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ADVANCE Perspective: Nurses

Remembering the Boston Marathon -- One Year Later
April 15, 2014 11:22 AM by Guest Blogger

Karen Pischke, BSN, RN, CCRN, RMT, CHT, TTS, is a regular contributor to ADVANCE, and is a Reiki practitioner.

"There but for the Grace.... " 

April 15, 2013, I was making a bee-line to the finish line when I looked back over my shoulder and paused. I took a few steps back to the corner of Hereford and Boylston, taking photos of runners coming around the bend to cross the finish line. Ten minutes later (time stamped on my camera) we hear the 1st explosion.

One year later, sights and sounds of the next few hours still ringing in my mind.

Stopping for those 10 minutes may have saved my life. For the next few hours, I was there with friends trying to find out if loved ones were okay, not knowing what might happen next. I was there 'with Reiki,' feeling a surreal sense of calmness. Hoping to bring a sense of 'peace and calm,' and help in some small way to find order in the midst of chaos and uncertainty. 

Today as I reflect, I think about the people I met that day, those impacted, my family, friends and co-workers that were there, most safe, some injured. Lives changed. Some lost. Sending prayers, positive thoughts and Reiki to all those impacted. Honoring the strength, courage, and resiliency of those that survived.

Feeling very grateful today.    

Hourly Rounding Improves Patient Care
April 15, 2014 7:46 AM by Guest Blogger

By Lauren Petrillo, MSN, RN-BC

As nurses, we are charged with the responsibility of ensuring patient safety and improving patient satisfaction. Although at first it may seem like another task to add to the list, hourly rounding can help us achieve these goals while also organizing our workflow. Hourly rounding, or checking on the patient at regular intervals to assess the 4 P’s- pain, position, potty and proximity of personal items, does not have to be done by the RN alone. Sharing the responsibility with the CNA is a good way to avoid becoming overwhelmed. For example, RNs can check on the patients on even hours and CNAs on odd hours (Halm, 2009).

Hourly rounding has been shown to decrease call bell usage, improve patient satisfaction and decrease falls rates (Olrich, Kalman & Nigolian, 212). These are three things that nurses are always striving to do! By planning ahead and performing hourly rounds while clustering tasks such as pain assessments and medication administration, nurses can achieve goals while organizing their workflow and becoming more efficient with time spent in patient rooms. When the patient knows when to expect someone back in his/her room, he/she is less likely to press the call bell, thus limiting interruptions to the nurse’s workflow.

Hourly rounding is a multidisciplinary action which can help improve the patient experience. By assessing patient needs on regular intervals, the patient is more satisfied, less likely to call and less likely to fall. In my institution, we hold each other accountable for performing hourly rounds by having a sheet in each room where the staff member making rounds on that patient can initial in the space next to the corresponding hour. We hold each other accountable by reminding each other to make rounds and passing along messages regarding patient needs discovered during rounds to the appropriate staff members. Making this a shared responsibility helps improve teamwork and benefits everyone.

Lauren Petrillo s a senior staff nurse at New York-Presbyterian/Weill Cornell Medical Center, New York City.

Halm, M. A. (2009). Hourly Rounds: What Does the Evidence Indicate? Am J Crit Care,18, 581-584.
Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly Rounding: A Replication Study. MESURG Nursing, 21(1), 23-36.


Do Cell Phones Belong in the OR?
April 3, 2014 2:15 PM by Robin Hocevar

If there’s any question about our collective dependence on cell phone, Peter J. Papadakos, MD, FCCM, FAARC, anesthesiologist and director of critical care medicine at University of Rochester Medical Center in New York, created a symptom checklist. You may recognize the questions, as they’re adapted fror the screener for alcohol addictions.

·         Have you ever felt a need to cut down on use of your personal electronic device?

·         Do you reach for the cell phone first thing in the morning?

·         Do people annoy you by criticizing your use of a personal electronic device?

·         Have you felt guilty about your overuse of your personal electronic device at work?

At the conclusion of its 2014 Surgical Conference and Expo, the American Association of periOperative Nurses (AORN) approved a position statement on distraction and noise in the operating room. The paper recognizes critical phases in surgical procedures like time out period, critical dissections, surgical counts, confirming and opening implants, care and handling of specimens and induction and emergence from anesthesia when the environment should be as quiet as possible.

Though cell phones aren’t the only distraction, Donna Ford, MSN, RN-BC, CNOR, CRCST, member of AORN’s clinical practice committee noted a surge in use of personal electronic devices in hospitals. She presented a 2012 statistic affirming that 80% of doctors use cell phones in the hospital.

Just this year, the Pennsylvania Patient Safety Authority’s report concluded 13 serious events could be attributed to technology distraction.

“The more distractions we have, the less time we’re spending running through the items on our safety checklist,” said Ford. “The checklists were created to have the opposite effect and give us a reason to stop and think.”

Judging by the crowds surrounding the Google Glass display at AORN, technological devices in the OR aren’t going away anytime soon.

AORN now joins the American Association of Nurse Anesthetists (AANA) and American College of Surgeons (ACOS) in crafting official positions on OR noise and cell phones in particular. ACOS said OR noise disrupts doctors’ auditory processing ability.

That’s not to say cell phones in the OR can’t be useful. Approximately 25% of the audience in a one of AORN’s highlight sessions on this topic said doctors ask nurses to text, not page, them when the surgical suite is ready. Others use medical apps.

The clinical application of cell phones makes it hard for institutions to verify staff violations, said one attendee. Many accused of using their phone unnecessarily say they were communicating with the doctor or looking up information. Short of confiscating phones and reviewing data history (which can be subpoenaed should a lawsuit occur), managers grapple with enforcing policies.

Then there’s the issue of handling the doctor’s phone.

“Somehow, nurses have become the gatekeepers of doctors phones and it’s affecting our practice,” said an audience member, who was applauded for voicing this concern. “Someone else needs to absorb this responsibility because it’s become a patient safety issue.”

Obviously, banning phones in hospitals isn’t realistic. Is cell phone use by staff a problem in your facility? What policies have been effective in governing cell phone use?

Will Banning ‘Bossy’ Make Better Nurse Leaders?
March 31, 2014 4:21 PM by Linda Jones
As a primarily female industry, nurses should have a lot to say about the movement to ban the word bossy as a way to "empower girls to lead."

Sheryl Sandberg, the COO of Facebook, claims that when used to describe young girls, bossy is a negative put-down that prevents girls from pursuing leadership. Sandberg has gotten support from former Secretary of State Condoleezza Rice and Girl Scouts CEO Anna Maria Chávez, among others. They've launched a public service campaign to make the change (see banbossy.com).

Do they think banning this word will solve gender inequality, which is ultimately what they are aiming for? I know their plan is not quite that simple, but that is the basis of it.

I agree there may be a time in a child's life when name-calling (or exclusion, or any of the other things kids do to each other), shapes a child's behaviors or actions. But it can happen to both boys and girls, and in many cases it probably has a momentary impact. The reasons why girls become less assertive in different phases on their development is much more complex than name calling. Plus, how many times have negative situations actually made people stronger?

Girls (or boys) who are bossy are not going to stop being bossy just because we can't call them that. Their bossy behavior won't be rewarded so how is this ban empowering girls to lead?

In a commentary on the movement, Yahoo Finance blogger Jeff Macke noted, "Children are leaders if others follow them and bossy if they push other kids around inappropriately." It would be more proactive to teach girls how to be leaders and to show them role models of female leaders - and to show them the difference between being bossy and being a leader.

Assertive females are threatening to some people and the words used to describe them often begin with B. They may not be nice, but assertive women - and especially if they are also leaders - can take it. We describe pushy boys and assertive men in business with insulting words, too and they start with a variety of letters.

Words have definitions, people give them meaning. Let's teach our youngsters to be respectful to each other and encourage them to be cooperative. And when we see a leader emerging, whether it's on the playground, in the classroom or in the workplace, let's give them the tools to succeed.

"I was called bossy when I was in ninth grade," Sandberg recalled ... Today she's the COO of Facebook. Sounds to me like bossy worked for her.

Instituting Controversial Bans on Hiring Smokers
March 25, 2014 6:28 PM by Guest Blogger

By Anny Su, BSN, RN

Approximately 45.3 million people smoke in the U. S. (CDC, 2008) Many of these smokers seek employment in healthcare institutions. Within the past 6 years, healthcare institutions have stepped up to challenge this unhealthy behavior by instituting controversial bans on hiring smokers with the goal of stigmatizing smoking further.

The message is clear: If you want a job, either do not smoke or quit smoking now.

Cigarette smoking is the leading preventable cause of death and is attributed to more than 440,000 deaths per year. (CDC, 2008) Decades of research have been invested into finding successful interventions to increase overall smoking cessation rates and reduce rates of relapse, thereby sustaining those quit rates for the long term. Studies show that while there may be effective ways to get individuals to stop smoking, rates of relapse can reach upwards of 80%. (Hajek et al., 2013) Furthermore, no type of intervention, behavioral or pharmacological, is more effective than the other when it comes to long-term smoking cessation. (Cahill, Moher, & Lancaster 2008; Cahill et al, 2013) Even the most successful of interventions in smoking cessation, cash or voucher incentives, did not have any long-term effect. (Cahill & Perera, 2011) Although controversial, banning the employment of smokers at healthcare institutions is a necessary measure that eliminates the choice of smoking, motivating people to quit smoking and to avoid picking up the habit.

From an employer’s perspective, a ban on hiring smokers makes sense when it comes down to numbers. Employers can be indirectly, but substantially, affected by having smokers as employees. Smokers take on average 11 more sick days a year (Lundborg, 2007) and amount to lost productivity of over $4,000/year for current smokers. (Bunn, et al, 2006) Alternatively, workplace productivity was increased and absenteeism was decreased among former smokers compared with current smokers. (Halpern, Dirani, & Schmier, 2001) From a nonsmoker’s perspective, the effects of smoking from an environmental standpoint are real. Patients receiving care can be put off by the smell of second hand cigarette smoke in their surroundings. A more recent discovery is called third hand smoke, tobacco residue that lingers the environment days to weeks after the smoker has left. This exposes nonsmokers to carcinogens that can build up over time despite cleaning efforts and has the real ability to cause significant damage to one’s DNA (Hang et al, 2013).

Opponents denounce the ban as being unethical. Smoking is an addiction, and it is blatant discrimination to not hire someone on the basis of a behavior not necessarily born out of personal choice. Smoking is disproportionately associated with individuals of a lower socioeconomic status. To ban smokers from employment is further injustice to a population most in need of employment. However, smoking can be disruptive to work performance. This is particularly true when an individual is experiencing such withdrawal symptoms as irritability, poor concentration, and emotional lability. Many would also argue that the danger of exposing patients to secondhand or third hand smoke, and/or the less than optimal care from an individual experiencing nicotine withdrawal interferes with the quality of patient care provided. Health care workers have a professional responsibility to another’s well-being and healthcare institutions must ensure that providers are providing that quality care.

Another argument posed against the ban is that it is hypocritical of an institution whose mission is to provide care for those who have illnesses as a result of health-related behaviors such as smoking, while simultaneously punishing them by denying them jobs, regardless of capability or merit. Such a ban creates a slippery slope for hiring practices as employers in the future could very easily implement hiring bans against those who drink alcohol, have unhealthy diets or are obese. It would seem more successful if employers were to offer workplace cessation support which could not only help them to quit smoking but could also potentially increase productivity and morale by creating an environment in which the employee feels supported and valued. Unfortunately, workplace health promotion programs have shown small effects in healthier behaviors (Rongen et al, 2013).

While workplace interventions for smoking cessation increase one’s likelihood of quitting, the actual sustained quit rates are low. (Cahill, Moher, & Lancaster, 2008) Other less stringent alternatives to discouraging smoking and/or motivating smokers to quit such as imposing campus wide smoking bans have shown little promise (Ripley-Moffitt, et al, 2010). Despite decades of research and experimentation, nothing has been found to drastically cut down smoking rates. Bans on hiring smokers at hospitals could be the answer to combatting the unhealthy behavior once and for all and for the greater good.

Healthcare facilities should be the role models for healthy behaviors and it is entirely within an employer’s right to determine what kind of work environment they want to create for their employees and for the services they sell. Employee absenteeism, productivity losses, and increased insurance costs due to smoking-related illnesses are costly to employers. Patients and other nonsmokers have the right to clean, non-toxic working environments. While bans on hiring smokers by healthcare institutions are still too new to show whether they will actually lead to lower rates of smoking, they provide compelling reasons for individuals to either quit smoking or to not pick up the behavior in the first place. As healthcare providers, it would be hypocritical, unprofessional, and dishonest to promote healthy behaviors but to not follow our own advice.

Anny Su is a 2014 Family Nurse Practitioner MSN candidate 2014 at the University of Pennsylvania School of Nursing, Philadelphia.


Reflection Is a Powerful Teaching Strategy in Nursing Education
March 18, 2014 3:12 PM by Guest Blogger
 By Kimberly Raines, professor in the nursing program at American Public University

When I first began teaching nursing some 16 years ago, I saw that nursing students are frequently overwhelmed by the fast-paced events that make up the daily reality in our complex and demanding healthcare environment. There is little time to stop, take a breath, put the puzzle pieces together, and formulate a plan.

Even for experienced nurses, there is little opportunity to take a time-out to think about the next steps in patient care. However, studies show that incorporating reflection into one's practice is a critical step in becoming an expert nurse.

Some compelling findings are found in E. Davies, "Reflective practice: A focus for caring," published in the Journal of Nursing Education; Jack Mezirow, "On critical reflection," published in Adult Education Quarterly; and E Shields, "Reflection and learning in student nurses," published in Nurse Education Today.

Kuiper and Pesut, in "Promoting cognitive and metacognitive reflective reasoning skills in nursing practice: Self-regulated learning theory," published in the Journal of Advanced Nursing, proposed that guided, structured reflection is especially beneficial to the novice practitioner because the necessary skills to analyze nursing practice are not yet in place.

There may be a link between improved patient care and reflective practice in complex care situations as explored by Stephen Brookfield in "The concept of critically reflective practice" in the Handbook of Adult and Continuing Education. Reflection narrows the gap between theory and practice according to Lisa Ruth-Sahd, "Reflective practice: A critical analysis of data-based studies and implications for nursing education," in the Journal of Nursing Education.

While exploring this topic, I discovered that the importance of incorporating reflection in learning has been the basis of past education theoretical framework. Reflective thought in learning was first described by none other than educational theorist John Dewey (the developer of that decimal system we all know so well!). In 1910 Dewey shared his belief that the inclusion of a reflective period in an educational exercise is integral to learning the meanings of experiences. He encouraged educators to strategically place reflection within the learning experience.

Intrigued by all these studies, the role of reflection in learning became the focus of my research. Using a simulation, my goal was to incorporate an instructor-guided reflective period in the middle of a medical scenario and measure the effect of this on student satisfaction and self-confidence.

A simulated medical situation offers an ideal opportunity to incorporate reflection by pausing the action. Students can then retreat to a quiet area in order to reflect upon the patient's symptoms and use that information to formulate goals and a plan of care.

The inclusion of the mid-scenario reflection period was positively correlated to the learning outcomes of satisfaction and self-confidence. Anecdotal comments revealed that students welcomed the opportunity to reflect upon their learning.

The available literature and my own research demonstrate that reflective thinking is necessary for the development of clinical nursing judgment. I believe this it is a component that should be present in our teaching.

Get Some Sleep! Advice for the Ages
March 5, 2014 12:40 AM by Chuck Holt

Japan’s Misao Okawa turns 116 years old today, making her the world’s oldest living person. [http://tinyurl.com/ljhatk8]

Among Okawa’s tips for a long life include eating sushi at least once a month and most importantly getting plenty of sleep. “You have to learn to relax” and nap as needed, she says. 

It’s not only sage advice, but also the kind that is never too early to begin following.

On March 3, the National Sleep Foundation released the results of the 2014 Sleep in America poll. This year’s poll “took a deeper look into the sleep practices and beliefs of the modern family with school-aged children,” according to the NSF.

An annual study that began in 1991, this year's poll finds children sleep better when parents establish rules, limit technology and set a good example.

Based on the results from the 2014 poll, NSF recommends trying  these 10 tips to improve your child's sleep:

1. Make sleep a healthy priority in your family’s busy schedule.
2. Set appropriate and consistent bedtimes for yourself and your children and stick to them.
3. Know how your child is using electronics in the bedroom. Create a plan for appropriate use at night and set boundaries about use before and after bedtime.
4. Educate yourself and your child on how light from electronic device screens can interfere with sleep. 
5. Talk to your child about the importance of sleep for health and well-being. 
6. Talk to your child’s teacher(s) about your child’s alertness during the day. Let your child’s teacher(s) know you want to be made aware if your child is falling asleep in school.
7.  Remember that you are a role model to your child; set a good example. 
8. Create a sleep-supportive bedroom and home environment, dimming the lights prior to bedtime and controlling the temperature (in most cases, temperatures above 75° F and below 54° F will disrupt sleep).
9. Try to encourage activities such as reading or listening to music before bedtime instead of watching TV, playing video games or surfing the web.
10. Make sure children’s activities, including homework, can be completed without interfering with bedtimes.

For more on the benefits of sleep, don’t miss the ADVANCE article “Sufficient Slumber” in the Lifestyle for Nurses section of our online edition. [http://tinyurl.com/9kgw3nu] The article by staff writer Rebecca Mayer Knutsen looks closely at home sleep tests and asks whether they provide a less expensive and more convenient alternative for diagnosing sleep apnea. An involuntary cessation of breathing that occurs while the patient is asleep, sleep apnea affects more than 18 million Americans. Risk factors of sleep apnea include being male, overweight and over the age of 40, but the condition is known to affect any age.

“People who are constantly tired in the daytime or having difficulty concentrating after getting a full night of sleep should make an appointment with a board certified sleep physician,” a doctor specializing in sleep tells ADVANCE. "If you present with any of the known symptoms and have a body mass index (BMI) over 30, a neck larger than 18 inches around, or high blood pressure, you may be a great candidate for taking a home sleep test." The at-home sleep apnea test, just like a full sleep study, must be prescribed, notes the physician.

What do you prescribe for a good night’s sleep? 

A Child’s Right to Choose?
February 24, 2014 7:24 AM by Catlin Nalley
After extensive debate and controversy, Belgium lawmakers made history with the recent decision to remove age restrictions on euthanasia.

"Under the amendments to the country's 2002 euthanasia law, a child of any age can be helped to die, but only under strict conditions," according to TIME. "He or she must be terminally ill, close to death, and deemed to be suffering beyond any medical help. The child must be able to request euthanasia themselves and demonstrate they fully understand their choice. The request will then be assessed by teams of doctors, psychologists and other care-givers before a final decision is made with approval of the parents."

Euthanasia and assisted-suicide is already a heated topic of discussion around the world, but Belgium's recent decision adds a new dimension to the debate.

When is a child old enough to understand death? And, how involved should they be in the medical decisions surrounding it?

A 2009 study, published in Pediatrics, found that "adolescent cancer survivors, like other adolescents, want to be involved in medical decision-making at the end of life."

However, not all adults agree. A Belgian nurse, who spoke to TIME, "argued that minors may not have the mental capacity or the vocabulary for requesting to die."

Before the issue of age can be resolved we have to come to a decision about euthanasia in general. For the U.S., assisted suicide is still, for the most part, illegal. Only four states - Oregon, Washington, Montana, and Vermont- allow it.

Where do you stand on assisted suicide? Do you support a terminally-ill child's right to decide when their life ends?

The IOM Report on the Future of Nursing—3 Years Later
February 18, 2014 10:23 AM by Guest Blogger
Elaine Keavney, is director of the nursing program at American Public University

The Institute of Medicine (IOM), working with the Robert Wood Johnson Foundation, released its landmark report, The Future of Nursing: Leading Change, Advancing Health in October 2010. With changes in the entire healthcare system anticipated as a result of healthcare reform, the IOM report said that nurses need to be prepared for changing and evolving roles in caring for patients and leading change.

The report contained eight clear recommendations for change:

  • Remove scope of practice barriers
  • Expand opportunities for nurses to lead and diffuse collaborative improvement efforts
  • Implement nurse residency programs
  • Increase the proportion of baccalaureate-prepared nurses to 80% by 2020
  • Double the number of nurses with a doctorate by 2020
  • Ensure that nurses engage in lifelong learning
  • Prepare and enable nurses to lead change to advance health
  • Build an infrastructure for the collection and analysis of healthcare workforce data

In the three years since the IOM report was released, exciting changes continue to take place throughout the country in support of these recommendations. There had been discussion of all of these topics at one time or another for years, but no previous work has had the impact of the IOM report. The clear messages in each of the eight recommendations have provided structure and specific goals. 

As an example, there has been discussion of associate vs. baccalaureate education as a professional entry point almost since the first associate degree program was developed.   But, a specific target number-80 percent of nurses with baccalaureate degrees by 2020-is achievable in most areas, and has completely eliminated the politically-charged conversations about whether nurses should be baccalaureate-prepared as they enter the profession.  

The IOM also led to the formation of Action Coalitions in all 50 states.  Each coalition is unique and is working within its own state nursing culture to evaluate needs and work toward the implementation of the IOM recommendations.  Some are supported by grants from The Robert Wood Johnson Foundation.

A recent three-year review by the Robert Wood Johnson Foundation provides other examples of activities spurred by the IOM report:

  • Seven states have removed major scope of practice barriers, primarily to advanced practice registered nurses (ARNP)
  • The Federal Trade Commission has challenged limits to nursing scope of practice in a number of states
  • The American Academy of Nursing has developed an initiative to advocate for the appointment of nurses to influential leadership positions
  • Many states report work on dual enrollment in associate and baccalaureate degree nursing programs and other initiatives to enhance seamless academic progression
  • Medicare is paying to support nursing education with a $200 million demonstration project in five hospital systems

There is much work that remains to be done.  But, for the first time, there is significant momentum move nursing forward, to recognize its considerable contributions to the health of the nation, and to place nurses in positions to truly lead change and advance health. It is indeed an exciting time to be a nurse in 2014!



Healthcare is a Human Right
February 10, 2014 9:56 AM by Chuck Holt

This post is written by Mbettie Worrell, BA, BSN, RN, a graduate student in the Adult/Gerontology Nurse Practitioner program at the University of Pennsylvania School of Nursing in Philadelphia.

Consider these scenarios:

A six-year-old girl is found dying from a disease that has had a vaccine available for decades.

A young woman lay dying in childbirth while her husband watches helplessly because they have no access to healthcare.

A 48-year-old mother who needs a kidney transplant, but she has no insurance and thus not “eligible” for the transplant list.

These are a few health struggles faced by people around the world, including the U.S., due to lack of access to healthcare.

The Affordable Care Act promises to insure an additional 36 million people, and escalated this debate over access to healthcare, health disparities, and citizens’ rights.

Proponents and opponents of this issue base their arguments in economics, ethics, medicine and law.

Proponents believe that if all Americans had access to healthcare it would decrease spending because individuals would seek preventative care instead of waiting to become seriously ill. Proponents also argue that as citizens of the richest democracy in the world we should have a right to affordable healthcare no matter who you are.

Opponents, meanwhile, now view the term “entitled” with contempt and define it as a reward for the undeserving. They argue increasing tax revenue on some citizens to help provide healthcare to others is socialism. Others say healthcare providers will be overstretched due to the high demand of individuals seeking care and this could lead to burn outs or decreased quality of care rendered, primarily through delays in appointments, surgeries, etc.

Growing up in a third world country, I have witnessed firsthand the consequences of inaccessibility to healthcare.

I believe good health and access to care is a human right, no matter which part of the world one may live.

All humans were created equal, though history and other social and economic issues like wars, social determinants, and poor economies have created a noticeable difference between individuals and among nations.

However, all humans are entitled to the same rights under similar circumstances. 

I do not necessarily believe this right means being in the best health state. However, governments should be able to provide those conditions necessary to facilitate the needs of its constituents when it comes to healthcare needs.

The ability of a government to help its citizens gain access to healthcare should not be viewed as “charity” or “socialism.” 

As World Health Organization Director-General, Margaret Chan, states:

“The world needs a global health guardian, a custodian of values, a protector and defender of health, including the right to health.”

Can we each be that person?

Better Patient Compliance
February 4, 2014 9:13 AM by Guest Blogger
This post is by Robert Wright, president/CEO of Behavioral Education and Research Services Inc., Orlando, Fla.

Whether we call them clients, patients, or some other term; all who seek our services are people. As such they are subject to the laws of behavior. That non-compliance represents a threat to the future of patients and providers is demonstrated by the disastrous statistics related to direct costs, overuse of the system, unnecessary healthcare, and 125,000 needless deaths per year.

There are a number of patient counseling models developed over the years designed to improve patient understanding. These models have been time tested and on the surface are straightforward, consistent, and logical. In spite of their clear appeal to "common sense" they are also not terribly effective.

Patient compliance today is about the same as it was in the middle of the 20th century. For that matter it is about the same as when Hippocrates was in practice. As complex as our central nervous system is and as sophisticated as we are, when it comes to behavior we do the things that make us feel good and are positively reinforcing and we avoid the things that don't make us feel good and are punishing. That includes recovery from disease, prevention and wellness programs. People can be reinforced by their disease or punished by taking their medications. Side effects are punishing, cost is punishing, maintaining medication schedules can be punishing. People avoid punishment particularly when the benefits (improved health) are in the future and the punishers (side effects and cost) occur immediately.

Rules and beliefs have clouded our view of behavior for hundreds of years. The "reasonably prudent wo/man" standard, the use of common sense, and man as a logical creature represents the tip of the behavioral iceberg. Perhaps it is too much to expect that people, who are otherwise unsophisticated about their biophysiology and the complexities associated with the disease process, will stop to consider the effects of not following their plan of care.

Lawyers have determined that informed consent means that the patient has a clear understanding of the consequences of their behavior, both good and bad, and have made an "informed" decision of what needs to be done. Clearly with a 50% failure rate in following the doctor's orders something in the message got lost in the behavior.

The Health Belief Model says that man is rational and can weigh the outcomes of the physician's directions and will follow those directions depending upon their beliefs about the recommendation. This model proposes that the patient will, if s/he believes the physician that the problem is significant, the prescribed treatment is likely to help, and the patient is able to implement the plan of care (e.g., afford the medication, change lifestyle, give up bad habits, take up new habits, etc.).

The Transtheoretical Model of behavior describes men and women as traveling through life with little or no concern about wellness or illness (precontemplation) until there is a change in their wellness status (contemplation) the person understands there is an issue and then plans to do something about this change (preparation) sometime within the next month. This contemplation and preparation stage (Action) is transformed when the patient does something about the healthcare concern. After accepting the diagnosis the patient moves into the maintenance stage in which theoretically behavior changes to prevent relapses.

Learning Theory believes that complex healthcare issues can be broken down into smaller more digestible steps that can have an effect on patient behavior. While this may have some applicability, here is the reality of human behavior: rules and logic do not change behavior, consequences do.

Motivational Interviewing vs Cognitive Behavior Therapy vs Therapeutic Behavior Management: Are these programs variations on a common theme? The short answer is no. Our behavior based perspective sets aside the above theories and examines the consequences of patient behavior. Behavior is what a man [patient] does, not what he thinks and not what he believes.

The clinical goal for a nurse educator is summed up by this statement: We want to increase the number of preferred behaviors and decrease the number of unpreferred behaviors. If the patient is not compliant with the plan of care we need to know the function of their behavior. Our observations show that people fall into two basic categories of response: 1) behaviors they cannot do and 2) behaviors they don't want to do.

If they cannot perform a behavior we have a patient training concern. If they don't want to do the behavior we have a patient motivational concern. This is important from the nursing perspective in terms of messaging and how we shape our training program(s). Both perspectives are related to what happens to the patient when they actually do the things we ask them to do. If the response cost is negative you can count on the patient not doing as you have either trained or asked them to do.

Behavior is always a function of the consequence that immediately follows or occurs during the behavior that strengthens or weakens the likelihood that that behavior will occur again in the future.

With "quality" withholds now a part of the Affordable Care Act providers will be punished if their patients fail to improve. The provider's course of action requires change. Change the patient's behavior to improve compliance or discharge the patient to reduce risk to the practice. The science of behavior has clearly demonstrated that any behavior that is positively reinforced is more likely to occur again.

Our behavior based training program does not end when the patient leaves the hospital or clinic. Behavior change requires follow up or positive reinforcement even after the patient has demonstrated high levels of compliance. Any behavior that is not occasionally reinforced will go back to baseline. For 50% of the total patient population that baseline is non-compliance. The nurse educator training programs we have developed and put into place provide tools that can be used to identify high risk patients and develop a patient education plan of care to shape and reinforce the target behaviors.

Black History Month: A Reflection on Civil Rights Movement
February 3, 2014 9:14 PM by Linda Jones

The following was sent as a press release from Mercy Hospital Oklahoma City. 

Lois Faye May remembers exactly where she was when she learned Dr. Martin Luther King, Jr., had been shot: working in an operating room at Mercy Hospital Oklahoma City – then Mercy General in midtown Oklahoma City.

“Someone heard it on the radio and came into the operating room to tell us. It was a really scary time because we weren’t sure what was going to happen,” said May, who was one of Mercy’s first African American nurses. “Everybody was more or less in shock. Because of what was happening in other places in the country, some of us were afraid to go to work.”

In shock, certainly, but May says she and her friends didn’t lose hope. She had already seen King’s impact and was a leader of change herself. Ten years prior to King’s death, May was in the first fully integrated class at Mercy Nursing School, from 1958 – 1961, at the height of the Civil Rights Movement.

“The year before us, there was one black student, but in our class there were seven of us,” said May. “Mercy was the only place around accepting African American nursing students at the time.”

Despite the 1954 Supreme Court ruling on Brown v. Board of Education of Topeka, Kan., which ruled segregation in public schools unconstitutional, many schools continued segregation or complete rejection of black students. It wasn’t until 1962 that James Meredith became the first black student to enroll at the University of Mississippi – a historical event which triggered violence and riots, prompting President Kennedy to deploy 5,000 federal troops to the university to restore peace.

Like Meredith, May and her fellow African American nurses faced adversity during their years at nursing school. But, just because their experiences didn’t make headlines doesn’t mean they didn’t make an impact.

“It was the way of the times. Your skills and integrity would be questioned simply because you’re black,” said May. “Before college, our high school teachers, parents, church and community leaders tried to prepare us for the hazards we would face. We had a lot of support, and Mercy had already come so far.”

May remembers leaning on her fellow black students, and being protected by her instructors and the Sisters of Mercy.

“The nuns and instructors had to stand up for us almost daily with patients and physicians who weren’t accustomed to working with black nurses,” said May. May also remembers one Sister of Mercy in particular who she describes as, “no nonsense.” Specifically, she remembers the Sister having zero tolerance for racial discrimination. “I remember Sister Mary Alvera. She was my supervisor in surgery. She was quiet and very caring – but she wouldn’t stand for any nonsense,” said May. “She expected people to change with the times, and she let them know it.”

In 1961 – seven years before King’s death – the seven black students graduated from Mercy Nursing School and went on to careers in nursing. May continued at Mercy General, where she became head nurse in thoracic surgery.

“One of the girls who started with me became a head nurse at Mercy,” said May. “That was unheard of in the 60s.”

There was a patient who didn’t want May to take care of her because of her skin color. She explained to the patient that she was the nurse in charge, but the patient still didn’t want May’s care.

“I asked my supervisor to find a white nurse to care for the patient,” said May. That didn't fly with her supervisor. Instead, May’s supervisor explained to the patient that May was the nurse in charge and there was no other choice. Finally, the patient agreed and May respectfully cared for the woman.

“The Sisters and our supervisors stood up for us. It was something we encountered quite a bit at that time, but we learned to handle it effectively and professionally,” said May. “It felt pretty good to have your supervisor stand up for you like that. And the really neat thing was noticing those incidents happening less and less as time went on.”

Without making headlines, May and her supervisors were quietly making progress. There was a new way of doing things at Mercy, and the community slowly came around because of the courage of people like May.

Lois Faye May stayed at Mercy until 1970, when she went on to St. Anthony’s to serve as nursing associate head of surgery. In 1974, May moved to OSU-OKC’s School of Nursing, where she helped shape future nurses as a professor and department associate head, until retiring in 1993. As a tribute to her service, there's a nursing scholarship in her name at OSU-OKC. May earned her nursing diploma from Mercy Nursing School, a bachelor’s in health education from Oklahoma City University, and a master’s in nursing from The University of Oklahoma. She stayed in touch with most of her fellow black nursing students, and sees them a few times a year.

Identity Theft: Who’s Got Your Number?
January 21, 2014 4:08 PM by Chuck Holt

In the wake of the massive data breach at retail giant Target, nurses likely will find patients expressing concerns about identity theft and the safety of their healthcare information.  

The threat is real. According to the Federal Trade Commission (FTC), 5% of identity theft victims report medical fraud.

 In response, FTC in 2010 enacted the Red Flag Rule. Essentially, any doctor’s office, hospital or other healthcare facility that regularly bills patients for the balance of fees not covered by insurance and/or allows patients to set up payment plans is either a creditor or a provider of a “covered account.”  Hence, healthcare providers must be aware of what Red Flags of identity theft to watch for, according to an article in Modern Magazine by FTC attorney Steven Toporoff. They include:

Suspicious documents: Obvious forgeries or alterations, such as a photo or physical description listed on an ID card that does not look like the patient presenting it.

Suspicious activity: Mail sent to a patient’s address is repeatedly returned as undeliverable, yet they continue to make all their appointments. Or, a medical history provided by a patient that is inconsistent with other sources.

Suspicious identifiers:  A birth date or Social Security number given by a patient that does not match what the insurer has on file.

In addition to the steps healthcare providers take to protect patients from medical fraud by identity theft, there are several steps all individuals should take to protect their personal information, says identity theft expert, Scott A. Merritt. The insurance and realty executive became an expert on the subject after being arrested for a felony committed by someone else whom had stolen his identity.  

“You can greatly reduce being a victim of such recent hacks that occurred at the major retailers by using cash more often,” he says. “But if you’re going to use credit, use a card from a national bank or a national credit union, and never [use] a debit card — no exceptions.”

Merritt, author of the new book “Identity Theft Dos and Don’ts” offers seven ways to guard your information:

1. Understand how and where ID theft happens. Most thefts occur in places where you do business every day. A place of business is robbed, a bad employee acts improperly or a hacker breaches the office through the computer.

2. Secure your wallet’s information. Photocopy everything in your wallet: photos, credit cards (front and back), membership cards – everything. Put the copies in the order the cards are arranged in your wallet, staple the pictures and place them in a strong box or safe.

3. Make sure your information is consistent. For all of your identity and financial documents, make absolutely sure, to the smallest detail, that all of your personal information is accurate and consistent! Discrepancies such as using your middle initial on some documents but not others, or having different addresses, can wreak havoc in proving your identity and can even compromise your credit score.

4. Secure your digital habits and data. Change your passwords at least twice a year on a non-scheduled basis, i.e., don’t be predictable. Have a strong firewall if you shop online and only access sites that are also protected by a strong firewall with high industry standards. Access accounts of a financial nature only from your personal computer.

5. Protect your banking information. While in the bank, keep account numbers and other data out of sight, and avoid saying account numbers, Social Security numbers or other information out loud. When planning a bank visit, prepare deposits and withdrawal slips in advance.

6. Account for your interactions with vendors. Every time you speak to someone with whom you do business, write down the time, date, name and the purpose or outcome of the call, including any animosity or reluctance from the vendor.

7. Don’t carry around your birth certificate or Social Security card. Unless it’s necessary, keep those vital items in a safe or at least a firebox. If you’ll need to provide a copy of your tax returns or your driver’s license to anyone for any reason make the copies ahead of time to avoid having your information inadvertently left sitting on an office copier.

While all are important means of protecting your identity they’re certainly not the only ways of doing so, of course. How about you?  What steps do you take to prevent identity theft? 

Remembering the Effects of the Sun in Wintertime
December 26, 2013 10:30 AM by Guest Blogger
Richard Bezozo, M.D., is the president of MoleSafe

Now that winter is upon us and the snowflakes have begun to fall, we often think back to the summer months filled with countless hours of sunshine. While looking back on those hot summer days, if you can remember receiving one or more bad sunburns, you may be at risk for melanoma.  Studies show that one blistering sunburn in childhood or adolescence more than double your chances of developing skin cancer later in life and repeated exposure to ultraviolet (UV) radiation is a major factor for most skin cancers, like melanoma, due to the damage it causes to your cells.  This winter be proactive about your and your patient's skin health by monitoring for changes skin and enrolling in an early detection melanoma screening and surveillance program. Performing self-checks on your skin and scheduling regular exams can help find and treat melanoma and other skin cancers effectively. Here are some tips on how to monitor your skin this winter, and I encourage you to share these tips with your patients as well:  

  • Continue your sunscreen regimen through the winter. Although the winter sun is not warm, it is still very dangerous and can be harmful to our skin.  UV rays are intense on both clear and cloudy winter days, making it essential to apply sunscreen with an SPF of at least 30, specifically to your face, hands, neck and scalp, at least 30 minutes before going outdoors. Due to the sun's reflections off the snow and conditions that occur at high altitudes, be sure to apply a sunscreen that blocks UVA and UVB radiation when you go skiing and snowboarding, to reduce your risk of sunburns and other long-term effects, including premature aging of the skin and even skin cancer.
  • Check your own skin. You are the only person who sees your body every day, so be proactive in your skin health and start examining your body from head to toe and everywhere in between. Make sure you perform your self-check in a well-lit room in front of a full-length mirror. Also, keep a hand mirror handy to help look at areas that are hard to see, especially your back and scalp. Performing a skin self-exam each month is a small time investment in what could end up being a life-saving procedure. Follow these 5 steps in performing your self-check, provided by MoleMap: http://bit.ly/17fYj8G
  • Learn your skin patterns. The first time you perform a self-check, spend time carefully examining the entire surface. Be sure to learn the pattern of moles, blemishes, freckles and other lesions on your skin, so you will better be able to notice any changes during your next exam. Take note of any new growths and bring them to your physician's attention at your next screening.
  • Know your moles. Normal moles are typically an evenly colored brown, tan or black spot on the skin. Most people have moles, and most are harmless. However, a warning sign of melanoma is a mole that is changing in size, shape or color.
  • Learn your ABCDEs. ABCDEs in melanoma detection represent asymmetry, border, color, diameter and evolving. Any changes in these characteristics can indicate an affected area and calls the need for immediate attention.
  • Enroll in an early detection screening and surveillance program. By enrolling in an early detection screening program, you can have peace of mind that your skin will stay healthy. Early detection of melanoma cannot be overstated, because when melanoma is found and treated in the initial stages, your chance of long-term survival is very high. Early detection screening programs are an ongoing way to ensure that you taking the most cautious measures to protect the skin you're in.

Your skin is your body's largest organ, so make skin health a priority during all months of the year, including these cold, snowy, winter months. If you have any questions or would like to learn more about enrolling in an early detection screening and surveillance program, please visit http://www.molesafe.com/.

Editorial on Kindness Prompts Response
December 20, 2013 10:41 AM by Linda Jones

A recent editorial on the need for more kindness in healthcare (Want to Raise Patient Satisfaction Scores? Be Nice) prompted several responses. Here are two.

 Be Nice Indeed

I have never written a letter to the editor before, but after reading your “Be Nice” letter in the latest Advance, I felt I had to speak up.  I prefer to remain anonymous, please.

I have been a nurse for 37 years.  In that time I have seen many things come and go and come back again.  One thing that has NOT changed is that nursing comes from the heart.  No matter how little or much education a nurse has, and how many or few letters he/she has permission to place behind the name, the single most important element in practice is kindness.  I also know, however, that in order to give kindness and love, the nurses’ vessel must be full of love and kindness.  Sadly, in today’s culture, nurses are empty or near empty vessels.  Those of us who are still fighting the good fight doing patient (now client) care, are being treated brutally. 


The older group of us are terrorized and run out of jobs, as we are too expensive and medically risky to be employed.  No respect for the years of experience and gut knowledge that cannot be taught in the classroom.  These positions are then replaced with new graduate nurses, for a fraction of the cost, and they are placed in now part time positions, with less company paid benefits, and more room to work extra hours without paying overtime.  Meanwhile the new nurses are fighting to get these jobs and being mandated (for client safety) to stay double shifts and extra time.  They are exhausted and frustrated and have NO company loyalty.


We are no longer respected as a knowledgeable professional doing a service, but now are ordered by clients to provide the service they request/demand.  The days of thank you and gifts from clients are long gone. 


At this time of year, it also reminds me of the holiday giftedness we once enjoyed from physicians, employers, drug companies, lab companies, formula companies, and patients.  That is something today’s new nurses do not know.  All they know is mandated additional time, complaints regardless how hard they try, and working holidays.  The “holiday pay”, by the way, is also decreased to only a few hours on the actual day.  The eves and off shifts no longer count to the employer, and too bad if it counts to you, because this is lock out time for vacation requests, so you may not take any time off.  And don’t even think about complaining about any of this to your employer, you are told to be thankful you have a job.  Make no mistake, we are!


So, to wrap this up, let me summarize my point.  Absolutely a little kindness is what our clients want…and so do the nurses, so they have kindness to give back. 


Be nice indeed.


Adequate Staffing

When I read your editorial in the most recent edition of Advance for Nurses I know I just had to write.


Quick questions—have you ever worked as a nurse? Have you recently had a family member or friend as a patient in the hospital? I have and so have two of my co-workers. 


Your editorial “Want to Raise Patient Satisfaction Scores? Be Nice.” The first sentence says it all—“Gourmet food, wireless access, waterfalls in the lobby.” Are you kidding me? How about ADEQUATE STAFFING? 


In this day and age hospitals are more concerned with pretty private rooms, designer-like gowns, and gourmet food, rather than providing excellent patient care. Try spending money on hiring more staff. The nurses are over worked and spend their time dispensing meds and data entry. They are no longer at the bedside. The nurses’ aides are. So much for “critical thinking” skills!


Example, I arrived at my Mother’s bedside at 9 a.m. Her breakfast tray was across the room, totally untouched though the woman (I don’t know what she did-no ID) insisted that someone had tried to feed my Mom. I did not see a nurse until a woman walked into her room with a syringe at 2:15 pm. She didn’t identify herself and when questioned, she stated, “why, I’m Patricia, her nurse.” I had to ask what was in the syringe. Guess what – it was Lasix being given to my Mother 15 minutes before she was scheduled to be transferred to a rehab facility. Great timing, she can soil herself enroute! I had seen this same nurse several times during the day sitting at her computer in the hallway.


I have numerous other stories. One co-worker’s husband was left in the x-ray department for a couple of hours (one day post-op hip replacement) because there was no one to transport him back to his room. Did the nurse miss him? Nope!


The sad thing is that the emphasis is now on BSN as an entry requirement. However, no hospital wants to hire new graduate BSNs—they are ill prepared to actually perform nursing assessment and care. Otherwise why would they need to have internships? Hospitals are constantly asking for at least 2 years of experience. Again, so much for critical thinking skills if you can’t use them! The “powers that be” really need to find a happy medium between college based and hospital based nursing education. The real joke is the “fast track” 1 year courses for people who have a bachelor’s degree in another discipline. Sure I’d like them taking care of me.


Again, if patients want kindness, hospitals need to step up and provide adequate staffing. I challenge you to rise at 5:30 am, work a triple shift and be kind and cheerful at 7 am the next morning.


Just needed to get all of this off my chest.




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