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ADVANCE Perspective: Nurses

Hand Washing: Painful or Protective
October 13, 2014 9:11 AM by Pam Tarapchak

By Martie Moore, RN, MAOM, CPHQ, chief nursing officer, Medline Industries Inc.

Who would have thought that the tools you count on every day to do so much for you would become the center of incredible tension within the care delivery system? 

In many ways, these tools are a perfect example of Polarity. Polarity Management teaches us that it is not black and white, nor is it gray. It is black and it is white. When using Polarity Management theory, you consider the polar points within an issue. In hand hygiene, the polar points I am speaking about are simple and yet very complex: They are the hands of caregivers. 

Hand hygiene has become a focal point of care settings in the U.S. Many hand washing programs have an "either/or" focus to them:  Either you wash or gel your hands, or you don't. I had one infection control practitioner say to me that she did not understand why this was such a difficult issue. You just wash your hands, period, end of story. "Enough said about the subject!" 

Given that conversation, I started to research the tension around hand hygiene. I would not argue with the IP that hand hygiene is critical. I agree on that point. But I do not agree that it is as simple as just washing your hands. 

I asked caregivers across the nation how they would describe their hands at the end of a shift. More than 70 percent of the respondents said dry, itchy, cracked, sweaty or red. The majority were in the dry and itchy category. Many expressed concern about their ability to maintain care at the bedside with the condition of their hands.

When asked if they would be more compliant with hand hygiene if their hands felt better, the vast majority of respondents said yes. They also acknowledged that they use a variety of products and solutions - rom homemade to commercial - to try to address the discomfort of the condition of their skin. 

Here lies the polarity: The very action that we are asking people to do this is causing them discomfort and pain.   

When we as leaders take the approach of an "either/or" to hand washing, we miss a very important component to being successful in protecting our patients and those who provide care. We miss the simple element of pain and discomfort and the influence that has on the brain and subsequent actions of the care providers.   

Understanding how to protect and heal the skin of the care providers is a critical first step. Look at what is available to them throughout their workday. If key steps are taken on a preventive measure to preserve the integrity of the skin and hands of the care providers, they will respond to what they know is so important: hand washing. 


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More Important Than Reimbursement
October 3, 2014 9:56 AM by Chuck Holt

U.S. Rep. Earl Blumenauer (D-OR) and 33 other members of the House of Representatives recently sent a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner asking her "to adopt recommendations that would adequately reimburse Medicare providers for having voluntary discussions about end-of-life care and planning with patients.”

According to the letter sent to CMS on Sept. 24, the time doctors currently spend having discussions with their patients about end-of-life care and planning is not reimbursed under Medicaid and Medicare.

Unfortunately, without this incentive, these conversations are not happening.

"Patients who wish to make clear their goals, values, and wishes through discussions with their trusted providers should have the opportunity to do so,” Blumenauer notes in a press release about the letter. “In order to have these conversations, providers must have the adequate time, space and reimbursement to conduct the complex and time-consuming discussions necessary to learn about the goals and values held by their patients and plan appropriately for their care.

“Every organization that has seriously considered this issue, from the American Medical Association to the Institutes of Medicine, knows we have to start respecting people’s choices about how they face the end of life,” continues Blumenauer. “Making this simple change will have a profound effect on the way patients and their families spend their final days, and everyone deserves that dignity.”

While I fully support the recommendations in the letter from the representatives to CMS, and although I understand healthcare is a business and also recognize that the culture in the U.S. rewards those who make the most money they can by charging as much as they can for their services at every turn, I have to ask how any physician can justify on moral and ethical grounds refusing to speak to a dying patient about their wishes at the end-of-life just because they may not get paid for having the conversation.

Is there really nothing left that is more important than money?  

The other signers of the letter, all of whom are Democrats, were:

Henry A. Waxman (CA-33), Suzanne Bonamici (OR-01), Peter DeFazio (OR-04), Ted Deutch (FL-19), Sander Levin (MI-09), Jim McDermott (WA-07), Lois Capps (CA-24), Rosa DeLauro (CT-03), Keith Ellison (MN-05), Sam Farr (CA-17), Rush Holt (NJ-12), Rick Larsen (WA-02), Barbara Lee (CA-09), Betty McCollum (MN-04), James P. Moran (VA-08), Chellie Pingree (ME-01), Alcee Hastings (FL-20), Jared Huffman (CA-02), Ron Kind (WI-03), John Larson (CT-01), John Lewis (GA-05), James P. McGovern (MA-02), William Owens (NY-21), Mark Pocan (WI-02), David Price (NC-04), Linda Sanchez (CA-38), Allyson Schwartz (PA-13), Mike Thompson (CA-05), Peter Welch (VT-At large), Bobby Rush (IL-01), Janice Schakowsky (IL-09), David Scott (GA-13), and Chris Van Hollen (MD-08).



Breast Cancer Up Close
October 2, 2014 3:25 PM by Pam Tarapchak

My friend and I were supposed to meet for a walk one night. But a text popped up on my phone that she had an extended doctor's appointment that included an emergency ultrasound after an annual mammogram. The word "emergency" always makes me feel uncomfortable, but I'd been through a series of breast cysts and knew that mammograms sometimes take longer when they find those types of things.

Later that night, my friend called me to relay a story that left me speechless. After reviewing her images, her radiologist recommended she visit her physician in the same building - that day. So she made her way to the next appointment. Her doctor examined her and the images and then revealed he had taken the liberty of making an appointment with a breast surgeon - that day. Confused, she made her way across the hall to surgeon's office. During that meeting, she heard the words no woman wants to hear - I'm pretty confident you have breast cancer.

This began a journey she's still traveling.

My friend was the first person I knew personally who had breast cancer, which is pretty surprising given about 1 in 8 (12%) women in the U.S. will develop invasive breast cancer during their lifetime. There are about 232,670 new cases of invasive breast cancer diagnosed in women each year, according to the American Cancer Society.About 62,570 new cases of carcinoma in situ (CIS) will be diagnosed (CIS is non-invasive and is the earliest form of breast cancer). And about 40,000 women will die from breast cancer.

As nurses, you no doubt have either cared for patients or know your own personal family and friends who are fighting a breast cancer battle. And as a nurse, you can provide a valuable resource for patients and families who must face questions, fear and the unknown. While October is Breast Cancer Awareness Month, I ask that you spread the word about this disease throughout the entire year. Below are some ideas from the U.S. Department of Health & Human Services you can incorporate into your healthcare facility's education program. Find the toolkit here: http://healthfinder.gov/NHO/PDFs/OctoberNHOToolkit.pdf

  • Send out tweets to your patients or friends. For example: Nervous about getting a mammogram? Watch this short video about mammograms and what to expect: http://1.usa.gov/fKtUB
  • Send out mammogram reminder e-cards: http://healthfinder.gov/StayConnected/ecards/DisplayCard.aspx?CardID=48
  • Partner with your community's women's organizations, community groups and senior centers to reach women ages 40 and older with important information on breast cancer screening.

And when caring for patients with breast cancer, share as many resources as you can to help them make difficult decisions about treatment, surgery and healing. Remember, you may understand radiation, lumpectomies and chemotherapy, but a patient with a new diagnosis does not. And perhaps, the most important thing you can do when encountering a patient with breast cancer is to show compassion.

After much research and soul-searching, my friend chose a double mastectomy. Two weeks post surgery, she continues the fight to get better. She received the wonderful news that no more cancer was found during the surgery and all had been removed. Now she can heal without the worry of continued treatments or cancer. Each day she gets a little stronger, and I'm thankful every day she's made it through. She's a survivor.

Let's work to spread the word on breast cancer awareness and early diagnosis and treatment - this month and throughout the year. Because there are thousands of people like me who have a friend who must hear the words "I'm pretty confident you have breast cancer." Let's get that number to zero.

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Why Are New Nurses Leaving?
September 29, 2014 10:47 AM by Pam Tarapchak

One in five. That's how many new nurses choose to change their job within their first year of nursing. One in three leave within two years. Given that new grads often struggle to find their first positions, one study shines a light on this interesting trend -- and why it might not be a bad thing.

These statistics were based on a study in the current issue of Policy, Politics & Nursing Practice, that was conducted by the RN Work Project, funded by the Robert Wood Johnson Foundation.

The data comes from surveys of three cohorts of newly-licensed RNs conducted since 2006.

RNs leaving their jobs (RN turnover) is costly for hospitals and also affects quality of care. Organizational costs associated with RN turnover can be as much as $6.4 million for a large acute care hospital, and studies have associated turnover among health providers with an increase in the use of physical restraints, pressure ulcers and patient falls.

The authors point out many of the problems with existing turnover numbers in the literature.

"One of the biggest problems we face in trying to assess the impact of nurse turnover on our health care system as a whole is that there's not a single, agreed-upon definition of turnover," said Kovner. "In order to make comparisons across organizations and geographical areas, researchers, policy makers and others need valid and reliable data based on consistent definitions of turnover. It makes sense to look at RNs across multiple organizations, as we did, rather than in a single organization or type of organization to get an accurate picture of RN turnover."

The RN Work Project is directed by Christine T. Kovner, PhD, RN, FAAN, professor at the College of Nursing, New York University (NYU); and Carol Brewer, PhD, RN, FAAN, professor at the School of Nursing, University at Buffalo. Other investigators for this study were Farida Fatehi, MS, BDS, data analyst at New York University; and Jin Jun, MSN, APRN, CCRN, research assistant at also at the College of Nursing at NYU.

The research team noted that there are different kinds of turnover, and that in some cases, RN turnover can actually be helpful. In cases of functional turnover, a poorly functioning employee leaves, as opposed to dysfunctional turnover, when well-performing employees leave. Authors recommend that organizations pay attention to the kind of turnover occurring, and point that their data indicate that when most RNs leave their jobs, they go to another health care job.

"Developing a standard definition of turnover would go a long way in helping identify the reasons for RN turnover and whether managers should be concerned about their institutions' turnover rates," said Brewer. "A high rate of turnover at a hospital, if it's voluntary, could be problematic, but if it's involuntary or if nurses are moving within the hospital to another unit or position, that tells a very different story."

The RN Work Project's data include all organizational turnover (voluntary and involuntary), but do not include position turnover if the RN stayed at the same health care organization.

The RN Work Project is a 10-year study of NLRNs that began in 2006. It is the only multi-state, longitudinal study of new nurses' turnover rates, intentions and attitudes-including intent, satisfaction, organizational commitment, and preferences about work. The study draws on data from nurses in 34 states, covering 51 metropolitan areas and nine rural areas.

What are your thoughts on nursing turnover standards? How does your facility handle the trends?



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Mandatory Flu Vaccines for Nurses: The Wrong Choice
September 8, 2014 2:22 PM by Guest Blogger

By Priscilla Ngo, BSN, RN, a staff nurse on critical care staff unit in Philadelphia and Family Nurse Practitioner student at the University of Pennsylvania School of Nursing.

For many years, the flu vaccine has been recommended for healthcare workers, especially nurses who have direct patient contact, to prevent the spread of the influenza virus from healthcare workers to their patients.

Recognizing the importance of vaccination, Healthy People 2020 has created a goal to increase the percentage of healthcare personnel who are vaccinated annually against seasonal influenza to 90%.1

Unfortunately, there has been difficulty with getting healthcare workers vaccinated, as vaccination rates have been as low as 45.5% in 2008.1

Getting desperate, hospitals and other healthcare facilities have started implementing policies mandating vaccination of their healthcare workers as a condition of employment. Many research studies do show that having mandatory vaccination policies are very effective in raising vaccination rates to above the 90% goal.

 However, instituting a mandatory vaccination policy is a drastic measure that is unnecessary.

Getting vaccinated is indeed a good way to protect yourself and your patients and should be encouraged for everyone, especially healthcare workers – but there is a big difference between encouragement and mandating.

Flu vaccination should be heavily encouraged, not mandated.

Freedom of Choice

Mandating flu vaccination violates freedom of choice for healthcare workers. Healthcare workers should have the autonomy to make their own informed decisions regarding their own health.

We as nurses are constantly advocating for our patients’ autonomy to make their own informed healthcare decisions, so why are we not advocating for ourselves?

Even the American Nurses Association came out with a statement saying that they do not support mandatory vaccination and that we “need to protect the rights of nurses to ensure that they are treated fairly and have the necessary workplace protections”.2

Voluntary Programs

Mandatory vaccination policies are not necessary because voluntary vaccination programs can be successful on their own.

Research studies have shown a significant increase in healthcare worker vaccination rates in voluntary programs over time. In one study, vaccination rates jumped from 61% in 2010 to 85% the next year in 2011.3

Research studies have also been conducted exploring the specific components of a vaccination program that are most effective in increasing rates of vaccination.  Some of the most effective components include emphasizing accountability to the highest levels of the organization, weekend access to the vaccine, and train-the-trainer programs.4

Using this information, we can strengthen voluntary programs. We can also strengthen voluntary programs by using research conducted on why healthcare workers decline vaccination. One study found that the most common reason was concern about side effects.5 If we provide better education regarding the side effects of the flu vaccine (which are not serious), then perhaps more healthcare workers’ fears would be allayed and vaccination rates would increase.

Another study found that a common reason among nurses for declining the vaccine was that they objected to being coerced or pressured into vaccination.6 If nurses do not like being coerced or pressured into vaccination, then clearly they would disapprove of mandatory vaccination policies.

Instead of enforcing a mandate that would create resentment among nurses and staff, a comprehensive voluntary vaccination program can be created using all of the research gathered regarding most effective components and reasons for declination.

With time, vaccination rates can reach the proposed goal of 90% with these strengthened voluntary programs.

Effectiveness of Flu Vaccine Questioned

After all this discussion on the flu vaccine, you have to wonder – exactly how effective is the vaccine?

We all know that the flu vaccine only protects against certain strains of the influenza virus. The Center for Disease Control and Prevention (CDC) takes an educated guess on what strains will be most prevalent during any given year, and creates a vaccine based on that information.

But really, how protected are we?

According to a recent large meta-analysis study, the flu vaccine was only 59% effective for adults aged 18-65 years old.7 This means that vaccinated healthcare workers can still potentially get the flu and transmit it to their patients. Instead, emphasis should be placed on encouraging healthcare workers to stay home when experiencing flu-like symptoms without any repercussions.

Too often, healthcare workers encounter problems when wanting to call out sick – for example, not having enough sick time or strict policies against calling out sick more than a certain number of times a year. These policies regarding calling out sick are ridiculous – if a staff member is feeling sick, there should not be any roadblocks to allowing them to stay home. Keeping sick healthcare workers at home is truly the best way to prevent the spread of the flu virus to patients.

Drastic Measures

Mandatory flu vaccination for healthcare workers is a drastic measure that is unnecessary and should not be implemented. It violates the rights of healthcare workers.

A comprehensive voluntary program using all the research that has been done in the past several years can be used instead to effectively increase vaccination rates. In addition, the flu vaccine isn’t guaranteed to be effective – more emphasis should be placed on allowing healthcare workers to stay home when feeling sick.

Certainly, mandating flu vaccination as a condition of employment can be the fastest and easiest way to increase vaccination rates to goal. But, after giving it some thought, is it really the right choice?

1.  Healthy People 2020. Immunization and Infectious Diseases. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=23.  Accessed September 15, 2013.
2.  American Nurses Association. ANA Urges Registered Nurses to Get the Seasonal Influenza Vaccine: Supports Comprehensive Prevention Plan. http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2010-PR/ANA-Urges-RNs-Get-Seasonal-Influenza-Vaccine.pdf.  Accessed September 15, 2013.
3.  Modak RM, et al. Increasing Influenza Vaccination Rates among Hospital Employees without a Mandatory Policy. Infect Control Hosp Epidemiol. 2012;33(12):1288-1289. doi: 10.1086/667384
4.  Talbot TR, et al. Factors Associated with Increased Healthcare Worker Influenza Vaccination Rates: Results from a National Survey of University Hospitals and Medical Centers. Infect Control Hosp Epidemiol. 2010;31(5):456-462. doi: 10.1086/651666
5.  Palmore TN, et al. A Successful Mandatory Influenza Vaccination Campaign Using an Innovative Electronic Tracking System. Infect Control Hosp Epidemiol. 2009;30(12):1137-1142. doi: 10.1086/648084 
6.  Ribner BS, et al. Use of a Mandatory Declination Form in a Program for Influenza Vaccination of Healthcare Workers. Infect Control Hosp Epidemiol. 2008;29(4):302-308. doi: 10.1086/529586
7.  Osterholm MT, et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12:36-44. doi:10.1016/S1473- 3099(11)70295-X. 

Nurses: Leadership, Is it Nature or Nurture?
August 22, 2014 3:09 PM by Guest Blogger
By Sandra Ann Evans, DNP, MSN, RN, CNS-BC, CCM, patient care services, Detroit Receiving Hospital.

Nurses, let us critically think about nursing leadership. Leadership, is it nature or nurture? While most would agree that a person's charisma plays a role, I suggest that leadership skills are developed over time through learning. Those of us who are educated in the area of science readily accept that science is a learned process.

While there are known leadership traits that help a leader to lead, much of leadership is a learned process according to Quinn (1996), Goleman (2002) and Kouzes & Posner (2002).

So the good news is, for those of us who are not gifted with inherent leadership charisma, leadership abilities can certainly be learned. Leadership behavior is dynamic. In fact, today, most collegiate nursing educational programs make leadership principles a part of their curricula. Certainly programs at the graduate and doctoral level for nurses contain a significant focus on teaching leadership principles.

Many of us know skilled leadership when we see it, especially when we look at nursing leaders in our organizations. In fact, for many of us, this is the way we learn best. By witnessing effective nursing leadership in action, we too can learn the art and science of leadership. "Titles are granted, but it's your behavior that wins you respect" (Kouzes & Posner, 2007). Kouzes & Posner continue, "Leadership is not about personality; it's about behavior (p.23)."

Leadership opportunities for nurses are abounding in today's healthcare. There are leadership characteristics demonstrated in various ways all around us every single day (Kouzes & Posner). The reality is that nurses, while pursuing advancement in their careers, often inherit leadership responsibilities. In other cases, leadership roles are simply thrust upon us.

In order to advance the leadership skills that you admire most, go out of your way to fulfill these roles by becoming a member of a nursing committee/council, orientate a new nurse or obtain certification in a specialty. If you have the leadership skills that others lack, then lead others by actively passing along what you have learned to those who are willing to follow in your footsteps.

Quinn (1996) states that "change" can only begin with one individual. We can change the world only by changing ourselves (Quinn, 1996). In the course of my career, I have been in the role of both mentor, and mentee and have chosen to learn about leadership. Every nurse can choose to be a nurse leader by learning leadership behavior beginning with self exactly where they are.


Goleman D, Boyatzis R & McKee A. Primal Leadership: Learning to Lead With Emotional Intelligence. Boston: Harvard Business Review, 2002.

Konuzes J M & Posner BZ. The Leadership Challenge (3rd ed.). San Francisco: Jossey-Bass, 2002.

Quinn R. Deep Change: Discovering the Leader Within. San Francisco: Josey-Bass, 1996.


Two Nursing Worlds that SHOULD Collide
August 19, 2014 9:54 AM by Guest Blogger

By Casey Hill, MSN, RN-BC, CEN, who is a nurse educator in Connecticut.

Recently I attended a nursing orientation at a hospital, composed of both new graduates and experienced nurses. As a nurse educator, I enjoy being in this type of setting, seeing former students grow into their new role as a registered nurse.  Yet, like my former students and everyone else in the room, I was there to get credentialed on a skill for hospital protocol purposes.

The nurse educator leading the presentation was informative, humorous and kept the tone light. When it came time for skill practice she said something that would really challenge my thought process over the next several days. She stated, “You’re not in nursing school anymore; let’s practice the real way.” 

My former students looked back at me and I laughed. I knew the instructor meant no harm in the statement and every experienced nurse knows about the two worlds that exist; Nursing school and professional practice settings. I thought nothing of at the time.

But over the next several days those nurse educators’ words couldn’t escape me. Why are there two worlds? Isn’t my purpose and everyone’s purpose as a nurse educator to be teaching best practice, to develop a competent, compassionate and safe future nurse? Moreover, after graduation and licensure, shouldn’t that nurse be empowered to take those practices learned in school and continue them when caring for patients?

It seems we have a major disconnect here in our profession. Two worlds existing at the same time does seem counterintuitive.  I have lived both aspects, I understand both perspectives. You go through school as a student; things are taken at a slower pace, every procedure dissected. Sterility held to its highest regard and every medication researched. Then as a professional nurse, conditions are altered in an instant, patient nurse ratio’s climb and both time management and prioritization must be perfected to survive.

But, now as a nurse educator, instructing the nurses of tomorrow, I feel we simply cannot have mentality of the “nursing school way” versus “real world, professional nurse way.”

Medications need to be researched whether someone is studying to be a nurse or practicing it every day. Sterility should always be maintained and time management needs to be practiced as a student, so it can be perfected as a professional nurse.

The method of caring for patients in nursing school and caring for patients as a professional nurse should be uniform. Yes, the experienced nurse is able to be more efficient and proactive.  But, being experienced does not mean that now corners should be cut and procedures should be streamlined. This is not to imply that every experienced nurse practices this way, but, I do believe this has become a sub-culture of our profession.

At the end of the day, it is all about the patient. That is something every nurse seems to agree upon. But, I believe the student nurse who learns to develop a solid foundation in nursing school, maintains it and builds upon it as a professional nurse, will be able to deliver the best nursing care possible for their patient.

So, if it really is all about the patient then, it’s about time these “two worlds” collide and experienced nurses stop forgetting about the “nursing school way” but rather embrace all that they have learned during their career. It will only make them a stronger and safer nurse.

Response to “Trust in Us”: The Art of Nursing
August 12, 2014 6:27 PM by Guest Blogger
By Marietta J. de la Rosa, BSN, RN, who works at Lourdes Specialty Hospital of Southern New Jersey in Willingboro, N.J., and Deborah Heart & Lung Center, Browns Mills, N.J.

We go to work, we get paid, we repeat the process. It is easy for many of us to fall into the habit of just "doing our jobs" that we forget what is truly at the core of the very thing we do: patient satisfaction.

The patient experience is what ultimately drives our hospital's name forward, and what nurtures our hospital's relationship with the public at large. As mentioned in the article, "Trust in Us," a hospital's financial stability is a direct consequence of the nurse-patient relationship that is formed immediately upon admission. "Trust in Us" outlines the importance of this relationship and how it has become the forefront of hospital culture, with facilities inducting changes to various factor such as reimbursement equations, all in the name of patient satisfaction.

I believe a job done right is a job done well. Different nurses may have different mindsets as to how to gauge a job well done. Some may view a larger paycheck or a big raise as a sort of "pat on their backs," for having successfully completed two weeks' worth of seemingly endless shifts. For others, it is the approval of their superiors. Perhaps the approval from a third party - a thumbs-up from friends or the smiling faces of their children?

How about the satisfaction of patients? Hospital reviews that rave about the care, as well as the competency of its nurses is the grand scheme of patient experience. We often overlook these two important gauges in a job well done and "Trust in Us" reminds us that how a patient feels emotionally as well as physically before, during and after care can be extremely crucial to a nurse's growth, as well as the growth of the entire hospital facility.

As cleverly stated by the brilliant Maya Angelou, "People will forget what you said. People will forget what you did. But people will never forget how you made them feel."

It is easy to overlook how many people a patient will come in contact with before being admitted to our floor. It is easy for us to forget the anxiety a patient must be feeling, not knowing what to expect, being transported floor after floor.

Often, we find ourselves so pressed for time throughout a night or day of work at the hospital that empathy gives way to stress. Rather than seeing a patient as a human being to be cared for as well as treated, we begin to see them merely as jobs that need to get done - another burden on our to-do list and another admission.

It is important to keep in mind, however, that upon discharge when a patient goes out into the world, that it is not the name of the man who transported her, nor the face of the nurse that aided her that she will remember, but how she was treated and how her overall experience was.

The empathy and care of one healthcare provider can stimulate the growth of an entire facility.

CMS Policy Hurting Hospice Patients & Families
July 29, 2014 8:40 AM by Guest Blogger

A hospice patient in Oklahoma City is being denied his medications to treat his COPD, while coping with a diagnosis and treatment for tongue cancer.  In Cadillac, Michigan a patient struggling with colon cancer is being denied insulin to treat his diabetes and is in danger of diabetic shock.  

Due to a recent and poorly thought out Medicare Part D Prescription Drug policy, dying patients are revoking hospice services to maintain access to other necessary prescriptions for diseases unrelated to their terminal illness that Part D paid for until recently.  

Patients’ families are left at the pharmacy counter with no refill of medications, after the pharmacist announces that because the patient is on hospice, the pharmacy is no longer allowed to fill their prescriptions – which in not accurate. 

Or, they are going days and sometimes weeks without the necessary medication to manage symptoms that were present before they elected the hospice benefit due to unnecessary complications in approving prescriptions under Part D. 

The intention of the new Medicare Part D policy implemented by the Centers for Medicare and Medicaid Services is to prevent the federal government from incurring duplicate costs for medications of hospice patients.  

NHPCO agrees that hospice providers should be held responsible for all drugs that are related to the terminal diagnoses and those drugs that are unrelated should be billed to Medicare Part D.   

NHPCO acknowledges that there have been instances of Part D payment for drugs that should have been covered by the hospice provider under the Medicare hospice benefit.  

“The hospice community understands there is a need to address the issue. NHPCO has worked with CMS on Part D implementation for months now with limited success,” said Schumacher.  “We requested that CMS convene several different stakeholder groups to determine the best way to carry out this process so that it would be uniform and effective and we have been denied that opportunity.”

The National Hospice and Palliative Care Organization has strongly opposed the inadequate and haphazard implementation of this guidance.   

“The guidance set forth by CMS requiring a claim to be rejected by Part D before a prior authorization process can begin  has created numerous and unnecessary challenges for terminally ill patients and their families,” says J. Donald Schumacher, NHPCO president and CEO.

“Hospice providers are being tasked with sorting out a process that is difficult, lacks standardization and is incredibly time-consuming, keeping the hospice clinician in the office when they could be in the field providing care to patients and families.”

NHPCO continues to encourage CMS to halt the implementation of the Part D guidance and convene key stakeholder groups to collaborate and create a strategic and uniform process. 

An effective solution can be reached so that Part D providers, pharmacists, hospice providers and beneficiaries have developed a coherent process together and hospice patients are not denied the medications they need at the end of life.     

With a workable system, hospice patients and their loved ones can receive the care they need without suffering, confusion and hassle of an ill-conceived process.

The preceding is the collective opinion of the National Hospice and Palliative Care Organization released June 9 in a statement to the press.

Energizing Our Teams
July 22, 2014 10:45 AM by Guest Blogger

Judy Blair is senior vice president, clinical services, and chief nursing officer, Glendale Adventist Medical Center, Glendale, Calif.

As I round and ask what is going well on this unit, I often hear, "Our unit has great teamwork."

What are the characteristics of great teamwork and how do we continue to enhance it? I'd like to share a few of my thoughts. A great team:

  • Has purpose, direction and clearly defined goals. The team works to achieve these goals.
  • Understands the bigger picture and why it is so important for the goals to be reached.
  • Recognizes those who are doing things well; celebrates small and large successes.
  • Finds ways to make work fulfilling. It's hard to be motivated and energized if work is a big pain. Ideas such as a monthly birthday celebration or potluck can energize us.
  • Conveys a positive attitude. Attitudes are similar to colds - they are contagious. Positive attitudes spread just as easily as negative ones. A great team recognizes that positivity energizes us.
  • Is comfortable with coaching and being coached. Sharing trust allows team members to respectfully coach one another as they continuously improve the quality of care for our patients.

I like how Helen Keller put it, "Alone we can do so little; together we can do so much." An energized team can accomplish almost anything it sets its mind to.

To all nurses, thanks for YOUR teamwork!

Does Social Media Have a Place in Healthcare?
July 16, 2014 3:54 PM by Catlin Nalley
The prevalence of social media outlets allows us to share every detail of our life in real time, but it also begs the question, how much is too much?

It has become commonplace to share details of your work day, but for social media savvy healthcare providers a seemingly innocent post could actually be a breach of not only a patient's privacy, but also their trust.

Katie Duke, a New York City nurse, found herself out of a job following an Instagram post that pictured "a messy but empty trauma room that had been used to treat a man hit by a New York City subway train. Duke posted the photo with the caption ‘#Man vs. 6 train,'" reported ABC News.

The incident played out during a recently aired episode of "NY Med," a documentary series on ABC that follows medical staff at Manhattan's New York-Presbyterian Hospital and Newark's University Hospital.

Duke told ABC that her dismissal was not due to a breach in hospital policy or HIPAA, but rather insensitivity.

In an interview with the "New York Daily News," Duke said the post was well-intentioned. "Somebody's life was saved in this room," she said. "I just thought it was a moving and impactful picture that I wanted to share with my followers. It was just a very genuine intention of ... want(ing) people to see what goes on in an emergency room, from the perspective of being an ER nurse."

"Make sure you understand what your purpose is on social media," she added. "Be a positive professional role model for the up and coming generation of healthcare workers and students. That's my personal mission for social media."

Since she was fired, Duke has found another job and her search was documented by "NY Med."

I find it interesting that she was fired from an organization that has a camera crew on site. How much access should the public have to the day-to-day workings of our healthcare system?

In the face of a society saturated by social media and reality television, it is important to take responsibility for what you put out there and how it may be perceived by others.

What do you think? Was this a fire-able offense? Do you use social media in the workplace?
Affordable Care Act is About Wellness & Prevention
July 7, 2014 9:02 AM by Guest Blogger

By Elinor Abraham, MSN, APRN, BC, Nurse Coordinator, Federal Occupational Health Unit, Program Support Center, National Courts Building, Washington, D.C.

The Affordable Care Act (ACA) is designed to help health professionals like me have more time and opportunity to see our patients and help them remain healthy.

A large part of the ACA is about preventative Healthcare services. Indeed the law itself establishes a National Prevention, Health Promotion, and Public Health Council headed by the Surgeon General to coordinate federal prevention, wellness, and public health activities.

The Council is tasked with developing a National strategy to improve the Nation’s Health. In fact, the healthcare provider literature is full of evidence-based or research-based health interventions and screenings, and immunization programs reflective of the intent of the law and giving us guidance.

The focus of a National Strategy addresses chronic disease reduction in city, rural, and frontier areas of the country. The Prevention Council consists of 17 members of Government agencies, such as Housing, Transportation, Homeland Security, HHS, Education, Veterans, and EPA. 

Some Priorities of Chronic Disease Reduction are:

·         Tobacco Free Environment

·         Prevention of Drug/Alcohol Abuse

·         Healthy Eating

·         Active Lifestyle

·         Injury and Violence Free Neighborhoods

·         Reproductive/Sexual Health

·         Mental and Emotional Well-being

There will be funding for Community Care Centers especially in medically underserved communities providing physical, oral, behavioral, and pharmaceutical services. All children will be able to get the dental services needed at an early age.

A new model of providing care is the Accountable Care Organization (ACO) which allows a group of providers and suppliers to jointly coordinate care for Medicare patients. But this will not restrict a person’s choice of a primary care physician. Nurses will have a major role in Quality Improvement within the ACO.

There will also be School-based Health Centers so students and families can receive a full range of health services and even Home Visiting so that health professionals can provide services to pregnant women and small children to improve health outcomes. Areas with more poverty and fewer resources will not be left behind more fortunate areas of the country.

Academia and the Center for Medicare and Medicaid Services will partner to provide Inter-professional Education and Collaborative Team-based Practice and innovative programs to keep people healthy and out of the hospital. Some examples:  Controlling Blood Pressure and Cholesterol, Diabetes Self-Management, and not needing re-hospitalization after an illness or procedure.

As more people will be seeking primary care, we will need doctors, nurse practitioners, and physician assistants to meet the needs. I asked my own primary care doctor how he thought the Affordable Care Act would affect his practice. He said, “I am looking for answers and structure so I know. We need more primary care providers and assurance of how we will be reimbursed. Waiting time in offices may become longer.”

Graduate Educational Training Scholarships will be available for all health professionals with incentives to go into primary care roles. Funding will target the current Nursing shortage to schools, and hospitals and other facilities where nurses are employed. Facilities will be eligible for extra funding as nursing roles are expanded. Nurses will have roles in policy on State Health Exchanges and Wellness Education for patients, and education for perspective insurance enrollees.

The new law allows for a new trauma center program to strengthen trauma care capacity. This has many meanings. The law addresses that mental health issues will be treated with interventions and services that are on par with other medical illnesses. The Mental Health Community is talking about the trauma involved in the lives of the mentally ill. So access to Trauma Programs/Care is in the literature of Mental Health Recovery. Rehabilitation from a serious injury or illness is familiar to all of us, but the ACA is also calling for more ‘habilitation’ services to help people live with chronic illness such as multiple sclerosis.

 A new Public Health Commissioned Core Ready Reserve will be established to serve during national disasters. A Senior Care Volunteer Program will encourage Seniors to do more volunteering. The Indian Healthcare Improvement Act will be reauthorized to aid Native Americans.

Electronic medical records will be implemented and should make having all reports more seamless. E-Prescribing sends those pesky prescriptions directly to your pharmacy.  The goal is to take paper work away from providers, so they will have more time with you!

 All programs will be implemented over time as many of these innovations sound overwhelming indeed.

According to a contributor to Forbes magazine, 4 groups will benefit from the ACA:

Insurance companies will benefit the most from the new law. There will be a larger pool of insured people, so more customers. Insurance premiums have already increased, especially for people with more medical problems and fuller coverage. Some unhappy with cost increases ask “Should sicker people pay more?”

Hospitals will benefit as they will be compensated for services of indigent people who had no health insurance and now should be covered.

Fitness Clubs and Health Education Providers will benefit as wellness becomes an important part of healthcare and some insurance policies will offer discounts to people who join a fitness club or take courses on Healthy Eating for Heart Health. My own practice at Federal Occupational Health (FOH) focuses on Wellness programs and Safety for Federal Employees.

Government, local and federal, will benefit as more people will need to be hired to maintain compliance. And the IRS should be in the mix!

Getting people to sign up for insurance involves politics and the person’s ability to exercise their rights to enroll. This often is affected by the individual’s mental state. Scammers who portray themselves as Navigators or insurance companies are a threat to the vulnerable. Providers from actual healthcare centers that treat mental illness and substance abuse are discussing the difficulty getting their clients to trust and understand the new law.  Some states are even encouraging prisoners to sign up for health insurance. I have spoken with many people who are just waiting for all the website problems to be fixed and see what others are going to do before they sign up.

Different states have made the implementation of the law either user-friendly or not according to political beliefs about Obamacare. Those Governors against the program refuse to expand Medicaid, and may be hurting many vulnerable citizens. Virginia has not fully embraced the ACA and has little outreach to consumers, whereas DC has Healthlink and is reaching out to citizens with new programs for adults and children. Maryland has also set up its own health insurance exchange and has outreach to consumers.

The story is unfolding.  

Don’t Pass the Salt Shaker Please!
June 19, 2014 3:45 PM by Guest Blogger
By Theresa Conejo, RN, cardiovascular nurse at Nazareth Hospital, Mercy-Health System in Philadelphia. She is also a You're the Cure Volunteer Advocate for the American Heart/Stroke Association. Her passion is helping children and adults learn the importance of healthy eating and an active lifestyle. 

As nurses, we know eating too much salt leads to high blood pressure and puts us at risk for heart disease and stroke. Most Americans consume too much sodium in the form of processed and restaurant food. It's easy to understand why. Sodium can be sneaky. It slithers into soups and sandwiches and cozies up to cold cuts and cured meats. It plants itself in your favorite pizza and poultry and burrows into breads and rolls. Sodium is an essential nutrient, but you don't need much in your diet. It adds up fast! Take bread, for example. One piece can have up to 230 mg of sodium, while a serving of turkey cold cuts can contain as much as 1,050 mg!
The consumer's confusion occurs with the variance on the daily requirement by organizations. The CDC recommended amount is no more than 2,300 mg a day. (The CDC also recommends that people over age 51, those who have high blood pressure, diabetes or chronic kidney disease stick to no more than 1,500 mg a day.) The WHO (World Health Organization) recommends 2,000 mg or less and the American Heart/Stroke Association recommends 1,500 mg per day.

Regardless of what rule you follow, most people consume about 3,400 mg of sodium a day - far too much than needed.
Why should sodium be on your radar? About one in three Americans has hypertension and a high-sodium diet may be to blame. In some people, sodium increases blood pressure because it holds excess fluid in the body, creating an added burden on the heart. Too much sodium also increases risk for stroke, heart failure, osteoporosis, stomach cancer and kidney disease.
How much sodium a day should we eat and what's the easiest way to track it? Thanks to a growing number of iPhone and smartphone apps, our patients can make healthier choices at home or on the go.

Sodium One sodium counter tracks your daily sodium budget providing a running count of how much sodium has been consumed and how much more you can eat while staying within the CDC recommended amount of no more than 2,300 mg a day. This app provides the sodium content in restaurant and supermarket foods as well and will also create a custom food menu.

Pretty Yellow Dog, a free app, keeps lists of your favorite foods and a running total of the amount of salt consumed. This app is compatible with an iPhone and iPad.

Fooducate an app that is growing in popularity, will allow you to scan the bar code of an item and find it's nutritional content.

iSodium 3.5 is one of 9 iNutrient apps based on the USDA National Nutrient Database. 
Whether you patients are trying to lower blood pressure or live a healthier lifestyle, they should learn to read between the lines. When buying prepared and packaged foods, read the Nutrition Facts label.

Here are sodium-related terms you may find on food packages:
Sodium-free: Less than 5 mg of sodium per serving;
Very low sodium: 35 mg or less per serving;
Low sodium: 140 milligrams or less per serving;
Reduced (or less) sodium: Usual sodium level is reduced by 25% percent per serving;
Light (for sodium-reduced products): If the food is "low calorie," "low fat" and sodium is reduced by at least 50% percent per serving;
Light in sodium: If sodium is reduced by at least 50% per serving.

Food labels cannot claim a product is "healthy" if it exceeds 480 mg of sodium per reference amount, according to the U.S. Food and Drug Administration and U.S. Department of Agriculture. "Meal" products must not exceed 600 mg of sodium per labeled serving size.

You can also read the ingredient list to learn more about the source of the sodium. Watch for the words "soda" (referring to sodium bicarbonate, also known as baking soda) and "sodium" (including sodium nitrate, sodium citrate, monosodium glutamate [MSG] and sodium benzoate). Once you start to recognize these terms, you'll see why there's so much sodium in some foods - even those that don't taste very salty.

For more information on sodium and food sources visit www.cdc.gov/salt or take the Sodium Challenge at www.heart.org/sodium.

A Milestone in Protection from Influenza
June 17, 2014 1:43 PM by Guest Blogger

The following is a statement released June 17 by Biomedical Advanced Research and Development Authority Director and Deputy Assistant Secretary for Preparedness and Response, Robin Robinson, PhD. 

This week, our nation reached a milestone in battling influenza, with the U.S. Food and Drug Administration’s first approval to manufacture seasonal influenza vaccine using cell-based technology in a U.S. facility. That facility, owned by Novartis of Basel, Switzerland, and located in Holly Springs, N.C., now can manufacture cell-based vaccine against seasonal as well as pandemic influenza viruses. This new capability demonstrates the effectiveness of a multi-use approach to emergency preparedness.

Since its establishment in 2006, the Biomedical Advanced Research and Development Authority (BARDA), part of the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR), has sponsored the development of new technologies for use in emergencies, including the cell-based technology at Holly Springs. These new technologies are flexible enough to produce vaccines and other medical products for a variety of public health emergencies.

In pursuing new technology, BARDA leverages public-private partnerships. We also support development of medical countermeasures – drugs, vaccines, diagnostics and devices – that can be used to diagnose or treat illness or injury in public health emergencies like pandemics or following acts of bioterrorism, as well as day-to-day medical conditions. This multi-use approach strengthens everyday systems and increases our resilience in emergencies.

The Holly Springs facility was built through a partnership established in 2009 between BARDA and Novartis to increase the domestic production capacity of pandemic influenza vaccine and quickly provide additional influenza vaccines to combat public health threats.

In 2012, BARDA broadened this partnership with Novartis and expanded the Holly Springs facility’s role in emergency preparedness as one of three national Centers for Innovation in Advanced Development and Manufacturing. These centers provide support for the development and manufacturing of medical countermeasures and can transition efficiently to manufacture pandemic influenza vaccines or other medical products for public health emergencies. The centers also aid in bringing new medical countermeasures to the market and help train the biopharmaceutical workforce needed in the future.  

As a center, the Holly Springs facility can produce up to 200 million doses of pandemic influenza vaccine within six months of the declaration of a pandemic.

In 2012, the Holly Springs facility opened to produce cell-based influenza vaccine that could be authorized by the FDA for use during the emergency. That same year cell-based influenza vaccine called Flucelvax, made by Novartis in Germany, became the first approved by FDA for use in the United States. Now, with the approval of manufacturing the Holly Springs facility, the capacity for seasonal influenza vaccine production in the United States has increase by at least 50 million doses.

This latest FDA approval affirms the value and success possible through public-private partnerships as we move forward bringing our nation the medical countermeasures needed to protect health and save lives every day.


BSN as Entry-Level Requirement
June 16, 2014 10:54 AM by Linda Jones
To those of you who earned an ADN several decades ago and believe you can nurse circles around today's new grads (and I don't doubt that's true), let me say, before you write a letter,  that I understand you are a good and valuable nurses. I don't question your skills, especially at the bedside, and I don't think you should have to go back to school to earn a degree if you have years of experience. That said, I believe the entry level education for nursing should be at least a bachelor's. Healthcare is not what it was 20 years ago and nurses need to change along with it.

To me, it's simple: research supports there are better outcomes when nurses have a BSN. Among the many resources to support this is "Charting Nursing's Future" from the Robert Wood Johnson Foundation. As an industry that supports evidence-based practice, nursing should follow the evidence in regard to education levels.

One of the benefits of the ADN is that is makes entry into nursing affordable. Paying for a two-year degree makes the field accessible to many more people who are qualified academically. Currently, as noted in this issue's cover story, community colleges and four-year universities are partnering in what is now RN-to-BSN programs. A similar model could be developed, but the requirement to take the licensing exam would be a bachelor's degree.

Advanced Practice

One of the things nursing is doing right is differentiating nurses who practice at advanced levels. Advanced practice nurses (NP, CNS, CRNA, CNM) are recognized by healthcare systems, physicians and increasingly by the public, as having knowledge and skills beyond the staff RN. The acknowledgement is well earned and necessary, especially for nurse practitioners and clinical nurse specialists, who are taking on more leadership roles within health systems (and independent practice in the case of the NP) in conjunction with their clinical expertise.

Nurses have to be part of the health system leadership team. In a recent online article, "Non-Nurse Nursing Directors?" we heard loud and clear that many believe only a nurse can lead nurses. But there are additional skills needed for most leadership positions and education is the way to acquire that knowledge and it begins with a bachelor's degree, which could lead to an MSN or doctoral degree.

Johns Hopkins School of Nursing recognizes the need for higher education for nurse leaders and has taken a unique approach. Just announced is the "Master's Entry Into Nursing" program designed for students with a bachelor's degree not in nursing. Students will graduate with a master's degree and be eligible to take NCLEX.

"The future of healthcare demands that nurses have a solid foundation in evidence-based practice, strong leadership skills, and a commitment to lifelong learning," noted Johns Hopkins School of Nursing Dean Patricia M. Davidson, PhD, MEd, RN, FAAN.

Time for Change

Other healthcare disciplines have successfully changed their entry level requirements. Physical therapy is a good example. It moved from certificate to a bachelor's degree in the ‘50s, to master's in the ‘80s. And now, the vision of the national association (APTA) is "By 2020, physical therapy will be provided by physical therapists who are doctors of physical therapy." The changes did not result in a devastating shortage, but instead elevated the field academically, professionally and clinically. It's time for nursing to catch up with other healthcare professions and require a bachelor's degree as entry to the field.



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