Nursing News

PBDS and Nurse Skill Testing

Posted in Nursing, Nursing Jobs, Nursing News

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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

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The “Bugs Be Gone” educational session outlined in this Nurse.com 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

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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.

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.

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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.

Nurse Leaders Happy with ACA Ruling

Posted in Nursing, Nursing News

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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 Nurse.com 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 Nurse.com.

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.”