Archive for June, 2012

Nurse Leaders Happy with ACA Ruling

Posted in Nursing, Nursing News

Image courtesy of dbking via Flickr

Huge news for healthcare yesterday as the Supreme Court decided to uphold the Affordable Care Act.

The decision was uncertain enough that many hospitals suspended their preparations for the ACA; now the changes that began soon after the passage of the law in March 2010 can continue, with the core measures going into effect by 2014.

The president of the American Nurses Association, Karen A. Daley, is quoted by as saying, “This decision means millions of people will have access to the basic healthcare and preventive services that they’ve lacked.” The ANA has been a staunch supporter of the ACA.

She states that there will be savings throughout the system as people get the care they need to recognize problems earlier or avoid them completely.

The law has the potential to increase the profile of RNs in the healthcare system through models like accountable care organizations, which would rely on RNs’ expertise in care coordination. The law also has an impact on nurses through the $71.3 million in grants that it made available for programs that would strengthen the nursing workforce.

The long-term goal of such programs is to alleviate a possible nursing shortage in the wake of what is expected to be an influx of newly insured patients.

“[Nurses] are well-positioned to lead in providing essential prevention and wellness services and care coordination for individuals and families,” Daley said. “The law enhances opportunities for nurse practitioners and nurse midwives to provide primary care. This will increase accessibility for the growing number of people needing basic health services.”

With the law upheld, a long list of reforms to the healthcare system can continue. The mandate for people to buy insurance or pay a tax, which was central to the court challenge, will take effect in 2014. That same year, state-based exchanges for buying insurance will begin operating.

Along with tax credits and the expansion of Medicaid — which was affected by the Supreme Court ruling, but can still go through in some form — these provisions could extend coverage to more than half of the estimated 50 million people who lack insurance.

“Though people will continue to require emergency care, this decision means that millions of people will have access to basic, primary healthcare and preventive services, which should ultimately reduce the numbers of patients seeking routine care in the ED,” said Gail Lenehan, RN, MSN, EdD, FAEN, FAAN. “Patients will get the care they need earlier instead of becoming seriously ill and requiring complex, acute care in a hospital ED.”

Key provisions of the law center on insurance reform, prohibiting insurers from denying coverage to people with pre-existing conditions, imposing annual or lifetime coverage caps or discriminating on the basis of gender when setting premiums. These measures, along with a requirement for insurers to cover young adults through their parents’ policies until age 26, can stand with the mandate remaining in place.

Numerous other changes to the healthcare system include incentives to both patients and providers to increase preventive care; Medicare-payment incentives to providers to improve quality of care while lowering costs; and grants to build and expand community health centers, which are staffed by nurses and nurse practitioners.

Lola A. Coke, APRN-BC, PhD, CNS, FAHA, FPCNA, president of the Preventive Cardiovascular Nurses Association, lauded the ACA’s emphasis on preventive care. She said the ruling addresses “important disparities in the application of evidence-based strategies for management of high blood pressure, cholesterol disorder and diabetes.”

The PCNA plans to support RNs and APRNs in implementing team-based approaches to preventive cardiovascular care. The ruling “will go a long way in amplifying what we can do, and how many patients we can reach, in the clinical setting.”

Gaming as Training for Nursing Students

Posted in Nursing, Nursing News, Nursing School, Nursing Specialties

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Practice makes perfect and nobody is a perfect nurse right away. So it would be nice if nurses could make their rookie mistakes on virtual patients rather than real ones. The University of Minnesota School of Nursing is helping to develop a bunch of computer games that allow that kind of practice for nursing students, the Minnesota Daily reports.

A clinical professor at the U of M named Tom Clancy (apparently no relation to the novelist) is working with the software company VitalSims and local hospitals to develop serious educational tools that would take their place alongside similar tools used by the military, for example.

Simulation is not new in health care — many nursing schools have fancy robot “patients” that are getting more and more sophisticated. They can be mighty expensive, though.

Games are more cost-effective and are able to provide an extremely wide variety of practice situations. Users can train for really complex situations or stick to the basics, according to their needs.

Clancy said gaming is not set to replace any of the familiar components of education, but it will supplement book work and lectures.

“Every time you go from one modality to another, you’re doing a different kind of learning,” he said. Clancy said adding gaming to students’ curricula may seem inefficient, but it reduces the time needed in other educational settings. VitalSims’ CEO Chris Duncan cited a 2008 study that showed serious gaming to assist information retention 91 percent more effectively than lecture attendance.

“We’re still trying to tease out exactly how to implement gaming in education.” Serious gaming is, Clancy said, “in its infancy.”

The game

Clancy opened an early version of his program and chose “Myocardial Infarction” (heart attack) from a list of injuries and ailments on the game’s main menu.

“You’ll have to excuse the graphics; they’re kind of old,” Clancy said.

The heart attack mission opens with a cutscene, or non-interactive scripted event, in which two identical nurses banter before entering the emergency room.

Soon after, they enter the ER, and from then on it’s strictly business. The game is played from a first-person perspective, with the player positioned over the patient. Intense music accents the time pressure, as do occasional comments from the assistant nurse.

There is a “toolbox” at the bottom of the screen in which the player selects from an array of instruments divided by category.

Clancy used his magnifying glass by finding it in a sub-menu and dragging it to the patient’s mouth. When he determined she wasn’t breathing, he opened a another menu, equipped an oxygen pump and selected the appropriate rhythm from a list. He then equipped a heart monitor, which brought up a cardiogram on the side of the screen.

“That rhythm,” Clancy explains, “happens to be very deadly.”

Next he demonstrated the scoring system by purposefully administering random drugs and using incorrect instruments. The patient eventually died.

These games will include multiplayer and cover a wide variety of cases, hopefully ensuring that students are given breadth of experience, Duncan said.

He said cultural considerations are also planned, such as settings that account for different languages and religious beliefs, which will help make it more accessible. There will also be leaderboards, which Clancy said he believes will encourage students to improve through competition.

‘The way of the future’

The new games are part of a growing trend of using gaming for professional development.

Linda Olson Keller, another professor of nursing at the University, is supportive of Clancy’s and the MHA’s project. She described a similar initiative by the U.S. Centers for Disease Control and Prevention to use games to promote public health. One game, called HealthBound, challenges players to solve health-related problems and then scores their results and encourages them to get involved in various community programs.

Another, from the Chicago Department of Public Health, is designed to prepare players for a possible anthrax outbreak.

Keller described this method of education as “the way of the future.”

Clancy foresees games becoming commonplace in other fields.

“We’re seeing this continuum of different ways of education, and gaming has its place in here now,” he said. “We’re still learning where exactly that place is.”

Teaching Empathy

Posted in Nursing, Nursing News, Nursing School

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A health care professional may have the best possible technical skills, and encyclopedic knowledge, but one more element is needed to be truly effective: empathy.

Studies have shown that this important attribute has been declining amongst nursing and medical students. The benefits of empathy go far beyond the exam room. Greater empathy levels is associated with fewer medical errors, better patient outcomes, more satisfied patients, and fewer malpractice claims.

Traditionally, empathy has been thought to be inherent — you have it, or you don’t. This article in the New York Times looks at some of the new research that indicates that it can be taught.

Building on research over the last decade that has shown that empathetic observers have brain activity, heart rate and skin electrical conductance that mirror those of the person undergoing the emotional experience — observing a friend’s hand getting slammed in a car door, for example, causes us to flinch because an image of the accident gets mapped onto the pain and threat sensors in our own brain — Dr. Helen Riess, director of the Empathy and Relational Science Program in the department of psychiatry at the Massachusetts General Hospital in Boston, created a series of empathy “training modules” for doctors. The tools are designed to teach methods for recognizing key nonverbal cues and facial expressions in patients as well as strategies for dealing with one’s own physiologic responses to highly emotional encounters.

In one lesson, for example, doctors watch a video of a tense exam room interaction while a striking graphic sidebar records the electrical skin conductance of both patient and doctor, the mismatched spikes peaking as each person’s frustration with the other escalates. Another lesson walks doctors through a series of pictures of a patient whose face expresses anger, contempt, happiness, fear, surprise, disgust or sadness.

To test the effectiveness of the lessons, Dr. Riess and several of her colleagues enrolled about 100 doctors-in-training and asked their patients to evaluate their empathy, based on the doctor’s ability to make them feel at ease, show care and compassion and fully understand patient concerns. Half of the doctors then took part in three one-hour empathy training sessions.

Two months later, the researchers asked a second group of patients to evaluate all the doctors again. They found that the doctors who had taken the empathy classes showed significant improvements in their empathetic behavior, while those who had not actually got worse at empathizing with patients.

“People tend to believe that you are either born with empathy or not,” said Dr. Helen Riess, lead author of the study. “But empathy can be taught, and you can improve.”

Compared with their peers, doctors who went through the empathy course interrupted their patients less, maintained better eye contact and were better able to maintain their equanimity if patients became angry, frustrated or upset. They also appeared to develop resistance to the notorious “dehumanizing effects” of medical training. After the empathy classes, one physician who had complained about being burned out said, “I feel as though like I like my job again.”

Responses to this study have so far been enthusiastic, in part because it is one of the first to rely on patient evaluations of empathy rather than physician self-assessment. “The holy grail of this kind of research is whether patients think doctors are empathic, not whether the doctors think they are,” Dr. Riess said. She and her colleagues plan to expand their research and offer the training to more doctors, as well as to nurses, physician assistants and others.

“We are in a special place in the history of medicine,” she said. “We have the neurophysiology data that validates and helps move medicine back to a real balance between the science and the art.”

Curious to know whether the empathy course worked, I decided to try out what I had learned in researching this column. The next day at the hospital, I took extra care to sit down facing my patients and not a computer screen, to observe the changing expressions on their faces and to take note of the subtle gestures and voice modulations covered in the course. While I found it challenging at first to incorporate the additional information when my mind was already juggling possible diagnoses and treatment plans, eventually it became fun, a return to the kind of focused one-on-one interaction that drew me to medicine in the first place.

Just before leaving, one of the patients pulled me aside. “Thanks, Doc,” he said. “I have never felt so listened to before.”

Developing Healthy Habits

Posted in Nurse Safety, Nursing, Nursing News, Obesity

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Physician, heal thyself — and nurse, get thyself fit.

It’s one of the paradoxes of the health care field that often the very people who are dispensing valuable advice about fitness have a hard time following it, themselves. According to several studies, more than half of all nurses are obese, and more than 10% smoke. Many nurses feel they are too busy to take care of themselves, tending to help others first.

Why is there this disconnect between the clinical knowledge about how to be healthier, and actually putting that into practice? How can nurses successfully reach their wellness goals?

One thing they can do is look to the behavior-change concepts they use with patients, such as the Stages of Change and the Health Action Process Approach, according to this article on

Behavior change science is still evolving, but nurses who are involved in wellness and behavior change say that the first step toward health is often finding a strong motivation to change.

It’s also important to set realistic goals, going inch by inch rather than trying to do everything at once (and getting discouraged when that doesn’t work). One nurse in the article started by just walking a mile or two around the neighborhood regularly. Another made sure she built breaks into her schedule — for every 50 minutes of work, she would take 10 minutes to get up to walk around and stretch. She not only made gains in her health but was more energetic and productive when she went back to work.

Planning for change and possible barriers also is important, said Karen Gabel Speroni, RN, BSN, PhD, MHSA, director of nursing research at Inova Loudoun Hospital in Leesburg, Va., and co-creator of a research program called Nurses Living Fit. She suggests nurses start any self-care plan by documenting their lifestyle practices — what they eat, how much water they drink, how much sleep they get — and use that information to work in small changes.

Darlene Trandel, RN, PhD, FNP, PCC, an International Coach Federation-certified professional health coach and consultant for health, wellness, lifestyle and chronic care, has worked with many nurses to create environments to help them succeed. This may mean keeping sweets out of the house, planning an activity program or finding a satisfying substitute for a cigarette. She also helps them plan for things that might sabotage their good intentions, such as treats in the break room or feeling too tired to exercise after work.

Start small, finish big

After nearly a year of neighborhood walking, Cotter’s friend suggested they walk the 2011 Oklahoma City Memorial Marathon. Cotter said she thought she could do the 13.1 mile half-marathon, so they began to increase their walking times and distances, got up early nearly every day, trained with a running group and entered short races.
Although she wasn’t dieting, Cotter started decreasing portion sizes and increasing fruits and vegetables. She didn’t lose weight at first, but she dropped a dress size and began feeling better. People started telling her she looked better, too.

The half-marathon was a success, and the friends agreed they would try for the full marathon in 2012. They finished the 26.2 mile race in 6 hours, 46 minutes. By the start of the April 29 marathon, Cotter had lost 50 pounds and six dress sizes. She was off all but one medication, including the blood pressure medications she’d assumed she would take for the rest of her life. In January, three months before the marathon, Cotter made a resolution to give up fast food, a vow she has kept “with three small lapses,” she said.

Worth the effort

Creating and sustaining a healthy lifestyle is not easy, said nurses who work in behavior change, and the process almost always involves setbacks. Tracking progress, enlisting the support of others and changing strategies to avoid boredom can help people continue with healthy changes. “Don’t hate yourself for doing behaviors that are not what you wanted,” Speroni said. “Forgive yourself and move on.” Support from friends, family and colleagues through the entire change process is crucial, Melnyk said.

There are professional reasons for nurses to take care of themselves, said Speroni, whose report, “Effect of ‘Nurses Living Fit’ Exercise and Nutrition Intervention on Body Mass Index in Nurses,” cites a recent study that concludes patients may not have as much confidence in the wellness advice of nurses who do not appear to have followed it themselves. “Weight-appropriate nurses had more public confidence in their teaching,” her report states.

Nurses who strive for a healthier lifestyle can provide inspiration for their patients to change, Harrington said. They can acknowledge that change is difficult, but also show it can be done. “Health isn’t a goal, health is who we are,” she said. Making healthy changes provides “an opportunity to be excellent role models, educators and advocates.”

Cotter said her new motivation is to be a model for others. When she teaches her students about the need to take care of themselves now, she is passionate. She brings in photos from her marathons and uses her own experiences as an example. She still has some back pain and wants to lose 25 more pounds, but she feels like she can do it. The most important lesson of her wellness journey, she said, was “figuring out that you just make time. Taking the time is hard, but eventually the benefits are worth it.”

Nurse Practitioners No Threat To Doctors

Posted in Nursing, Nursing Jobs, Nursing News, Nursing Specialties

History has shown that physicians don’t always appreciate sharing with nurses.

The field of obstetrics, which was once dominated by midwives and lay midwives, has been a battleground for years, with physicians laying claim to the right to attend all deliveries. Physician’s groups in the past went so far as to say that women who were attended by midwives were putting themselves and their babies at risk, although statistically this notion was never proven to be a reality. Midwives fought long and hard and are only now attaining the respect they deserve as non-interventionists who are fully capable of handling low-risk deliveries. Ceding to midwives has been a hard pill to swallow for many physicians.

Some physicians are now uneasy with the expanding role of nurse practitioners. The Institute of Medicine recommended in 2010 that barriers to practicing to their full scope be removed so that nurse practitioners could help to ease the shortage of primary care physicians. To date, 16 states (plus the District of Columbia) have embraced more liberal laws to allow nurse practitioners to practice fully what they have studied and trained for. Other states, such as Nebraska, are currently considering such laws.

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One would think that easing the shortage of primary care physicians would be embraced wholeheartedly by physicians, but this has not been the case. What has been the major concern voiced by primary care physicians? It seems that some physicians are worried that nurse practitioners moving in on their turf will result in lowering of physicians’ incomes. Granted, many primary care physicians earn far below what physician specialists earn, so there may be some justification for their concern.

In the first study to assess the impact of nurse practitioners in states with liberal policies versus states with more restrictive policies, researchers from the George Washington School of Public Health and Health Services found no evidence that using nurse practitioners to their full scope of practice had an adverse effect on earnings of family physicians.

This is good news on two fronts: easing the physician shortage and expanding the roles of nurse practitioners. As of May 30th of this year, the Health Resources and Services Administration stated that there are 5,902 HPSAs (health professional shortage areas) serving 59.9 million people. At a ratio of 2000 patients for every one physician, this means that 16,349 practitioners are needed to meet the primary care needs of the population. Such a vast shortage seems to indicate that there is plenty of room for all, and that nurse practitioners can fill a rather large gap in healthcare services that is not currently being filled.

As with the obstetric field, it will take time before nurse practitioners are recognized for what they alone can offer, a unique set of skills and knowledge that can complement and enhance the skills and knowledge that physicians offer. As health care policy changes in the United States, nurse practitioners are entering into a new era, one in which they will be permitted to practice to the fullest extent possible.

Love Me, Love My Microbiome

Posted in Maryland, Nursing News, Obesity

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Bacteria is bad. Right?

That is now being rethought. The New York Times has a fascinating article about new research into the “good bacteria” that live in or on the human body — all 100 trillion of them.

They’re needed for digesting food, forming barricades against the bad bacteria, even synthesizing some vitamins. But we’ve known remarkably little about them — what they look like in healthy people, and how they vary amongst individuals.

The Human Microbiome Project has been looking into this, and what they’ve found is pretty cool.

Each person’s collection of microbes, the microbiome, was significantly different from another person’s.

Their work has helped establish criteria for a healthy microbiome, so more is known about how to fix one that isn’t functioning correctly. It also helps figure out what antibiotics do to a microbiome, and how long it takes for the microbiome to recover from antibiotics.

The various microbiomes also help explain why different people react differently to various drugs, and why some people are more vulnerable to certain infectious diseases. When microbiomes cease to function correctly they are thought to contribute to chronic diseases and conditions such as asthma, irritable bowel syndrome, and maybe even obesity.

Dr. David Relman, a Stanford microbiologist, describes the microbiome as analogous to coral, with humans taking the coral role and the bacteria as the many life-forms that live within it. Dr. Barnett Kramer, from the National Cancer Institute in Maryland, says that instead we should instead consider ourselves mostly made of microbes. “We may just serve as packaging.”

The microbiome starts to grow at birth, said Lita Proctor, program director for the Human Microbiome Project. As babies pass through the birth canal, they pick up bacteria from the mother’s vaginal microbiome.

“Babies are microbe magnets,” Dr. Proctor said. Over the next two to three years, the babies’ microbiomes mature and grow while their immune systems develop in concert, learning not to attack the bacteria, recognizing them as friendly.

Babies born by Caesarean section, Dr. Proctor added, start out with different microbiomes, but it is not yet known whether their microbiomes remain different after they mature. In adults, the body carries two to five pounds of bacteria, even though these cells are minuscule — one-tenth to one-hundredth the size of a human cell. The gut, in particular, is stuffed with them.

“The gut is not jam-packed with food; it is jam-packed with microbes,” Dr. Proctor said. “Half of your stool is not leftover food. It is microbial biomass.” But bacteria multiply so quickly that they replenish their numbers as fast as they are excreted.

The bacteria also help the immune system, Dr. Huttenhower said. The best example is in the vagina, where they secrete chemicals that can kill other bacteria and make the environment slightly acidic, which is unappealing to other microbes.

Including the microbiome as part of an individual is, some researchers said, a new way to look at human beings.

It was a daunting task, though, to investigate the normal human microbiome. Previous studies of human microbiomes had been small and had looked mostly at fecal bacteria or bacteria in saliva in healthy people, or had examined things like fecal bacteria in individuals with certain diseases, like inflammatory bowel disease, in which bacteria are thought to play a role.

But, said Barbara B. Methé, an investigator for the microbiome study and a microbiologist at the J. Craig Venter Institute, it was hard to know what to make of those studies.

“We were stepping back and saying, ‘We don’t really have a population study. What does a normal microbiome look like?’ ” she said.

The first problem was finding completely healthy people for the study. The investigators recruited 600 subjects, ages 18 to 40, poking and prodding them. They brought in dentists to probe their gums, looking for gum disease, and pick at their teeth, looking for cavities. They brought in gynecologists to examine the women to see if they had yeast infections. They examined skin and tonsils and nasal cavities. They made sure the subjects were not too fat and not too thin. Even though those who volunteered thought they filled the bill, half were rejected because they were not completely healthy. And 80 percent of those who were eventually accepted first had to have gum disease or cavities treated by a dentist.

When they had their subjects — 242 men and women deemed free of disease in the nose, skin, mouth, gastrointestinal tract and, for the women, vagina — the investigators collected stool samples and saliva, and scraped the subjects’ gums and teeth and nostrils and their palates and tonsils and throats. They took samples from the crook of the elbow and the folds of the ear. In all, women were sampled in 18 places, including three sites in the vagina, and men in 15. The investigators resampled subjects three times during the course of the study to see if the bacterial composition of their bodies was stable, generating 11,174 samples.

To catalog the body’s bacteria, researchers searched for DNA with a specific gene, 16S rRNA, that is a marker for bacteria and whose slight sequence variations can reveal different bacterial species. They sequenced the bacterial DNA to find the unique genes in the microbiome. They ended up with a deluge of data, much too much to study with any one computer, Dr. Huttenhower said, creating “a huge computational challenge.”

The next step, he said, is to better understand how the microbiome affects health and disease and to try to improve health by deliberately altering the microbiome.

But, Dr. Relman said, “we are scratching at the surface now.”

It is, he said, “humbling.”

UC-Davis Graduating First Class of Nurses

Posted in California, Nursing, Nursing Jobs, Nursing News, Nursing School

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Five years ago, philanthropist Betty Irene Moore donated $100 million to the University of California – Davis, moving the School of Nursing from dream to reality. This week, the first group of nurses will graduate from the program.

25 students who were recruited for their talent and whose education was fully funded by scholarships will be graduating. The hope is that they represent a new breed of well-educated nurses who will transform the health care system.

In this article in the Sacramento Bee, the School of Nursing Dean Heather Young said, “Our goals and priorities are to improve the health care system and advance the health of our communities. We realize that nurses can, and should be, the catalysts of change.”

Young called this year’s class of graduating nurses “just a beginning.” Already another 25 students are queued up for the next two years, with more than 30 percent of them coming from underrepresented ethnic communities. The school also enrolls doctoral students in a four-year program.

In a seminal 2010 report on the future of nursing, the Institute of Medicine concluded that health care reform meant “nursing education must be fundamentally improved both before and after nurses receive their licenses.”

With the population growing older and chronic diseases taking center stage, the IOM report, which Young endorses, determined that “nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”

Young said she was drawn to the position of dean because she, too, was inspired by the vision of Betty Moore.

The story of how Moore decided to commit $100 million over 11 years to a new school of nursing is a tale of personal belief in change.

Moore had been in a hospital and experienced a medication error. A nurse had insisted she take a shot, but Moore objected. The nurse gave her the shot anyway.

It turned out the shot of insulin was meant for a neighboring patient and potentially put the health of both patients at risk.

Says nurse Johnston, “What impresses me most is that Betty Irene Moore, a person with a lot of money, didn’t go blaming the individual or the system, she did the opposite. She decided she could do something positive about the problem of medical errors, make change for the better and build a better nurse.”

Specifically, Johnston’s job, which he says is a project of the Gordon and Betty Moore Foundation, is to be an educator, a monitor and a resource to prevent patients from getting hospital-acquired infections from improper use of ventilators, intravenous tubes, catheters and the like.

In the status-quo health care system, such infections have come to be seen as somewhat of a statistical inevitability – even to the point where patients’ rights groups routinely tracked and reported their occurrence in various hospitals.

“The culture and belief that infections are a part of a hospital stay needs to change,” Johnston said.

In an interview at the UC Medical Center where he works, Johnston said his job is called “nurse champion.”

He works as part of a collaborative system for higher quality by advising and teaching medical staff on ways to curb hospital infections.

It’s a challenging and new role for Johnston, who’s worked as a nurse for 5 1/2 years.

“We are colleagues with physicians and nurses and aides,” he said. “We are change agents in the system.”

To be sure, Johnston’s gotten some push back already in his new job in the UC Davis Medical Center’s burn unit. But he’s prepared to tap into the communication and leadership skills he’s learned to overcome the skepticism.

“I was seen as an outsider, someone to audit them and get them in trouble,” Johnston said of his colleagues. “There was some question of my credibility and credentials both from nurses and the physician side. It’s a challenge. It takes time to get that buy-in.”

School Nurse Visits Up

Posted in Nursing, Nursing Jobs, Nursing News, School Nurses

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Visits to school nurses have significantly increased, likely because of the difficult economy. People often lose health care when they lose their jobs, meaning that they will sometimes send their kids to the school nurse before their primary care doctor.

In Rhode Island, increases in the last five years total in the thousands, according to this article on in the Valley Breeze.

Linda Newbury, a school nurse, provided figures that indicated that visits doubled at one school (3,800 visits to 7,554 visits) and increased significantly at almost all schools. Only one school had a decrease, from 11,000 to 10,930.

Newbury acknowledged that an increase in population is a contributing factor, but not the only one. Parents will ask school nurses, “Before I spend money, what do you see?”

School nurses also are expected to address a much wider range of medical issues, from standard sore throats and fevers to allergies and diabetes.

Cumberland school nurse Margaret Wharton said while the district had not compiled specific figures, she has also noted a similar increase in visits as the neighboring town.

“All I can say is that student visits to the nursing offices appear to continue to increase each year as many families have lost health coverage due to economic issues,” she told The Breeze.

“School nurse teachers, in many cases, have become the first person to see a child for a health issue because they provide free interim nursing care until they are able to refer the child for appropriate medical care.”

Wharton said she is “very concerned” for the next school year, when there will be one fewer nurse in the schools due to budget cuts.

The illnesses seen are cyclical, Villeneuve reported at the meeting. While strep was prevalent several years ago, this year saw more cases of pneumonia, she said.

The nurses all spoke about the increase in number and types of food-related allergies.

Wharton said when she started in the schools 21 years ago, she had about five EpiPens for children with allergies. Now she said she has “a wall full” with about 35.

Newbury said food restrictions, like not allowing peanut butter in the cafeteria, “change the climate of the classroom.”

Newbury said more “medically fragile” students are enrolled in school with more cases of autoimmune diseases and diabetes in children as young as 3.

K-9 Team Puts Nurses at Ease

Posted in Maryland, Nurse Safety, Nursing, Nursing News

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The emergency department in a hospital can be a very tense place. Injured people want to be tended to immediately, their family members get upset on their behalf, two people from an altercation can both wind up at the same hospital — there are many reasons why emotions can spill over and difficult situations can develop. And such situations can be stressful and dangerous for nurses as well as patients and their families.

At a hospital in Baltimore, a two-member security team is called when things start to get heated. One member of the team is human, but the other is a German Shepherd. Often just the dog’s presence can serve as a calming influence, according to this article on The dogs add “another level of authority,” according to the hospital’s clinical director for the ED, and “They have a nice presence.”

The hospital is in a high-risk crime area, and started using a K-9 unit in 1994 to help curb violence on the campus. Administrators think that the dogs’ presence has had a profound effect.

“Our director goes to downtown meetings in Baltimore [with other hospital administrators] and they share crime statistics,” said Mark Ross, captain of Mercy’s K-9 Unit. “It’s well-known within the city that Mercy has dogs and it’s not a place to go for crime.”

Ross and four other handlers have their dogs with them at work and at home. The dogs are imported from Europe and trained for protection and to hunt human and explosive odors. Ross, who has partnered for two years with Iko, said the dogs can track someone on the campus, find explosive devices and protect hospital personnel. Working in a hospital requires the dogs to be more sociable than other police dogs. The Mercy dogs must have the ability to be friendly one minute and ready for business the next. “It makes it a little more tricky when it comes to selecting a dog for this environment,” Ross said. “The dogs are tempered because they have to be sociable. They also have to have the ability to work or apprehend on command.”

The dogs at Mercy develop friendships with nurses and patients and are able to enjoy some attention.

“The staff loves them,” said Janet Norman, RN, MS, PCCN, nurse manager, progressive care unit. “When they are training a younger dog, a guard may say, ‘You can’t come close to this one.’ The older dogs, you can talk to them and pet them.”

There is time for pleasure, but during most of the 10-hour shifts, the handlers’ and dogs’ time is for work.

“There is an added sense of protection here,” Norman said. “We had a disturbance once and a family had become so angry. I’m not sure it was directed at us, but it was very frightening. Security came up with the dog and everyone quieted down. There was no feeling that there would be any harm to anyone.”

Handlers and dogs also may walk nurses to their cars in the parking lot. “It gives us peace of mind,” Disney said. “It’s interesting the effect when you have a really busy waiting room. The dogs have a tendency to calm everybody down. It’s a distraction as much as anything, (to) watch the dog for a minute. We joke and call them our favorite security officers.”

And like any smart dog, the Mercy K-9 dogs remember where their friends are when making the rounds. “We have a couple nurses who sneak biscuits for them,” Disney said. “They know where those nurses work and go right to them.”

On Discouraging Unnecessary Medical Tests

Posted in Nursing, Nursing Jobs, Nursing News

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Recently, the American Board of Internal Medicine (ABIM) Foundation, working in conjunction with numerous medical specialty boards and Consumer Reports, instituted an initiative to decrease the number of medical tests ordered unnecessarily by physicians. It also has contributed to new recommendations for annual exams. The initiative is called “Choosing Wisely.” The following are some of the pros and cons of this initiative.

Reduction in healthcare spending
: An article appearing in Kaiser Health News reported that $6.8 billion dollars were spent in 2009 on twelve unnecessary tests and treatments, such as ordering routine blood work during yearly physicals on healthy patients, performing Pap smears on teens who were unlikely to have cervical cancer, and ordering drugs for children with sore throats that were caused by viruses. Some experts estimate that up to 1/3 of every health care dollar spent in the U.S. is wasted on unnecessary tests, treatments and medications. A McKinsey report states that “health care spending reached record levels in 2009, both in absolute terms and as a share of GDP” . Few people will disagree that we need to spend less money on healthcare and reduce waste where possible; therefore, cutting out unnecessary tests and treatments may be a good place to start.

Reducing the risk to patients: First, do no harm. Performing unnecessary medical tests or prescribing unnecessary treatments to patients could be potentially harmful. For example, performing an unnecessary x-ray exposes the patient to harmful radiation. Prescribing antibiotics that aren’t clearly indicated (i.e. for viral infections) could result in an unforeseen drug reaction or antibiotic resistance. In addition, ordering unnecessary tests and procedures may result in increased patient anxiety.

Missing a diagnosis: One concern about discouraging tests is it might result in missing a diagnosis that otherwise may have been caught through routine testing. Some physicians may feel uncomfortable about the new initiative for this reason. A big part of the reason that physicians order multiple tests is due to the fact that doctors are vulnerable to being sued when they miss a diagnosis. Fear of litigation is a driving force behind physicians’ ordering practices. Until this fact changes (or the laws do) some doctors may be reluctant to Choose Wisely.

Removing autonomy: Some might argue that physicians go to school for many years and should be able to practice as they see fit. If insurers and payers determine that certain tests and treatments will not be reimbursable, this can be seen as a challenge to physicians’ autonomy and decision-making ability. Many doctors will be less than appreciative of this kind of oversight. On the patient side, such an initiative might not be met with favor by patients who have become used to certain treatments and test. These patients may also feel that money is being given a higher priority than their health.

As nurses, it will be our job to explain to patients why tests and treatments that they have grown accustomed to receiving are no longer being offered. Rather than confronting their physician, patients may choose to confront nurses instead. Researching “Choosing Wisely” can help us prepare for these questions.