, clinical nurse specialist, nurse educator for more than 30 years, nurse manager, director and associate vice president and served patients in areas of chronic, catastrophic illness (e.g. cancer, AIDS), addictions, general nursing and mental health. I also have my own practice that focuses on psychotherapy, medication management, counseling and educational programs.
Nor would I have envisioned being founding president of the Academy of Doctors of Nursing Practice in New Jersey, a member of the Hudson County Mental Health Board and an NJ Disaster Response Crisis Counselor, sitting on a national nursing specialty organization board and now serving as the president of a state nursing association under the American Nurses Association.
Nursing today is quite different from my initial years, and our profession has definitely become more inclusive and welcoming. As an educator, mentor and president of the New Jersey State Nurses Association, I plan to keep raising awareness and pushing the boundaries.
It has been some journey so far, and I can't wait to see what the next chapter brings. I look forward to sharing it with you.
Ben Evans is the first male president of the New Jersey State Nurses' Association. He also is an assistant professor in the graduate nursing program at Felician University.
By Maureen Salihar, RN, BSN, RNC, and Leeann Cacovean, RN, MSN, ACNP-BC
Recently the Centers for Medicare & Medicaid Services announced a bundled payment model associated with the impending roll out of the Medicare Access and CHIP Reauthorization Act legislation. This means a hospital will receive a single, target-price reimbursement for an entire 90-day episode of care associated with an acute myocardial infarction (AMI) admission. At Advocate Good Samaritan Hospital in Downers Grove, Ill., we have taken a proactive approach to deal with this change by focusing on how nursing can impact the care of our AMI patients.
We sought input from bedside nurses, nursing leadership, advanced practice nurses and cardiologists in addition to researching literature and evidence-based techniques. The result: a single, comprehensive program for the management of patients presenting for primary management of AMI both during the inpatient phase of care and the immediate post-hospital transition phase.
Both the bedside nurse and the patient receive a road map at the initiation of inpatient phase I cardiac rehabilitation. The road map details education, treatment, and activity expectations from admission to discharge. For uncomplicated patients, we selected a 48-hour goal to discharge. The remaining components of our AMI clinical pathway include:
- Planned early ambulation.
- Nutrition consultation.
- Teach-back. Numerous experts recommend using the teach-back method at the end of every patient education session regardless of the patient's health literacy level. The technique has been shown to have a positive impact on disease-specific knowledge and treatment plan adherence and has been associated with a trend toward improved self-care and reduced hospital readmissions. The goal is to convey adequate information to facilitate immediate post-discharge self-care and prevent short-term readmission (prior to initiation of outpatient cardiac rehabilitation) without overwhelming the patient. The teach-back questions will be shared with our home health and cardiology physician partners to ensure consistent patient education throughout the continuum of care.
- Standardized patient-facing materials. Patients report feeling confused and overwhelmed by the volume of educational materials they receive. On the program go-live date, existing materials will be replaced with a custom education offering based on the teach-back questions used for inpatient education.
- Pharmacist-led discharge medication reconciliation. A recent meta-analysis found that pharmacist-led medication reconciliation programs at care transitions are associated with a substantial reduction in all-cause hospital readmissions.
- Automatic referral to outpatient cardiac rehabilitation.
- Heart attack patient promise. Patient contracts establish clear expectations for post-discharge patient self-management and document the patient's commitment to participation in their own care. Our patient promise is composed of open-ended questions designed to supplement inpatient education, provide a framework for patient engagement, and summarize the patient's immediate post-discharge responsibilities. The contract is to be completed on the date of discharge with the patient by either a cardiology advanced practice clinician or a nurse.
- See you in seven. All patients with home health services will have a cardiology follow-up scheduled within seven days of discharge prior to departing the hospital. Patients without home health services will follow up with cardiology in 48-72 hours.
- Post-discharge electronic follow up. Patients will receive an e-mail communication on the first business day after discharge including their cardiologist's electronic business card, their primary care provider's electronic business card and links to reputable internet resources.
- Transition management by advanced practice clinicians. Cardiac advanced practice nurses have been shown to have a positive impact on 30-day emergency department and hospital readmissions. Home health nurses will have an open line of communication with the appropriate cardiology advanced practice team to resolve post-discharge problems before they result in readmission.
Our AMI Clinical Pathway is built on a foundation of shared expectations. When they know what to expect during their hospitalization, we've discovered that patients and their family members are more engaged and feel less anxious about what lies ahead.
Maureen Salihar, RN, BSN, RNC, and Leeann Cacovean, RN, MSN, ACNP-BC, are registered nurses at the Advocate Heart Institute at Good Samaritan Hospital in Downers Grove, Ill. Salihar is manager of clinical operations for cardiovascular services and Cacovean is cardiovascular outcomes coordinator and cardiac alert coordinator.
By E. Todd Bennett
As the presidential and congressional elections and nominations to the HHS and CMS have taken center-stage in healthcare discussions, providers continue considering the implications of Medicare Access and CHIP Reauthorization Act (MACRA)-related programs. The ruling was finalized in October 2016.
MACRA's execution is complicated, and providers will want to know how MACRA will impact reimbursement and how they can position their organizations successfully for value-based payments in the future. Underlying the operational complexity are three data management challenges that need further examination: reporting, interoperability, and care coordination.
All three depend on maintaining accurate data about practitioners and patients. By managing accurate patient and practitioner data sets, providers can maximize efforts and efficiencies in the rest of the program.
Which quality metrics are reported on and when will depend on the ‘pace' selected and requirements of specific Quality Payment Program (QPP) tracks. Regulators have specified that those who must report include physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Certified Registered Nurse Anesthetists (CRNAs), Clinical Nurse Specialists (CNSs), and pathologists and groups that include these clinicians, including some additions or exclusions.
One of the data management needs that has arisen is practitioners will be identified in different ways, depending on their participation in the merit-based incentive payment system (MIPS) or advanced alternative payment models (APMs). While MIPS will identify eligible clinicians through a combination of taxpayer identification numbers (TINs) and national provider identifiers (NPIs), the APM programs will likely identify eligible clinicians via a unique identifier utilizing APM, APM Entity, and TIN/NPI combinations.
So, in the instance where an eligible clinician joins a new group practice in mid-2017 or later, the identifier describing that individual will also change. Keeping these identifiers updated will ensure that reports to CMS are accurately submitted by and credited to the right individuals and groups.
Interoperability presents another data management challenge. It involves accurate patient matching, known semantics, patient authorization and more. Senders must know that they've selected the right patient records and be confident in an intermediary's ability to locate the right patient's additional information and transmit it. Yet, while this may seem like an easy data management task, matching patient data that is constantly changing, and captured and stored inconsistently, can be a daunting task. In fact, even large, sophisticated health systems can struggle with interoperability, as evidenced by the rate of fragmented or duplicated medical records uncovered by providers. Updated and robust patient data sets will aid patient matching for those striving for interoperability outside of their homogenous EHR environments.
Lastly, care coordination, which is also linked to interoperability, presents a related data management challenge in knowing which practitioners to coordinate with. Patient care teams are burdened with situations that lead to inefficient use of their time. For example, they are asked for information like the correct phone number for a patient's primary care physician, the address of a skilled nursing facility where a patient was discharged, the names of local psychiatrists to call for a patient evaluation so that an appropriate discharge location can be selected, and the address of a specific emergency department or urgent care center where the patient can be directed to once they are phone-triaged. All of these scenarios require accurate demographic profiles on individual practitioners and care settings that are easily available to help ensure practitioners are consulted and the most appropriate and convenient care settings for the patient are selected.
Combining the President-Elect, new healthcare appointees to the new administration, and the bi-partisan nature of MACRA's legislative approval, no one knows exactly what will change in MACRA, if anything. Even so, complete, current, and comprehensive patient and practitioner data sets can help providers and their health IT vendors avoid creating additional work for clinical and administrative teams, safety issues for patients, and workflow inefficiencies that could jeopardize the intended benefits of the program.
E. Todd Bennett is the HealthCare Market Leader at LexisNexis Risk Solutions.
By Jennifer Gibson, RN, HCS-D, COS-C
Value: a fair return or equivalent in goods, services or money for something exchanged; relative worth
Medicare's Home Health Value-Based Purchasing Model is new to the home health nursing space this year, but value-driven care has been gaining traction across care delivery systems for years. While the concept of VBP may not be new, the metrics used to define value and quality change frequently. Currently, STAR ratings, Consumer Assessment of Healthcare Providers and Systems results, and Home Health Compare are used to assess value of care provided by an agency.
The home health nurse's day-to-day workload differs greatly than our counterparts in a typical brick-and-mortar acute care setting. We still perform intricate wound care, IV therapy, LVAD therapy and disease management, but we work in the setting of a patients' residence and on their turf. Needless to say, this presents an entirely different set of challenges and opportunities to the home health nurse. We feel the impact of fighting traffic, connecting with physicians to obtain orders in a timely manner and managing patient and caregiver expectations. At the same time, we maintain professionalism, confidence and people skills during those Foley catheter changes done in dark rooms while keeping the family pet out of the sterile field.
How does the care we provide translate into measurable value? For home health nurses, it boils down to outcomes. Did the care we deliver improve the patient's outcomes? Did we decrease instances of infection, complication, exacerbation while increasing compliance and functionality through our services? Equally as important, did we ensure the patient was kept informed of the care they received in their home?
A nurse's workload should be structured so that valuable outcomes are demonstrated to the patient, the caregiver, the payer and the employer. This can be done by:
- Informing the patient of his or her rights and responsibilities before care begins
- Understanding the patient's outcome goals and sharing your goals for care
- Educating the patient and/or caregiver that standard precautions and hand washing are performed before and after care is given
- Calling the physician (or other team members) in the home to report changes and coordinate care
- Notifying the patient that you need to look at all their prescriptions and over-the-counter medications and supplements
- Ensuring that the patient is aware you are assessing their home for safety so that they can stay at home, where they want to be, without fear of injury
- Dressing in a professional manner and ensuring your name and title is clearly visible
- Ensuring the patient or family knows how to reach you or your supervisor
- Notifying the patient or caregiver when you will arrive and if you are running late for any reason
- Preparing and reviewing patient information before the visit begins
- Ensuring the patient is informed of ordered care and how you are going to carry out that care
- Focusing care delivery on interventions and goals that relate to desired outcomes and keeping the patient engaged of their progress
- Real-time documentation in the clinical record to ensure accuracy
These measures may seem elementary, but in an environment in which we are facing yearly financial cuts and doing more with less, it is easy to be distracted by daily stressors. Care delivery is not enough-we must ensure value is demonstrated and communicated. We not only know our value, but it is also up to us to ensure that our patients and our industry understand our worth as well.
Jennifer Gibson, RN, HCS-D ICD-10-CM, COS-C, is senior clinical services representative for Axxess and an RN with more than 20 years of home health industry experience. She is a certified OASIS and Coding Specialist.
Mary Naylor, PhD, FAAN, RN, is the Marian S. Ware professor in Gerontology, director of New Courtland Center for Transitions and Health
Patients, family caregivers, clinicians and health care systems each play a significant role in achieving high value health care. The path to this goal is most challenging for vulnerable patient populations with complex health and social needs. Prominent among these groups are older adults coping with multiple chronic conditions (MCCs). Findings from multiple studies have demonstrated that the health needs of this patient group are often poorly managed, commonly resulting in devastating human and economic consequences. As the number of chronically ill older adults continues to grow, what research-based solutions are available to better respond to their needs? What can be done to prepare the current and emerging health care workforce to address their complex challenges? What are the responsibilities of health care systems in assuring person-centered, effective and equitable care for vulnerable older adults and their family caregivers, while enabling wiser use of society's finite resources?
Research-Based Solutions. A robust body of science has uncovered the dimensions of care management for vulnerable older adults that are essential to achieve high value health care and positive health and quality of life outcomes. In brief, effective care management is a process that engages older adults, family caregivers and clinicians in collaboratively identifying patients' needs and in implementing individualized care plans aligned with patients' preferences and goals. We are fortunate to have a number of research-based interventions that have demonstrated better care and outcomes for hospitalized, community-based older adults as well as those receiving care in residential settings. In a few weeks, I look forward to joining you at the 2016 Annual NICHE Conference when I will describe to you the work of a multidisciplinary team of clinical scholars and health services researchers based at the University of Pennsylvania and our efforts to generate, disseminate and translate one such approach known as the Transitional Care Model. I hope to explore with you how together we can promote and accelerate widespread adoption of high value, rigorously evidence-based interventions.
Workforce Development. Successful implementation of evidence-based care management strategies will only be achieved with simultaneous efforts to redesign the workforce. Competencies in areas such as patient and family caregiver engagement, complexity management, palliative care, cultural diversity, team-based care, population health and performance improvement are essential. Based on available evidence, patients, family caregivers, and nurses are and will continue to assume expanded roles and will require additional investment. At the NICHE meeting, I look forward to discussing with you the competencies essential for the existing and emerging workforce to assure high value care for older adults with MCCs.
Health Systems' Accountability. Health systems and their community partners are ultimately accountable for creating the environment essential for high value health care of chronically ill older adults and their family caregivers. The following are a few examples of how systems can support effective care management of older adults with MCCs across the care continuum:
We have much to discuss when we get together at the NICHE conference in April and I look forward to this terrific opportunity.
In today's healthcare environment, workers are being asked to do more with less. See more patients in less time with fewer resources is a common refrain. As reimbursements grow harder to come by, hospitals are tightening their purse strings and looking for more cost-cutting measures.
Linda Boly, RN, an Oregon nurse with 34-years of experience, took a look at her hospital's time and cost-saving measures and said, this is not right. She told management she feared nurses were being made to rush through patient assessments at the price of safety.
This was not the first time Boly advocated for patients' and nurses' rights. Some of her story may be familiar to other nurses. She had been written up for failing to meet productivity quotas and for charting off-the clock. How many of you face similar unrealistic standards? Have you ever entered notes into an EMR after your shift because you chose to spend time caring for your patients instead of staring at a computer screen?
She also fought for Oregon's Nurse Staffing Law, action that got her deemed a "troublemaker." Using real-life examples from her hospital, she twice testified before the state legislature in support of the law. The Nurse Staffing Law mandates that committees made of nurses have the final say in staffing plans, among other safety measures. After her appearances, she began to be written up various infractions.
For speaking up to management about time constraints placed on nurses, Boly was fired in 2013. Two years later, after suing her employer for wrongful termination, a jury sided with her and she won $3 million in damages.
Of course, every nurse who is wrongfully fired might not have the same vindication. Then again, every nurse who questions the status quo might not lose their job. The question is, when you see something that threatens patient safety, what do you do? Do you bite your tongue and not rock the boat? Or do you take a cue from Boly and other nurse advocates and say, "This is not right."
Nurses must ask themselves, What is the price of safety? Standing up for the best interests of patients may come at a cost.
Danielle Bullen is managing editor of ADVANCE for Nurses. You can reach her at firstname.lastname@example.org
Guest editorial by Michael LaFerney, PhD, RN, PMHCNS,BC, Abour SeniorCare in Haverhill, Mass.
2016 is not a good time to be a psychiatrist or psychiatric clinical nurse specialist in long-term care. Long-term care mental care is in crisis. Overregulation, nursing home politics, and ineffective medications are making practicing in this environment difficult. Psychiatrists and psychiatric nurse prescribers are being told to cut medications of all classes secondary to regulations. Pharmacy consultants review charts and make dose reduction recommendations that the psychiatrist must accept or reject and provide documentation for every decision. The volume of paperwork this generates is significant. Behavior management team meetings are now common in most facilties where staff members from directors of nurses to social workers are suggesting dose reductions. While no one denies a multidisciplinary team approach in patient management and treatment is helpful, the psychiatrist can often feel under attack as he/she is the one who has ordered these medications. In addition primary care physicians and nurse practitioners are often are adding and eliminating medications without input from psychiatry. A common practice is for the primary physician to hear that a patient is depressed, start the patient on an antidepressant, and then order a psych consult eliminating the choice available to the psychiatrist. Recently a primary care physician came in and discontinued all anti-anxiety medications with no tapering. Another frequent example is a primary physician will request a psychiatric consultation but not agree with it, then a week later a new consult is put in for these same behaviors. The black box warning on antipsychotics, while needed to protect patients with dementia from severe side effects, is impeding treatment of others. In the haste to reduce or cut antipsychotics, patients with schizophrenia are having their medications reduced, resulting in symptoms to be managed solely by behavioral interventions. Bipolar disorder in nursing homes is not listed as illness where antipsychotics are indicated. Using an antipsychotic for its mood-stabling property or to enhance the effect of an antidepressant is not allowed.
Patients with legitimate psychiatric symptoms such as hallucinations and delusions are denied treatment with antipsychotics even though the benefit will outweigh the risk. Medications such as trazodone are often used where an antipsychotic is indicated.
Denial of off label use is strictly enforced, often leading to conflict between patients and staff. Many patients are prescribed Seroquel for sleep in their community by their prescribing physician. This is often after failing other sleeping pill trials. They enter the nursing home where this drug is not allowed due to it being an antipsychotic. They then get disrupted sleep during a time when they might need it most - in rehab.
In addition to antipsychotic use being cut, regulations are now calling for dose reductions in other classes of medications. Antidepressants must have dose reduction trials twice a year even if the patient is stable. This often leads to decompensating and a kindling effect. Anti-anxiety medications can cause many issues as falls, disinhibition, and increased confusion, to name a few side effects. But there are cases where they may be needed or are tapered too fast to comply with reduction regulations.
Many families and attorneys assigned to represent patients now contest the request of a psychiatrist to use an antipsychotic medication when the psychiatrist in good faith feels it is needed. This delays treatment and often prevents it. Involuntary admissions for patients to gero-psych units are overutilized (1) and patients often return back no better off because the medications and treatments used in these hospital settings are not allowed in long-term care (e.g., benzodiazepines, restraints, antipsychotics). A patient’s delusions may clear up in the hospital on an antipsychotic. As soon as he returns, suggestions start for a dose reduction.
Patients with dementia often voice depressive and suicidal statements. They rarely have the executive functioning ability to carry these out and often forget they may have said it. Many nursing homes respond to this by a “safety first protocol," sending these patients to emergency departments and psych units unnecessarily. These are some of the problems facing psychiatry in the nursing home setting.
There are many others of course that all prescribers face as the prior authorizations, insurance denials, and staff politics.
Psychiatry consultants are often asked to document “resident-to-resident” altercations and other incidents that should be part of or routine patient management and at the time of the event. I am often asked to evaluate incidents that have happened days before and, in the case of patients with dementi,a already forgotten about. These notes are requested because we have to “notify the state.”
A final issue I will bring up is the perception (or reality) that the drugs available in the nursing home settings for patients who are elderly and with dementia are not all that effective.
Antipsychotics have the black box warning that they are not indicated for the treatment of psychotic symptoms in patients with dementia. Recent studies indicate antidepressant use is linked with increased atherosclerosis (2); a limited benefit in dementia patients (3); and increased risk for death, stroke in postmenopausal women (4). Antidepressants may only be effective in treatment of the severest depression (5), and citalopram linked to abnormal heart rhythm (6). Is their use helpful or creating more medical problems for patients?
Cholinesterase inhibitors and Namenda have proven to provide little benefit in nursing home patients. (7) Studies also indicate mood stabilizer effectiveness for the treatment of behavioral incidents in patients with dementia is limited and may be harmful (8). Other non-medication treatments as psychotherapy and counseling may have value in the patients without cognitive deficits, but patients with these deficits make up the majority of patients in many nursing homes.
I find working in long-term care mental health frustrating but rewarding. Changes are needed in the current policies that increases costs, take up time and, can destabilize patients. Hopefully, the future will bring new policies, treatments, and medications to further aid this challenging population.
1. LaFerney M. In/Voluntary Admissions. ADVANCE for Nurses. 2006;6(8):35.
2. Shively C, et al. Effects of long-term sertraline treatment and depression on coronary artery atherosclerosis in premenopausal female primates. Psychosomatic Medicine, April 2015 DOI: 10.1097/PSY.0000000000000
3. Banerjee S, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial. The Lancet, 2011:378(9789),403-411.
4. Medscape. Antidepressants linked to increased risk for death, stroke in postmenopausal women. http://www.medscape.org/viewarticle/714315
5. Fournier J, et al. Antidepressant drug effects and depression severity. JAMA, 2010;303(1):47-53. DOI:10.1001/jama.2009.1943
6. FDA. FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide). http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm
7. Laferney M. Testing and monitoring: Essential for cholinesterase inhibitors. http://www.reflectionsonnursingleadership.org/Pages/Vol37_2_Col_LaFerney_testing.aspx
8. Xiao H, et al. A meta-analysis of mood stabilizers for Alzheimer's disease. Journal of Huazhong University of Science and Technology. Medical Sciences 2010;30(5):652-658.
Guest editorial by Debbie Moore-Black, RN, ADN, charge nurse/staff nurse at Pineville Medical, Charlotte, NC, and Devin Black, BA, at the Center for Behavioral Health, North Charleston, SC.
She came rolling into the ICU. Intubated, chest tube, restraints, propofol, fentanyl and Levophed drips infusing through her veins. Her blood pressure is low, we pour normal saline IV into her veins as fast as possible. She's only 28 years old.
She crossed the median of the highway int the oncoming traffic. Barreled into four vehicles, randomly. She sent three people to the ED. One young father is dead. Her hair is filled with shattered glass; her face has lacerations. She has a tension pneumo.
The ED nurses and doctors are on high alert, and she is emergently intubated, a chest tube is inserted. The nurses give her drugs to slow her respirations, restrain her to make sure she doesn't pull out her endo-tracheal tube.
She was a young mother, not ready for the real world. Had minimal support. A boyfriend that drifted in and out of her life. When her little boy was 4, she picked him up when he was crying, he jerked out of her arms, and she pulled a sciatic nerve in her back. Severe back spasms set in.
She moved furniture, hurt her back again, and a period of strange "events" kept happening, where her back "gave out." So she went to her physician. She said her pain was a "10". He wrote her a prescription: hydrocodone. It worked pretty well, but not good enough. Then she graduated to oxycodone. Oxy was good. Drifting off on the couch, pink clouds, angels, rainbows, and the pain was gone, emotionally and physically. It didn't matter that Timmy was in his crib crying because he was hungry, it didn't matter that the sink was piled high to the ceiling, it didn't matter that she missed several days of work. Two tablets every day, grew to three tablets a day. And it was never enough. She needed more. After a year, Jen needed more. But her MD said he was unable to write her any more prescriptions. And so after one year of chewing down her oxycodones, she was without for 18 hours. Her boyfriend would supplement her with drugs being sold on the street, but it was $30 a pill. Jen ran out of money, and she ran out of pills.
Covered in sweat, stomach churning, goose flesh skin, restless legs. She was in withdrawals. She haphazardly roamed the streets and there it was. Magic. Black. Black tar. He said half a gram of heroin is $80. That was cheaper than the $120 it took to get Jen through the day.
She wrapped the belt around her upper arm. The syringe was loaded. He inserted the needle in her arm, and pushed. Suddenly, she was wrapped in a warm hug in the clouds of heaven, suddenly everything was OK. There was no pain, no sadness. Jen was euphoric.
And Jen did this whenever she could. Whenever she had the money, or "found" the money.
But this time, after shooting up, she jumped into her car. Driving, on the highway, her head tilted back as she felt that rush go through her veins. And she drove, unaware of driving ... and she plowed into four cars. Four cars totaled, three people sent to the ED, one man dead. Blue lights, red lights, ambulances, police, fire department, people gawking on the sidelines.
And you wake up in the ICU; several weeks have gone by. You are out of your coma, chest tube pulled, breathing tube gone. And you squeeze my hand, and ask where you are.
How do I tell you that you put three people in the hospital? How do I tell you that Social Services has your little boy? How do I tell you, you no longer have an apartment? How do I tell you that you killed a man? An innocent man, driving home from work to his wife and three children.
Could she even put these pieces back together again? Rock bottom.
With the assistance from her doctors, nurses, counselors, rehab, Jen slowly, painfully pulled her life back together.
Not everyone makes it.
Three months later, Jen came back to the ED. DOA. Body bagged. Famous deaths by heroin: River Phoenix, John Belushi, Janis Joplin, Jim Morrison, Sid Vicious, Cory Monteith, Dee Dee Ramone, Philip Seymour Hoffman, Chris Farley.
Non-famous deaths: Over 8,200 deaths in 2013 per the CDC. Every day, 44 people in the U.S. die from overdose of prescription painkillers, and many more become addicted.
Greatest risk: prescription opiods, painkillers such as codeine, fentanyl, hydrocodone, Demerol, morphine, methadone, oxycodone and dilaudid.
Treatment: Recognize and acknowledge your problem. The WILL to quit. Drug treatment centers. Psycho-therapy. Drug rehab. Methadone clinics. 24/7 hotline: "Narcotics Anonymous: 1.888.827.7180. Educate yourselves, give out this number. If "they" don't quit heroin, the alternative is death.
November is National Hospice and Palliative Care Month, and I would like to share an open letter to all the nurses, social service, home health aides, chaplains, volunteers, and office staff who work every day to make Hospice care a seamless transition at end of life.
To My Dear Hospice and Palliative Care Workers:
- For all the times you answered your phone, thank you
- For all the paperwork and explanations, thank you
- For coordinating beds, supplies and wound care, thank you
- For taking time in your day to ask how my family is, thank you
- For all the meals you missed while working to make "healthcare" happen for us, thank you
- For all the phone calls you've made, agencies you've contacted referrals you completed, thank you
- For all the tender care you provided my loved one, thank you
- For including massage therapy, healing touch and giving me a peaceful presence, thank you
- For sending me memorial cards and hand writing them, thank you
- For remembering my loved on in your ceremonies during the holiday, thank you
- For helping me to organize my life both during and after those final hours, thank you
- For teaching me it's okay to be happy and laugh in times of grief, thank you
- For crying with me, thank you
- For your follow up care and bereavement, thank you
- For including me and my loved one in your prayers, thank you
Some nurses ask, "How can you work in Hospice?"
Our response, "How can you not provide a beautiful end of life experience?"
Hospice and Palliative care staff work to create the best end of life experience for the patients as they move from this world to the next. We don't choose to work in Hospice, Hospice has called us to work
Happy Hospice and Palliative Care Month!
Karen Gagliardi MSN, CRNP, Holy Redeemer Home Care and Hospice
This guest post is written by Lisa Wolf PhD, RN, CEN, director, Institute for Emergency Nursing Research, Emergency Nurses Association
Moral distress as it is currently understood in nursing has been studied in many settings, but there is a lack of research on the nature and content of moral distress as it manifests in the emergency department (ED).
Moral distress has been described by Corley and colleagues1 as "the painful psychological disequilibrium that results from recognizing the ethically-appropriate action, yet not taking it, because of such obstacles as lack of time, supervisory reluctance, an inhibiting medical power structure, institution policy or legal considerations." Because researchers find a relationship between moral distress and aspects of burnout, nursing retention and job satisfaction, this is an important area of study.
To investigate moral distress among emergency nurses, we conducted a qualitative exploratory study in which 17 nurses participated in two focus groups held at the Emergency Nurses Association's 2014 Annual Conference. The nurses had an an average of 24 years of experience in nursing and 19 years of experience in emergency nursing.
Overall, nurses in the study described a profound feeling of not being able to provide the quality of care they believed patients deserved. They told us about "challenges of the emergency care environment" that included staffing levels, quality and safety of patient care, the use of technology and conflicting expectations of the nursing role. "Being overwhelmed" included categories concerning frequent users, time pressures and patient volume and flow. "Maladaptive/Adaptive/Coping" included categories referring to emotional fallout, physical symptoms and stress management strategies.
What we found was that unlike in the ICU and other care areas, where sources of moral distress were interaction-based (ie, conflicts between particular nurses and patients, or nurses and families, or nurses and physicians), feelings of moral distress in the ED centered on the practice environment itself.
Nurses reported physical manifestations of moral distress that included disturbances in sleep, food intake, and complaints of gastrointestinal (GI) distress, fatigue and high blood pressure. The emotional repercussions of moral distress were reported as helplessness, despair, complacency, burnout, emotional withdrawal, anger, depression/anxiety and desire to leave the job. Nurses reported coping with this distress by using "positive" mechanisms such as training for a triathlon, or unit support groups, but also reported using less positive coping mechanisms such as alcohol and food to mitigate the feelings of moral distress.
There are two really important implications of this study, for both emergency nursing specifically as well as nursing as a discipline: the first is that for emergency nurses, the cause of moral distress is an inability to provide care to the standard they see as a disciplinary obligation, stemming from a lack of resources and support. In short, the factors in moral distress are environmental, and therefore the solutions must also address the work environment.
The second implication is that nurses describe high levels of "moral residue," or lingering moral distress, from what appears to be an almost continuous series of compromising events and lack of external support, or capacity, to remedy the way in which care is provided. This leads to burnout and compassion fatigue, and ultimately patient care suffers.
The issue of moral distress affects both nurses and their patients. Addressing the individual and environmental factors of moral distress may lead to a healthier work environment and better patient care.
1. Corley MC, Elswick RK, Gorman M, Clor T. Development and evaluation of a moral distress scale. J Adv Nurs. 2001;33(2):250-256.
Guest editorial by Matthew F. Powers, MS, BSN, RN, MICP, CEN, president of the Emergency Nurses Association, the leading nursing association serving the emergency nursing profession through research, publications, professional development, and emphasis on quality and patient safety.
A trip to the emergency department can be a stressful event for any patient just given the fact they are sick or injured. As emergency nurses, we are on the front line helping patients to remain calm and get the care they need. But what happens when something avoidable goes wrong and it turns into an even more traumatic situation? For a transgender patient, this is often a reality.
According to a 2011 study (Injustice at Every Turn: A Report of the National Transgender Discrimination Survey, 2011), nearly 30 percent of transgender people report harassment or violence during their medical visits, and 33 percent of transgender people postponing medical care as a result of these implications and dangers.
These statistics are unacceptable. It's crucial for us, as emergency healthcare professionals, to provide care to transgender patients that's proactive, accurate, compassionate and considerate, as we strive to treat all patients the same without judgement
In fact, new research from the Journal of Emergency Nursing highlights the importance of acting appropriately when caring for transgender patients in the ED. The article chronicles the experience of Brandon James, (a pseudonym), in an American ED in 2015. According to the case study, the patient's ED visit was filled with situations that a transgender person might experience with ED personnel who are unfamiliar with treating transgender patients.
For instance, James, a masculine transgender man who transitioned using hormone replacement therapy five years before his ED experience in 2011, describes his check-in process as humiliating. When James presented his driver's license, which identified him as a female, he was met with staff debating his gender aloud and pulling in an additional two to three people to assist him. This occurred despite the fact that his electronic medical records from previous hospital visits included female gender markers. James describes feeling like a "freak show at the circus."
After waiting several hours to be treated, a nurse who listened to James' friend recount the check-in experience apologized and validated their experience. It's critical for all nurses to take actions like this to make sure every patient's dignity is preserved.
James' story identifies new implications for emergency nursing practice when treating a transgender person, as nurses today care for an increasing number of transgender patients. Nurses and their ED colleagues must understand how to give these patients the care and respect they deserve.
Here are a few important takeaways from James' story that emergency nurses should consider when caring for transgender patients in the future. Nurses should take these steps to provide a high-quality and comfortable experience for the transgender patient:
Ask the person how they would like to be addressed. In the case of Brandon James, many insensitivities could have been avoided if the ED staff member asked the patient how he would like to have been addressed.
Use the proper pronoun. When speaking to a transgender patient, use the pronoun that matches the gender to which he or she currently identifies.
Keep conversation clinical. Only ask clinically relevant questions during the examination of a transgender patient as one would with all patients.
Be sensitive to shared spaces. When taking a transgender patient into an area of the ED where he or she might share a space with another patient, keep gender to which he or she identifies, top of mind.
Lead by example. Because nurses are on the front lines of patient care in the ED, they should take a leadership role in showing respect to all patients regardless of how they identify themselves, and step in to help defuse any sensitive situations they observe.
James' story is told in the article, "I Was a Spectacle...A Freak Show at the Circus: A Transgender Person's ED Experience and Implications for Nursing Practice," to prevent similar events from happening in EDs across the country. You can find the full article here.
Guest editorial by Stacy Slater, MSN, BS, RN-BC, Revenue Cycle Coordinator, Munson Healthcare, Traverse City, MI
Pay-for-performance, value-based purchasing, the triple aim of healthcare, HCAHPS, volume to value - Nurses need, at the very least, a rudimentary understanding of these terms and how the care they provide directly affects reimbursement and how reimbursement impacts the care they provide to their patients.
What is this: The two main goals of the Patient Protection and Affordable Care Act of 2010 are reforming health insurance (the Marketplace) and reforming delivery and payment systems (pay-for-performance). Pay-for-performance is the reimbursement model that Medicare is using to drive the triple aim (improved value, improved outcomes, and improved patient experience). Value-based purchasing is just one of the elements of pay-for-performance.
What does it mean and how does it impact nursing: Value-based purchasing (VBP) is a method of payment that involves penalties or incentives. This method allows CMS to "purchase" value when it pays for healthcare versus paying for services based on volume or "fee-for-service." Currently, all healthcare providers that participate with Medicare are transitioning from volume to value. One of the measures of the VBP program is patient experience. The patient satisfaction scores, measured via the Hospital Consumer Assessment of Healthcare Providers and System (HCAPHS), surveys inpatients post discharge and includes questions that are directly related to nursing care. Questions such as nurse-patient communication, how well pain was controlled, quietness and cleanliness of the patient's room, how well discharge orders were understood, responsiveness of staff, and communication about medications. The quality of care that nurses provide can be measured and can be positively reflected in patient outcomes and payments received by the health system. This collaboration between nursing and finance can lead to improved patient outcomes and improved value.
In her blog, Pamela Austin Thompson, chief executive officer of AONE, eloquently states the need for nursing and finance to be on the same team. To prevent patient care from becoming secondary to reimbursement, we need nursing professionals who understand finance and the financial impact of clinical decisions, and financial professionals who understand how cost-reduction measures impact the delivery of patient care.
This is our time to shine and step out front - nurses and the quality of care that we provide can improve the value of care, improve patient outcomes, improve the patient experience and in essence be the drivers of healthcare reimbursement.
Editor's Note: This guest post is written by Veronica Gutchell, DNP ‘13, RN, CNS, CRNP, assistant professor, University of Maryland School of Nursing
On any given night, about 3,000 people in Baltimore experience homelessness. To help with this ongoing problem, University of Maryland School of Nursing (UMSON) faculty members Katherine Fornili, MPH, RN, CARN, assistant professor, and Rosemary Riel, MAA, clinical instructor and associate director, Office of Global Health, and I participated in the Baltimore City Point in Time count last winter. We worked with both sheltered and unsheltered individuals. The data from the count is used to advocate for resources, plan programs, implement policies to address homelessness, and evaluate the use of existing resources and programs.
I came upon this opportunity through the Global Health Certificate program at the University of Maryland School of Nursing. The Global Health Certificate program helped me think about my practice through the lens of social justice. It challenged me to understand my own biases and how they impact my practice as a nurse practitioner. Using the lens of social justice changed the way I work with underserved patients in primary care.
We spent a lot of time in the certificate program focusing on the social determinants of health and then we applied those concepts in a field placement experience. Going abroad for four to six weeks didn't work for my life at the time, so I asked for the opportunity to practice applying the social determinants of health locally.
My assignment addressed the issue of homelessness in Baltimore. Through the faculty's network of contacts, I was introduced to some very talented people at Health Care for the Homeless, a nationally-recognized model for the delivery of health care to those experiencing homelessness. Through Health Care for the Homeless, I was able to work on a project to start up a mobile clinic program. The mobile clinic delivers primary health care to those experiencing homelessness in Baltimore and surrounding areas.
In researching my project proposal, I came across 2013 data from the Mayor's office on the Baltimore City Point in Time Count. After my field placement was completed, and I presented my experience, a colleague talked to me about volunteering for the next Count. I was immediately interested in organizing volunteers from UMSON, so I sent an email to the School's faculty and staff announcing a service opportunity. Nine people responded and three of us ended up being able to participate. The organizers needed most volunteers for the overnight count and it turned out that the three of us were able to volunteer for both nights.
The Count involved conducting a survey to try to better understand who experiences homelessness. For example, from the 2013 Count, 52 percent of respondents reported a history of mental illness, 56 percent a history of substance abuse, and 11 percent indicated they were veterans. This information helps communities determine how to tailor services to those in need.
Questions on the 2015 survey looked at mental illness, substance abuse, Post Traumatic Stress Disorder, and veteran status. Additionally, there were questions about previous experience with trauma and how long an individual had been experiencing homelessness. Almost every person I surveyed agreed to participate. I even had one individual who was sleeping on the street in 27-degree weather say "God bless you."
The experience of homelessness can seem overwhelming. Even so, I feel optimistic about the goal of making homelessness "rare and brief." Journey Home Baltimore, the organizers of this event, estimates over 300 people volunteered to help with the 2015 count. I'm hopeful because there are a lot of people who cared enough to come out in the middle of two cold winter nights to conduct this important survey. The volunteers were a widely diverse group of community members; for me, there's something moving and promising about that. I am inspired by those who dedicate their professional lives and those who volunteer to make homelessness a temporary experience for individuals and families. It's that work and commitment that keeps me encouraged.
Editor's Note: This guest post is written by Lisa Bingham, MSN, RN from Newburg, Oregon. She has been a registered nurse for 18 years and is currently pursuing her FNP from Gonzaga University
I fully support the idea about leveling "the playing field" when it comes to requiring advanced degrees for nurses to practice. I believe that my advanced education has greatly improved my nursing care; however, there is very important aspect related to this debate that is often neglected.
One of the problems with requiring advanced degrees for nurses, is, according to the American Association of Colleges of Nursing (AACN), we not only have a nursing shortage but a faculty shortage as well. As a recent nursing faculty member, I can tell you that I worked in one of at least 700 nursing schools with vacant faculty positions (http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-shortage). Although the average salary of a nursing instructor is slightly over $78,000 per year, I was making a little more than half that amount and working every day of the week to prepare my students for the workforce. When my students graduated and obtained a job, they made more money than I did. A nurse practitioner, who also requires a master's degree, averages over $91,000 per year (http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-faculty-shortage).
Compensation, although important, is not the most important aspect of a career. As I previously stated, I worked every day. I am an organized person by nature, but not only were there papers to grade and research to be done in order to prepare for lectures and clinical experiences, in an academic setting service is a requirement of scholarly research and publication in order to gain promotion. There were often marathon faculty meetings as well as hours of advising of students. Most of the time, it feels like you don't get to spend enough time with working with the students which is the whole reason you started teaching. People say, "Well, you get the summer off." Again, we are doing research, service and preparing for the next academic year. We are volunteering at new student orientations and academic advising for the incoming freshmen and transfer students.
I am not complaining about the job as I loved spending time with students, but I am trying to show that there is much more to being a nursing faculty member than working 12 hours and then going home. (I'm not saying that working a 12 hours shift in a hospital is not difficult). I also have a spouse and four children. I had to stop working as a nursing faculty in order to be present with my family. I now have a part-time nursing position in which I spend 24 hours and make more money per hour than I did as a nursing faculty.
The compensation for the amount of hours that a nursing faculty is required to spend is not adequate. Until this is remedied, requiring advanced degrees for nurses is going to be an uphill climb. It's a wonderful idea and has been shown to improve patient outcomes, but thought needs to be put toward nursing faculty retention and compensation in order to make advanced practice degree requirements work.
Editor's Note: This guest post is written by Kathy Eliscu, BA, RN, who worked more than 30 years as a nurse in maternal/child health, office nursing, school nursing, and psychiatry at a major mental health clinic.
After 30-plus years in nursing, I've accumulated plenty of stories. You get it, if you've been in nursing for a while. Like for at least a week.
In the first decade, nursing experiences floated through my mind like sand pebbles dumped from shoes after an afternoon at the beach. I was aware of them, but didn't put them much into conscious thought, since my brain was already figuring out a grocery list for the way home and wondering if pizza and ice cream for the fourth night in a row was really such a bad thing. Wait. There were a few outstanding memories - some of us who have been nurses for a long time will recall - when being hollered at by a doctor was not uncommon, when working night shift meant cleaning up the floor after a delivery and checking on mom and baby in between swipes of the mop. And, of course, there are the tender recalls of the gift of truly being present with a patient, the basics of helping, which brought most of us into the profession in the first place.
There have been controversies around union issues, the transient, occasional lateral violence between nurses ... there are probably few experienced nurses today who don't have stories to tell.
Then came the big insurance changes - more restrictions on hospital stays, the advent of prior approvals for treatments and certain medications, often shifting the day-to-day focus of nurses. For me, time spent with patients was greatly reduced due to increased time on the phone with insurance companies and an increase in staff meetings largely focused on keeping up with regulations and the changing systems required to do that. At times, it all seemed so ridiculous. BECAUSE IT WAS.
It wasn't long before I began to imagine humorous scenarios beyond the agony. It was either that, or consume large quantities of chocolate at eight in the morning. Sitting through what once seemed largely patient-focused meetings now felt like board meetings, with graphs and charts and outcomes - yes, there were lots of numbers. Big numbers, small numbers, scary numbers. The way of corporate thinking had reached medicine in a big way. I'd look around the room: 20 or 30 professionals crammed into a classroom, eyes glazing over watching a powerpoint presentation filled with statistics. It made me want to run home to take a shower. Soon, I couldn't help myself from looking at nearly everything more critically, and thankfully, with laughter. For now, I was also dealing with my the middle years, complete with aging parents, a child still in college, my inability to say no when someone needed a favor ... and I began to imagine "what if" scenarios. I confess I may have missed a few of the important facts of some of the unending "initiatives" at these meetings. But using humor as a tool for coping with the boredom and get-me-outta-here thoughts each time actually gave me all the more smiles and charity for when I did - finally and blessedly - get to actually interact with a patient.
Not Even Dark Chocolate Can Fix This Mess is fiction. It's the wildly, silly story of a woman who nurses by day and crams her overwhelmed life into the rest. She gets roped into doing a good deed for her niece and in her constantly-overwhelmed state, ends up making a huge, embarrassing mistake. Even though she's tried all that deep breathing stuff. Friends, you will learn nothing from this novel. But it will give you some much-deserved laughs. You've earned it.
Now, pay attention to the powerpoint. And nod slowly up and down. It looks good.