Archive for July, 2012

Quality Care and the Bottom Line

Posted in Nursing, Nursing News

VIP Design –

Uncompensated health care is a major issue for hospitals, with an estimated $39.3 billion of care going uncompensated in 2010. The size of this financial burden has forced hospitals to use more creative debt collections, such as asking for payment at time of service versus asking solely for insurance information.

Hospital debt has lead to the development of companies like Accretive Health. Accretive Health states on it’s website, “Accretive Health increases access to care by bringing increased discipline to the revenue cycle.” Non-profit health care organizations would all agree that a positive revenue cycle allows them to fulfill their missions. But how they collect “bad debt” has become the challenge and the legal question.

For many, the hospital is seen as a “sanctuary to treat the sick and infirm” as stated in a report by Minnesota’s Attorney General, Lori Swanson. Swanson has been working to push the issue of debt collection in health care to the forefront, forcing us to wonder what can and should hospitals be doing to address bad debt with the hope of remaining financially stable. It’s important to keep the doors open, but how to best do this?

An ill patient who is asked about payment before care is given may understand or hear the question, “how would you like to pay for your care today” very differently then a patient asked the question after care is provided. And a patient who is able to hand the hospital staff member a health insurance card is likely to have a different level of stress then one who does not have this option.

Nurses, who do not routinely have knowledge of patients’ insurance coverage or ability to pay, need to be aware of the practices being used by their employers to decrease bad debt. As the first health care professional the patient is likely to encounter after completing registration or checking in, nurses are in a key position to reassure patients that the quality of the care they will receive is not based on their ability to pay.

The nurse does this by showing the patient respect and dignity; answering questions about cost and billing honestly; and seeking help from any internal resources available in the organization, such as Social Services, a financial counselor, or a pharmacist. The nurse can also act as a patient advocate in relationship to treatment plans. The selection of a less-expensive dressing or stoma pouch versus selecting the clinic or hospital standard could mean dollar savings for a patient, with no decrease in quality.

Nursing as a profession has the responsibility to understand both sides of the bad debt issue. Advocating for patients to receive quality care regardless of ability to pay is important. However, nurses will fail patients if this is their only involvement. Nurses also can be active in quality improvement and resource projects directed at reducing cost and length of stay for patients. These are the actions that will provide our national health care with sustainable choices by addressing the cost of health care for all patients.

The Nurse’s Role in Helping to Educate Doctors

Posted in Nursing, Nursing News

iceteastock –

In this article on, a professor of nursing named Laurie Gottleib examines the role that nurses have in educating doctors.

She points to the combination of theoretical and practical knowledge that nurses possess, as well as their tendency to be much more accessible than senior doctors. Nurses frequently point out the warning signs of a patient’s deterioration to medical interns and residents, correct their misinterpretations of signs and symptoms, suggest diagnoses, and anticipate when and how to intervene. In this recent post about the “July Effect,” for example, a nurse recounts how she had to convince a new young doctor that his patient was in dire need of more pain medication.

Gottleib says that physicians are often grateful for this sort of guidance, yet nurses are not usually given credit for their role in doctors’ education.

Knowledgeable nurses protect the system in countless ways, not least by ensuring that physicians have the most up-to-date and salient information about their patients so they can make medical judgments and take appropriate action.

They are people who have committed themselves to nursing as a career and have selected workplaces that value nursing. Experience working in one place or with one group of patients is required to develop expertise and intuitive know-how – a key to reading the signs correctly and predicting which patients are in trouble.

Two decades of research have exposed the deleterious effects of devaluing and undermining nurses and nursing. The cost has been high in terms of nurse burnout and patient morbidity and mortality.

Research has also revealed the conditions needed to retain professional nurses. When nurses are recognized and respected for their expertise and given status, resources and opportunities to function autonomously within their scope of practice, they stay in the profession. The most intriguing finding in this research is that the most consistent predictor of nurse satisfaction and good personal health (i.e. a low burnout rate) is positive professional relationships with doctors. When doctors partner with nurses and there is clear communication between them, patients’ needs are met.

Within the McGill university and hospital network these lessons have been heeded. For example, there has been ongoing dialogue within McGill’s Faculty of Medicine and School of Nursing about how to improve inter-professional education. (This discussion extends to physical and occupational therapists and speech therapists.) At the Jewish General Hospital, nurse-physician partnership is the organization’s managerial structure in all matters of patient care.

These are important beginning steps for restoring the health-care system and a healthy nursing workforce. We are still recovering from the effects of the recent past, when Quebec’s nursing operations were dismantled and the nursing workforce was left not adequately prepared for today’s health-care challenges.

In the next decade we need to continue to build a workforce of front-line nurses who are well educated, knowledgeable, skilled, compassionate and committed to nursing as a career. Quebec nurses took this step themselves when they voted at this year’s meeting of the Ordre des infirmières et infirmiers du Québec to make university education a basic requirement for entry into the profession.

Employers need to continue to create workplaces where nurses are given support to practise to the full extent of their training, and where physician-nurse partnership is the governance structure. Physicians need to treat nurses as respected and valued partners, not as subordinates. Nurses need to embrace these new opportunities and become accountable for their practice. And governments need to dedicate resources to support innovative nursing roles that complement those of doctors and other health professionals to meet the complex needs of patients and their families.

When this happens, the health-care system will be transformed and quality, safe patient-and family-focused care will follow.

Media Messages about Nursing are Mixed

Posted in Nurse Safety, Nursing, Nursing News

Peter Kim –

How are nurses portrayed in the media? A group of researchers decided to find out, by examining the YouTube database to find the most viewed videos for “nurses” and “nursing” as of July 2010.

According to this article on, out of 96 videos surveyed, about 40% of them presented nurses as smart, educated, and skilled. The rest of them presented nurses as “a sexual plaything and a witless incompetent.”

This was found to be in keeping with other forms of mass media portrayals of nurses. The study indicates that these stereotypes are not merely annoying; they can have a real effect on how patients interact with the nurses who are caring for them. Nurses are highly-trained professionals who play a crucial role in American health care, yet these portrayals trivialize what they do and who they are.

The study authors suggest that the nursing profession harness the power of YouTube to promote a more positive image.

Key findings of the study, which appears in the August issue of the Journal of Advanced Nursing, included:

• The 10 most viewed videos reflected a variety of media, including promotional videos, advertising, excerpts from a TV situation comedy and a cartoon. Some texts dramatized, caricatured and parodied nurse-patient and interprofessional encounters.

• Four of the 10 clips were posted by nurses and presented images of them as educated, smart and technically skilled. They included nurses being interviewed, dancing and performing a rap song, all of which portrayed nursing as a valuable and rewarding career. The nurses were shown as a distinct professional group working in busy clinical hospitals, where their knowledge and skills counted.

• Nurses were portrayed as sexual playthings in media-generated video clips from the sitcom Frasier, a Virgin Mobile commercial set in a hospital, a lingerie advertisement and a “soft news” item on an Internet videocast. All showed the nurses as provocatively dressed objects of male sexual fantasies and willing accomplices in their advances.

• The final two clips were a cartoon that portrayed a nurse in an Alzheimer’s unit as dim and incompetent and a sitcom that showed the nurse as a dumb blonde, expressing bigoted and ignorant views about patients and behaving in a callous and unprofessional way.

“Despite being hailed as a medium of the people, our study showed that YouTube is no different [from] other mass media in the way that it propagates gender-bound, negative and demeaning stereotypes,” Fealy said. “Such stereotypes can influence how people see nurses and behave toward them.

“We feel that professional bodies that regulate and represent nurses need to lobby legislators to protect the profession from undue negative stereotyping and support nurses who are keen to use YouTube to promote their profession in a positive light.”

The July Effect

Posted in Nursing, Nursing News, Nursing Specialties

MAFord –

July is the month that medical students, fresh from medical school, start learning how to be doctors. That gives rise to the “July Effect,” where medical error rates increase as these new doctors learn on the job.

In this article in the New York Times, Theresa Brown, a nurse, looks at whether the July Effect exists, and how nurses can deal with it if so.

She notes that the medical literature is inconclusive regarding the July Effect, but cites two articles that found evidence of it. The author of one off the articles compared the deployment of new resident so to having rookie football players replace veterans “during a high-stakes game, and in the middle of that final drive.”

Brown’s own conclusion is that the July Effect “is undeniably real in terms of adequacy and quality of care delivery.”

She goes on to describe an experience she had as an oncology nurse, where a patient was dying of cancer and was in unbearable pain. She paged the first-year resident, brand-new to actual doctoring, and explained why the patient needed a much higher dose of pain medication. The doctor refused to up the dose. After trying repeatedly to convince him, as her patient writhed in pain, Brown paged the palliative care physician on call, who she had talked to about the patient day before.

I described the patient’s sudden lurch toward death, the sharp increase in pain and the resident’s reluctance to medicate the patient enough to give him relief. “Ah,” she said, “I was worried about that,” meaning that the patient might begin actively dying sooner than the medical team had expected. She ordered a morphine pump. I got the drug, loaded and programmed the machine. The patient died fairly soon after. He was conscious to the very end, and I can say he did not meet his death in agonizing pain.

A FEW hours later I ended up in the elevator with the new resident. He and I both started talking at once. Looking stricken, he apologized to me for having been busy, overwhelmed with several new patients. Knowing it is never easy to have someone’s footprint on your head, I apologized for having called in an attending physician. “I don’t usually jump the line,” I started to explain, when he interrupted me. “You did the right thing for the patient,” he said.

Such an exchange is rare. A nurse who goes over a doctor’s head because she finds his care decisions inappropriate risks a charge of insubordination. A resident who doesn’t deliver good care risks the derision of the nurse caring for that patient. Nurses aren’t typically consulted about care decisions, and this expectation of silence may lead them to lash out at doctors they see as inadequate.

The July Effect brings into sharp relief a reality of hospital care: care is becoming more specialized, and nurses, who sometimes have years of experience, often know more than the greenest physicians. We know about medicating dying patients for pain, but we know a lot of other things, too: appropriate dosages for all kinds of drugs, when transfusions and electrolyte replacements are needed, which lab tests to order and how to order them, whether consulting another specialist is a good idea, whether a patient needs to go to intensive care because his vital signs are worryingly unstable.

The problem can be limited by better supervision from senior residents, fellows and attending physicians, as well as by nurses. We need to acknowledge this fact, because admitting that new residents need help, and that nurses can and do help them, is the beginning of owning up to our shared responsibilities in providing care. For the good of our patients, nurses and doctors need to collaborate.

PBDS and Nurse Skill Testing

Posted in Nursing, Nursing Jobs, Nursing News

landrade78 –

If you want to discuss a nursing topic that everyone has an opinion about, just bring up Dr. Dorothy del Bueno’s PBDS testing program among a group of travel nurses or nurse managers.

The testing was designed to be used as a tool to help identify nurses’ weak areas so that they might receive additional training in those areas. The end goal of the testing would be a better equipped nursing staff at a reduced cost to the facility in terms of both time and money. However, some people view the test as a tool to keep licensed nurses from gainful employment even after they have passed all of the state licensing requirements to practice nursing.

According to the National Council for State Boards of Nursing website, “NCSBN Member Board jurisdictions require a candidate for licensure to pass an examination that measures the competencies needed to perform safely and effectively as a newly licensed, entry-level nurse.” But the nurses being subjected to the testing are not always entry-level, but seasoned RN’s who oftentimes have many years of practice and travel nursing experience. In this economy, nothing can strike more fear into one’s heart than the prospect of losing a good employment opportunity because of superfluous testing.

In nursing forums and on nursing blogs, travel nurses have reported having very different experiences with the testing. Some have reported the testing was fairly basic, while others say that it was silly and included unrealistic scenarios. Others complained more generally about being “tested to death”.

Either way, easy or difficult, travel nurses have reported becoming anxious in response to the idea that the testing might be a road block to landing a job. Whether it stems from the litigious nature of society, or the focus on better quality of care, skill testing is not likely to go away. If anything, testing seems to have become more prevalent in workplaces over the last decade.

The PBDS tests three skill areas: interpersonal skills which relate to customer relations, team building, and conflict resolution. These critical thinking skills encompass nursing processes used on medical and surgical floors, in critical care wards, OB and the ICU, along with other technical elements which may include creating and following a variety of care plans, based upon the diagnosis.

PBDS testing, of course, was not created to prevent nurses from working, but to be used as a tool, to keep nurses safe and to help provide the most positive patient outcomes. In response to skill testing, travel nursing companies and other staffing agencies have begun to provide study guides and additional test prep information to their nurses, both to reduce testing anxiety and to present the most qualified candidates to employers.

Bugs Be Gone

Posted in Nursing, Nursing News, Nursing Specialties

alexfiodorov –

The “Bugs Be Gone” educational session outlined in this article wasn’t about the things that bite you when you’re out on an evening walk. The bugs in question are the ones that cause infections, a serious issue for hospitals, with about one in every 20 patients developing an infection related to hospital care.

Over 60 healthcare professionals from a variety of disciplines, including many nurses, attended the half-day event to learn how to reduce that number of infections.

A registered nurse named Ellen Rankin said that it was important to gather healthcare professionals from many different disciplines “to show that this is a cross-setting issue and that we all face the same problem.”

One speaker was Janet Phillips, RN, Healthcare Quality Strategies Inc., New Jersey’s federally designated quality improvement organization, who summarized the healthcare-associated infections focus under the Centers for Medicare & Medicaid Services’ nationwide initiatives.

“The event highlighted the problem and encouraged shared improvements that can positively affect us all no matter what area we’re in,” Susan Hermida, RN, MSN, GCNS, CWCN, clinical nurse specialist at RWJ Hamilton, said in the release. “The most important step toward that goal is for everyone to wash their hands. Wash, wash, wash their hands.”

Neha Merchant, RN, of Hamilton Continuing Care, emphasized the importance of hand washing before providing a detailed look at catheter-associated urinary tract infection, central line-associated bloodstream infection and the components of an effective infection prevention program.

Among the attendees was a group of nursing students from The College of New Jersey School of Nursing. “The information presented today was really valuable,” said Corimae Gibson, a Robert Wood Johnson clinical program participant. “I’m a student at TCNJ and I’m about to enter the nursing profession. This information is the first step toward avoiding all the complications and patient loss we heard about today.”

Developing a presentation to take on the road is the collaborative’s next goal. By traveling to educate nurses in Mercer County, the team can help them identify signs and symptoms of infections that may reduce readmissions and improve patient care.

NPR Offers Answers to ACA Questions

Posted in Nursing, Nursing News

Matthew Benoit –

The Supreme Court has upheld almost all of the Affordable Care Act, a fact applauded by many nurses. It’s a complicated law, though, and many people are not completely sure what’s in it.

NPR solicited questions from their audience online and on air and received many questions, and then went ahead and answered those health care questions in this article.

Many of the questions have a short answer and a long answer — which is part of why there is so much confusion. For example, when someone asked about whether the penalty for not having health insurance affects people at all income levels, or whether low-income people will be spared, a simple yes or no answer doesn’t quite suffice. Basically, if you can’t afford insurance, you don’t have to buy it. That means (using 2010 numbers) $9,350/ year for an individual, or $18,700 for a married couple.

What if you make more than that, but you still are struggling financially? ($19,000 a year still doesn’t go very far.) Under the ACA, you can’t pay more than 8% of your household’s income for health insurance, after whatever help you might qualify for from your employer or government subsidies.

Some other questions and answers:

Q: I understand that businesses above a certain size have to provide a health care insurance option, but do they have to pay for it? Does the law require a certain contribution from the employer, or can the employer make the employees just pay, say, 99 percent of the premiums?

A: This is where the law seems a little bit tricky. It doesn’t stipulate how much of the premiums employers have to pay, but it does say that overall, employers with more than 50 workers have to provide a plan that covers 60 percent of the covered expenses for a typical population. And that plan can’t cost more than 9.5 percent of family income.

Q: How does the law affect Medicare recipients? I heard it cuts billions of dollars from the program. Does it have other effects?

A: Let’s take these one at a time. Yes, the law does reduce Medicare spending by roughly $500 billion less than it would have been without the law. That’s over 10 years, by the way, and Medicare will cost a little under $500 billion this year. But none of that comes out of benefits guaranteed under the law.

The biggest single chunk comes from reducing what had been overpayments to private HMOs and other health plans that serve about 20 percent of Medicare patients.

The next biggest chunk comes from hospitals and other providers of health care that hope to get that money back because more people will have insurance.

As to other changes to Medicare, there are actually some new benefits. The doughnut hole, that gap in coverage for prescription drugs, is being gradually closed. And Medicare patients are now getting new preventive screenings, like mammograms, without having to pay a deductible.

Q: My son lives overseas, where he is covered by the national health insurance plan. As an American citizen, would he be required to pay the fee for not being covered under an American plan?

A: No, only residents of the U.S. and its territories are subject to the insurance requirements.

Q: I am a veteran getting my medical care from Veterans Affairs. Am I correct that this counts as having insurance, when it comes to the requirement that everyone be covered or pay a penalty?

A: Yes, the VA counts. So does TRICARE and other military health plans. In fact, just about all government health care program, including Medicare and Medicaid, count as well. That’s why the Urban Institute estimates that come 2014, only about 7 million people out of the U.S. population of well over 300 million will have to either purchase insurance or be subject to paying the penalty.

Q: If my current insurance policy does not meet the minimum requirements in the Affordable Care Act, and my insurer must raise the standards of my policy, can my insurer raise the premiums I pay?

A: In a word, yes. That was part of the goal of the law, not just to get people without insurance to have it, but to get people with what was considered substandard insurance up to par. This is controversial, and it’s the part that leads to claims that the government is interfering in the private insurance market, which in this case it is. But it’s in the law because Congress heard about lots and lots and lots of cases where people who had insurance nevertheless ended up bankrupt because the insurance didn’t cover what they thought it did. So will this make healthy people who have to spend more unhappy? Yes. But will it protect people better when they do get sick? Yes, it will do that, too. And will the arguments about it continue? Yes, undoubtedly.

Nurse Puts Diet Where Her Mouth Is

Posted in Nurse Safety, Nursing, Obesity

Elenathewise –

One thing that comes up sometimes with nurses is the disparity between the talk and the walk — when great advice is being given about how to get and stay fit, but the nurses giving that advice are not fit, themselves.

A Minnesota nurse named Michelle Williams says that she always felt hypocritical when she stressed the importance of being fit to her patients. “I’m telling people to lose weight, watch their diet. And I weighed 270 pounds,” she says in this article in the Star Tribune.

Not anymore, though. After a lot of hard work and dedication, she’s dropped 95 pounds. She has improved her health, changed her outlook, and serves as an inspiration to patients and colleagues.

Her identification badges at the hospital still have photos that were taken before her weight loss — she keeps wearing them, to show patients that she’s putting her diet where her mouth is. She’s been on a strict diet while also exercising regularly.

Long before she decided that her ideal meal was a cup of garden vegetable soup with pesto and a half sandwich at Panera, she pretty much ate whatever she wanted, whenever she wanted. Her parents were overweight. Williams was big as a child. For her, this was normal.

And she’s a good cook.

Obesity brought Williams awkward moments as a child. But when she reached 33, she was in crisis mode. She was diagnosed with hypertension. As a cardiology specialist, she didn’t have to read any health charts to predict what her future might be like unless she drastically changed her lifestyle.

North Memorial offered the Optifast program. Williams, who is single, began 14 months ago. She has lost 34 percent — or one-third — of her total body fat.

It hasn’t been a piece of cake.

“I’d go hours and hours without eating,” she recalled. “And then I’d eat a ton.”

When she started the program in May of last year, she immediately gave up soda, which she loved. She reduced her carbohydrate intake, a difficult task for someone who loves bread. But the hardest part was the exercise.

“I’m not crazy about running or some of the machines,” she said. “But I do what I need to do. At first, I forced myself. Eventually, it became part of my routine.”

Doctors at North Memorial now point to Williams as an example of what can be.

She’s not sure how far her journey will take her. But on Labor Day weekend, she will be in New York, where half of one of those 2-inch-thick deli sandwiches could last the entire three days.

“I’m excited,” she said. “This is a dream come true.”

The trip to New York is just the cherry on the cake. Her greatest reward is what she no longer sees in the mirror.

Nursing and the New Face of Health IT

Posted in Nursing, Nursing News, Nursing School

As technology changes, nursing transforms its model of patient care. With the advent of personal digital assistants, smartphones, tablets and pocket-size computers, nursing has had to integrate new tools into its practice in order to provide better, safer patient care, improve patient outcomes, and communicate better with other members of the healthcare team.

The Institute of Medicine and the Robert Wood Johnson Foundation have released a landmark report, The Future of Nursing, Leading Change, Advancing Health, which issues recommendations for nurses to effect positive change in health care delivery. Each recommendation offers an opportunity to use IT tools to improve the quality, efficiency and safety of patient care.

Recommendation 1: Remove scope of practice barriers. Extending authority and reforming practice acts will enable nurses to receive incentive payments from Medicaid for “meaningful use of electronic health records” (EHRs) as provided in the Health Information Technology for Economic and Clinical Health Act, which is part of the American Recovery and Reinvestment Act of 2009. Under the Act, nurses are classified as “eligible providers,” which means nurses can use EHRs to collect and exchange patient information, resulting in better care and outcomes.

Oscar Espinoza -

Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Nurses need to take a more active role as leaders of healthcare teams, whether in research, design of practice environments, or sharing best practices. When implementing new technologies, nurses should track the impact the changes have on delivery of care in order to provide positive and negative feedback to the design team.

Recommendation 3: Implement nurse residency programs. Whether a nurse has just received her license or has earned an advanced degree, nurses need time to master the skills and knowledge of a new role. Technology can assist nurses in learning new competencies by using electronic patient simulation tools, which require critical thinking skills and psychomotor skills while providing experience with using EHRs.

Recommendation 4: Increase proportion of nurses with BSN degree to 80 percent by 2020. This goal represents a 30 percent increase overall in the number of BSN-prepared nurses. Distance learning is a valuable means towards this end, given its flexibility. Distance learning also reduces the cost factor of higher education, which enables more students to take advantage of educational opportunities.

Recommendation 5: Double the number of nurses with a doctorate by 2020. The faculty shortage in U.S. nursing schools is responsible in part for the nursing shortage today. Again, technology can help by offering online education opportunities as well as providing opportunities for information-sharing and collaboration.

Recommendation 6: Ensure that nurses engage in lifelong learning. In order to stay current in their field, nurses need to learn new technologies and competencies and integrate them into their practice.

Recommendation 7: Prepare and enable nurses to lead change and advance health. All nurses need to embrace technology, whether it is being used at a patient’s bedside or in a nurse leadership position. The nurse informatician must take the lead in a strategic and operational role to bridge the gap standing between clinicians and technology. The nurse informatician gathers input from clinicians, designs an efficient workflow and tracks the results.

Recommendation 8: Build an infrastructure to collect and analyze healthcare workforce data. Data that is not organized in the best possible way wastes time, effort and money. Nurses need to keep an eye out for inefficiencies and either propose change themselves or seek out experts to keep an organization’s IT systems current.

The recommendations in this report have been a sort of call to action for the 3 million nurses in the U.S. to embrace and integrate health IT into their daily practice. The long-standing goal of health IT has always been to improve patient care and outcomes, but it can also affect nursing education, research, leadership and policy, ultimately improving nursing as an art and science.