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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.

Pros:
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.

Cons:
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.

Helping New Moms Achieve Success

Posted in Nursing, Nursing Jobs, Nursing News

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The Nurse-Family Partnership in Virginia assigns a nurse to visit low-income, first-time mothers at home every week, starting early in pregnancy and not ending until the child’s second birthday.

This article in the Virginian-Pilot followed nurse Glenda Asterilla-White as she visited a pregnant 24-year-old named Crystal Stewart in her home.

They discuss things like nutrition, what to expect from each doctor’s appointment, and the need to decrease caffeine intake.

The nurses in the program offer information about how to achieve a healthy pregnancy and also help the mothers prepare for the child. Then after the baby is born, they help offer guidance and information for successful parenting strategies.

Nurse-Family Partnerships have been shown to be extremely successful, when done right. (Especially, the more skilled the nurses, the better the outcomes.)

“This technique that they have really focused on in the Nurse-Family Partnership is intended to help the family be empowered rather than simply supplying them the information,” said Dr. Nancy Welch, acting director of the Western Tidewater Health District.

More than a dozen studies have documented the Nurse-Family Partnership’s impact over three decades.

Researchers say the program improves prenatal health, reduces the number of subsequent pregnancies for the mother, and increases the number of months she is employed. The children experience fewer injuries and are better prepared for starting school.

The program’s success comes from the trust that nurses inspire and the long-term bonding between the nurses and the mothers, said Lauren Baker, chief marketing and communication officer for the partnership.

The results impressed Welch, who also is the director of the Chesapeake Health District. In that capacity, she had evaluated a similar nurse home visiting program in Chesapeake.

Her conclusion: Over a five-year period, families supported by the Baby Care program had lower infant mortality rates, a smaller percentage of low-birth-weight babies and fewer premature births than families in a control group. If the program was expanded to cover all of the city’s premature births, it could save $1.34 million in hospital costs annually, a 129 percent return on the original investment, according to her estimates.

That analysis, along with the Nurse-Family Partnership studies, reinforced Welch’s conviction that home visiting programs work.

Some already existed in Western Tidewater, including one that focuses on parenting education and one for teens who are pregnant or parents.

When the national health law provided more money to the state for such programs, Welch applied for a grant. Relatively high poverty, dropout rates, unemployment rates and pre-term deliveries put Suffolk and Southampton County families at higher risk for unhealthy children, she wrote. Both localities could benefit from another home visiting program.

The health district was awarded a combined $450,000 from the government and Obici Healthcare Foundation. The grant allows five nurses to serve a total of 100 families for four years in Isle of Wight, Franklin, Suffolk and Southampton.

A nurse for more than 30 years, Asterilla-White decided to join the program for a new challenge and because she had been a teen mother herself.

“I’m getting a kick out of being able to make sure that the resources are known by the mothers and that I’m making a contribution,” she said.

Stuart signed up because she wanted as much support as she could get.

“It’s not like a business coming to you,” Stuart said. “It’s more like family.”

Effective Communication and Patient Safety

Posted in Nursing, Nursing Jobs, Nursing News

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Communication has a direct impact on patient safety, according to a new report which found that hospitals where physicians and nurses scored highest on communication also had fewer patient safety events.

The report from HealthGrades is summarized in this article on Nurse.com. The report analyzed patient safety data for hospitalizations between 2008 and 2010.

They found that during that time period, 254,000 patient safety events among Medicare patients could have been prevented, and that 56,367 Medicare patients who died experienced one or more of these events. Data was also taken from Medicare patients’ satisfaction scores. The better the communication, the better the care.

Among the report’s key findings:

• 27% more overall patient safety events occurred in hospitals performing in the bottom 10% for nursing communication, compared to the top 10;

• 15% more overall patient safety events occurred in hospitals performing in the bottom 10% for physician communication, compared to those in the top 10%;

• 13% more patients at hospitals performing in the top 10% for patient satisfaction reported they received instructions on what to do when they left the hospital, compared to the bottom 10% — key guidance that underscores the importance of communication, according to the report.

HealthGrades conducted the analysis as part of its process for identifying the HealthGrades Patient Safety Excellence Award and HealthGrades Outstanding Patient Experience Award recipients. This year, 263 hospitals received the Patient Safety Excellence Award (http://bit.ly/JDRf3e) and 332 received the Outstanding Patient Experience Award (http://bit.ly/JIHBly), with 47 receiving both.

“We have reached a point where Americans must acknowledge the connection between communicating with their healthcare provider and their own safety and satisfaction as patients,” Kristin Reed, MPH, the author of the study and vice president of clinical quality programs for HealthGrades, said in a news release. “Our research revealed some shocking disconnects.”

For example, Reed said, catheter-related bloodstream infections were about 56% more common in hospitals with poor nursing or physician communication.

Waiting for Nurses

Posted in Nurse Safety, Nursing, Nursing News

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A new poll has found that 34% of patients who were hospitalized for at least one night in the past year said that “nurses weren’t available when needed or didn’t respond quickly to requests for help.”

The poll was conducted by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health.

NPR was surprised at the findings and decided to find out more, so they put a request on Facebook for nurses to respond to the poll and provide their own stories. They received hundreds of responses, with stories about nurses feeling overworked, not getting enough breaks or even no breaks at all, and even barely enough time to go to the bathroom.

Most of the nurses who responded did not want to be interviewed for a broadcast, because they were worried about their employers’ reaction. Many were willing to be interviewed anonymously, though.

They conveyed a picture of being understaffed and overworked — even though the nursing shortage is considered to be over in most places, each individual nurse still has a whole lot on his or her plate.

“We’re always afraid that something will happen to our patients during the time we’re off the floor,” one nurse says, “and I personally don’t feel comfortable leaving them unless I know that a co-worker is actually looking after them during the time that I’m off the floor.”

This nurse says she rarely stops. Not for 12 hours. She’s an emergency room nurse in a busy urban hospital. The ideal, she says, would be one nurse for every three patients in her ER. But she typically cares for five patients or more — often eight, if she’s covering for a colleague taking a lunch break. She says there are times when she can’t leave patients’ bedsides.

“Maybe I was injecting medication that you have to push slowly over five to 10 minutes so it doesn’t harm them,” she says, “and I can see the call bell going off in the hallway, and there’s no way I could respond to that.”

The only option is to literally yell down the hallway and hope another nurse hears her and responds to the patient call bell. There have been times when she has driven home at the end of her 12-hour shift, white-knuckling the steering wheel and wondering whether she “missed something.”

Another nurse likens her job to “spinning plates,” just “praying,” she says, that one doesn’t fall. “And these are human beings,” she says, “not products on conveyor belts.”

Stories like this suggest there’s a shortage of nurses. But Linda Aiken, a researcher and professor of nursing at the University of Pennsylvania School of Nursing, says that’s not the case. There was a shortage about a decade ago, she says. Today, that has changed. The number of RNs graduating has increased dramatically over the past decade, but many can’t find jobs.

“There’s not an actual nursing shortage,” Aiken says. “There’s a shortage of nursing care in hospitals and other health care facilities.”

Nancy Foster, a vice president with the American Hospital Association, says hospitals are facing big financial challenges.

“In part, it’s because our patients are sicker — coming to us with more intense diseases and disorders than they did 25 years ago,” she says. “In part, it’s because there’s so many more medications and devices and other interventions at our fingertips; we can help many more patients and restore them to health.”

That is terrific, of course, but it’s not cheap. Any reduction in nurse staffing at a time of increasing patient demand jeopardizes patient care, Aiken says.

“Nurses are the surveillance system in hospitals for early detection and intervention [to save patients’ lives],” she says.

According to one nurse, little clues from patients are critical.

“I mean, you might walk into a room, and they are breathing and answering your questions,” the nurse says, “but if you look at their neck and the jugular vein is slightly distended … taking the time to pick up on the small details like that are the early warning signs that somebody is getting sicker fast.”

Putting Patients First

Posted in Nursing, Nursing Home, Nursing News

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Going to the hospital is just plain not fun.

But there are some hospitals who are trying new ways to make their patients’ stays as pleasant as possible. They are working with an organization called Planetree, founded by a former patient named Angelica Theiriot.

In the 1970’s, she was very ill and had to be hospitalized. The actual care she got was pretty good, she said, according to this article on the NPR website, “but she was really horrified by the human experience that she had.” She founded Planetree with the goal of changing the health care system to be more patient- and family-centered.

After more than three decades of pursuing this goal, Planetree has “designated” 30 hospitals and nursing homes in the U.S. and four other countries as meeting their criteria as someplace that provides truly patient-centered care.

One such hospital is Fauquier Hospital in Warrenton, Virginia. Its CEO, Rodger Baker, says that while he made the decision to get Planetree certification partly for business reasons, he agrees with the organizations goals and that was a primary motivation. He decries practices such as gowns with no backs on them as “stripping patients of their dignity.”

Fauquier offers services such as making all of its patient rooms private; food is cooked and delivered to order; the walls are decorated with local art; and the hallways are carpeted. They also offer massage therapy onsite, and even bake cookies!

The hospital’s concierge (it has a concierge) says that Fauquier has a “different energy about it” since it adopted the Planetree model.

Doctors and patients seem to agree.

Interventional radiologist Adam Winick admits he was a skeptic at first.

Winick says he was particularly concerned about doing away with set visiting hours, which among other things gave patients’ families open access to the intensive care unit.

“My own little area that I was most worried about was in a code setting when the patient’s heart stops. And having the family members standing there watching I felt would traumatize the patients’ families, because they don’t understand what’s going on,” he says.

But that hasn’t turned out to be a problem after all: The hospital always makes sure a staff member is on hand to explain to the family what’s going on in those situations.

Winick also says that communication has improved between patients and staff, and between doctors and nurses as a result of the changes. Poor communication in the hospital was a key complaint in the poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard School of Public Health.

“It puts everybody in the mindset that I’m doing this for the patient,” he says. “A doctor doesn’t mistreat a nurse out of anger because he’s doing it or she’s doing it — asking a question for the patient’s benefit.”

Patients also seem to appreciate what they see as more personal care.

“It’s friendly, it’s more like home,” says Marianna Traczuk, who’s been in and out of Fauquier several times being treated for ovarian cancer. She says she prefers Fauquier to the hospital where she used to get care in Maryland. “It’s nice to have someone walk in and say, ‘Hi, how are you today?’ instead of walking by and acting as if you’re invisible.”

And how much more does all this pampering cost?

Actually, unlike many hospitals, Fauquier doesn’t charge extra for private rooms or fancy food.

And Planetree President Susan Frampton says that providing the kind of care that involves patients and their families, and that patients actually want, can cut costs. She says that one hospital system that has some hospitals in the Planetree system and some that aren’t compared its orthopedic patients.

“And they found that the length of stay was actually shorter” in the Planetree hospitals, she says. “People healed quicker, they were discharged more quickly, and so the cost of care came down. So [it was] interesting to counter that misbelief that care has to be more expensive if it’s done in a patient-centered context, or in a place that’s more pleasant to be in.”

But health quality experts like Don Berwick, the former head of Medicare, warn that the most important part of places that are designated by Planetree aren’t the fancy extras like alternative therapies or fancy food — it’s the actual involvement of patients and families in their own care.

“The amenities are nice, of course,” he says. “But what really counts in patient-centered care is that the more patients and families and their loved ones participate in their own care, really play an active role in the care itself, the better the care gets. Outcomes get better, costs fall, and satisfaction increases. So this isn’t about the amenities; this is about the core of health care.”

Berwick and other quality experts also warn that being a patient-centered facility doesn’t itself guarantee high-quality care. Patients still have to make sure the medical staff is following proper guidelines for care and getting those good outcomes. But they say that keeping the patient and family highly involved in their care is one important indicator of a good hospital.

Horizontal Violence in Nursing

Posted in Nurse Safety, Nursing, Nursing News

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Nurses can expect the occasional outburst from a patient whether verbally or physically, but when violence or bullying comes from their co-workers, nurses may find themselves unsure of how to react. Horizontal violence is when some sort of violence comes from a peer, rather than a consumer or a supervisor. Victims of horizontal violence can experience psychological distress, and their workplaces can suffer decreased morale and a higher turnover rate. But why and how does the violence start? It is a mere dislike for a co-worker or a culturally imbedded phenomenon?

One theory suggests that in order to assimilate into a group, an individual first observes the behavior, attitudes and emotional reactions that the members of the group display, and the individual then mimics that behavior in order to be accepted. This pattern is also known as reciprocal determinism. In theory then, if the group engages in bullying a co-worker, the individual who wants to join the group will engage in the same behavior. It is not surprising then that at a 15-member meeting on nursing retention, all but one member could relate a first-hand experience of workplace bullying.

In a study led by Nancy Walrafen, MS, RN, OCN, respondents scored the top five behaviors considered bullying or workplace violence, and as witnessed as being done to others, as follows:

– Backstabbing – complaining to others about one individual (77.0%)
– Failure to respect the privacy of others – gossip or talking about others without their permission (76.0%)
– Nonverbal negative innuendo – raising eyebrows or face-making (72.2%)
– Bickering among peers (72.1%)
– Covert or overt verbal affront – snide remarks, withholding information, abrupt response (66.7%)

The most egregious behavior, undermining clinical activities (not available to help, turning away when asked for help), was witnessed by 50% of the respondents. If half of all nurses witness this behavior, how is it affecting patient outcomes or satisfaction scores?

One-third of the respondents reported that they had engaged in negative behavior because they had gotten caught up in the moment or the culture surrounding them. Some did not realize that the displayed behavior was considered bullying or workplace violence.

Nurse victims of workplace bullying often do not report the incidents. Reasons for this vary, from a desire to avoid making waves on a team that needs to maintain cohesion, to feeling that one more report won’t make a difference to supervisors or administrators who have been actively ignoring a problem.

In the study, respondents were also asked to contribute positive suggestions on possible methods for dealing with workplace violence and bullying in the nursing profession. Cultural awareness and appreciation for the differences and similarities was viewed as a possible solution, especially if hospital-sponsored continuing education credits on cultural awareness could be given. One respondent suggested practicing the golden rule of “do unto others” as no one wants to be treated negatively. One nurse offered that adequate staffing could reduce much of the stress on co-workers, giving them the opportunity to focus more on their own needs. All of the respondents agreed that all levels of management should work to address and solve the problem of horizontal violence in their workplace.

Nurses Play a Crucial Role in American Health Care

Posted in Nursing, Nursing Jobs, Nursing News, Pennsylvania

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In an editorial, the Reading Eagle says that the community should take a moment to salute its nurses.

Noting that pretty much everyone has been cared for by a nurse, a nurse practitioner, or a licensed practical nurse, the editorial recognizes “all in the nursing profession who have come so far since Florence Nightingale founded the modern nursing movement.”

Nurses have always been important but are becoming even more important for a variety of reasons, including changes in the law and industry trends. Nurses are an integral part of a patient’s medical team and are consulted along with the primary care doctor, physical and occupational therapists, pharmacists, and more. Nurses are also increasingly taking on an advocacy role, studying patient histories and catching mistakes in medications.

They’re also doing more in-home care, due to health insurance trends towards shorter hospital stays.

And nurse practitioners can write prescriptions and do some of the more routine tasks that doctors usually do, thereby easing some of the pressures on the system and filling the gap left by the decreasing number of family doctors and general practitioners.

Nurses aren’t just generalists anymore. All require continuing education, and many require certification in a specialty, such as surgery, pediatrics or trauma. As was recently reported in the Reading Eagle, some nurses even are trained in the specialty of collecting forensic evidence from rape victims to be used by law enforcement in court cases.

Along with all the other changes in the profession, technology has changed nursing in ways that still are being measured.

As The New York Times reported in January: “In just a few years, technology has revolutionized what it means to go to nursing school, in ways more basic – and less obvious to the patient – than learning how to use the latest medical equipment.

“Nursing schools use increasingly sophisticated mannequins to provide realistic but risk-free experience; in the online world Second Life, students’ avatars visit digital clinics to assess digital patients.

“But the most profound recent change is a move away from the profession’s dependence on committing vast amounts of information to memory. It is not that nurses need to know less, educators say, but that the amount of essential data has exploded.”

We hope that the use of technology doesn’t replace the personal care members of the nursing profession are known for and that attracts men and women to the profession.

It is that personal care that we and other members of the health care profession depend on.

The Power of Nurse-Family Partnership

Posted in Nursing, Nursing Jobs, Nursing News

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A single program can cut the number of abused or neglected children in America in half; reduce the number of babies or toddlers hospitalized for accidents or poisonings by more than half; and provide a 5 to 7 point I.Q. boost to children born to the most vulnerable mothers.

This program is the Nurse-Family Partnership program or NFP, founded by David Olds in the early 1970’s. It has been studied carefully and has shown “sizable, sustained effects on important life outcomes which were replicated across different populations,” according to this article by David Bornstein in the New York Times’ Opinionator.

The program arranges for registered nurses to make regular home visits to first-time mothers who are low-income or otherwise vulnerable, starting early in their pregnancies and continuing until the child is two years old. The program has assisted 151,000 families to date and has the potential for even larger impact, due to the Affordable Care Act’s Maternal, Infact, and Early Childhood Home Visiting Program. This provides $1.5 billion for states to expand programs like the NFP.

Bornstein says, “Done well, it could be among the best money the government spends.” The problem is that not all such programs are done well. He encourages policy makers and proponents of home visiting to pay attention to the specific elements of the NFP model that account for its success.

One of the most important elements proved to be nurses. When it came to improving children’s health and development, maternal health, and mothers’ life success, registered nurses got results that were much better than when other, similar programs used paraprofessionals instead.

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin. But there were other reasons nurses were effective. Pregnant women are concerned about their bodies and their babies. Is the baby developing well? What can I do for my back pain? What should I be eating? What birthing options are available? Those are questions mothers wanted to ask nurses, which was why they were motivated to keep up the visits, especially mothers who were pregnant for the first time.

Nurses had more influence encouraging mothers to delay subsequent pregnancies, Olds explained. They could identify emerging complications more promptly, and they were more successful at getting mothers to stop or reduce smoking, drug or alcohol use. This is vital. Prenatal exposure to neurotoxicants is associated with intellectual and emotional deficits. It can also make babies more irritable, which increases risks of abuse. (A mother who was abused herself is more likely to misinterpret an inconsolable baby’s crying as “bad behavior.”)

“A lot of the young mothers have had some pretty terrible early life experiences,” says Olds. “It’s not uncommon for them to have been abused by partners or never have had support and care from a mother. Their lives haven’t been filled with much success and hope. If you ask them what they want for themselves, it’s not uncommon for them to say, ‘What do you mean?’”

A big part of NFP’s work is helping them answer this question.

Consider the relationship between Rita Erickson and Valerie Carberry. Rita had had a methadone addiction for 12 years and was living from place to place in Lakewood, Colo. She found out she was pregnant; a parole officer told her about NFP. “I’d burned bridges with my family,” Rita told me. “I was running around with the wrong people. I didn’t have anyone I could ask about being pregnant.” In the early months, Valerie had to chase her around town, Rita recalled. “I was worried she might say, ‘This is too much hassle. Come back when you have your act together.’ But she stuck with me.”

Over the next two years, they embarked on a journey together. “I had a zillion questions,” Rita recalled. “I was really nervous at first. I had lived most of my adult life as a drug addict. I didn’t know how to take care of myself.” On visits, they discussed everything: prenatal care, nutrition, exercise, delivery options. After Rita’s daughter, Danika, was born, they focused on things like how to recognize feeding and disengagement cues, remembering to sleep when the baby sleeps, how to manage child care so Rita could go back to school. For Rita, what made the biggest impression was hearing about how a baby’s brain develops — how vital it was to talk and read a lot to Danika, and to use “love and logic” so she develops empathy. Once Valerie explained that when babies are touching their hands, they’re discovering that they have two. “To me that was really amazing,” Rita said.

This month, Rita is graduating from Red Rocks Community College with an associate degree in business administration. She’s going to transfer to Regis University to do a bachelors degree. Her faculty selected her as outstanding graduate based on leadership and academic achievement — and she was asked to lead the graduation procession and give one of the commencement speeches. Danika is thriving, Rita said. Recently, she came home from preschool and announced: “Mommy, I didn’t have a good day at school today because I made some bad decisions and you wouldn’t be proud of me.” (She had pushed another child on the playground.) As for the NFP, Rita says that it helped her recover from her own bad decisions. When Valerie came along, she needed help badly. “I didn’t care about my life. I didn’t care about anything. I never ever thought I would have ended up where I am today.”

“When a woman becomes pregnant whether she’s 14 or 40, there’s this window of opportunity,” explained Valerie, who has been a nurse for 28 years and hasworked with more than 150 mothers in NFP over the past seven. “They want to do what’s right. They want to change bad behaviors, tobacco, alcohol, using a seat belt, anything. As nurses, we’re able to come in and become part of their lives at that point in time. It’s a golden moment. But you have to be persistent. And you have to be open and nonjudgmental.”

Beyond the match between nurses and first-time moms, there are multiple factors that make NFP work. (NFP has identified 18 key elements for faithful replication.) The dosage has to be right: Nurses may make 50 or 60 visits over two and a half years. The culture is vital: It must be non-judgmental and respectful, focusing on helping mothers define their own goals and take steps towards them. The curriculum should be rigorous, covering dozens of topics — from prenatal care to home safety to emotional preparation to parenting to the mother’s continuing education. Nurses need good training, close supervision and support, and opportunities to reflect with others about difficult cases. And, above all, data tracking makes it possible to understand on a timely basis when things are working and when they are not.

With the government making such a large investment in home visiting, it’s crucial for programs to get the details right. Otherwise, society will end up with a mixed bag of results, and advocates will have a hard time making the case for continued support. That would be a terrible loss. “When a baby realizes that its needs will be responded to and it can positively influence its own world,” says Olds, “that creates on the baby’s part a sense of efficacy — a sense that I matter.” It’s hard to imagine higher stakes.

Blame The Nurse, A Time-Honored Tradition

Posted in Nurse Safety, Nursing, Nursing Jobs, Nursing News

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Theresa Brown, an oncology nurse, describes a situation in which an entire medical team on its morning rounds stands in a patient’s room, waiting for a test result. The patient, a friendly middle-aged guy, jokingly asked his doctor whom he should yell at. The doctor turned and pointed at the patients’ nurse and replied, “If you want to scream at anyone, scream at her.”

In this article on the New York Times’ Well blog, Brown notes that this bullying didn’t happen 30 years ago and it didn’t happen on a TV show like “House” — it happened to her, just a few months ago.

Brown later asked the doctor if she could quote him for the article, and he nonchalantly said “Sure, it’s a time-honored tradition — blame the nurse whenever anything goes wrong.”

While Brown was stunned and insulted, she also was concerned about the problems such attitudes pose to patient health. Nurses are the hospital’s front line, and such attitudes can create a hostile and even dangerous environment in a setting where “close cooperation can make the difference between life and death.” While many hospitals have anti-bullying policies, the seriousness of the issue is too rarely recognized.

While most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

When a doctor thoughtlessly dresses down a nurse in front of patients or their families, it’s not just a personal affront, it’s an incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are.

That said, the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

And because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

Such an uncomfortable workplace can have a chilling effect on communication among staff. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about the role of bullying in medical errors, the Joint Commission, the primary accrediting body for American health care organizations, has warned of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.

What can be done to counter hospital bullying? For one thing, hospitals should adopt standards of professional behavior and apply them uniformly, from the housekeepers to nurses to the president of the hospital. And nurses and other employees need to know they can report incidents confidentially.

Offending parties, whether doctors or nurses, would be required to undergo civility training, and particularly intransigent doctors might even have their hospital privileges — that is, their right to admit patients — revoked.

But to be truly effective, such change can’t be simply imposed bureaucratically. It has to start at the top. Because hospitals tend to be extremely hierarchical, even well-meaning doctors tend to respond much better to suggestions and criticisms from people they consider their equals or superiors. I’ve noticed that doctors otherwise prone to bullying will tend to become models of civility when other doctors are around.

In other words, alongside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.

This shouldn’t be hard: most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them. But unless we can change the overall tone of the workplace, doctors like the one who insulted me in front of my patient will continue to act with impunity.

I wish I could say otherwise, but after being publicly slapped down, I will think twice before speaking up around him again. Whether that was his intention, or whether he was just being thoughtlessly callous, it’s definitely not in my patients’ best interest.

Nurse Celebrates Week With Pride

Posted in Nursing, Nursing Jobs, Nursing Specialties

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Nurses everywhere are celebrating National Nurses Week May 6th through 12th.

One such nurse, Renee DeRider, says that nursing has been one of the most rewarding experiences she’s ever had.

DeRider has over a decade of experience nursing. She graduated in 2001 and immediately started working in pediatrics, with a concentration in hematology, oncology, and surgery. Now she works in a hemophilia center where she coordinates patient care for both children and adults with bleeding disorders.

This article on the Democrat and Chronicle website looks at DeRider’s experience and why she finds being a nurse so fulfilling.

DeRider said she loves her job as a nurse and her work environment due to the endless possibilities.

“As a nurse, there are numerous paths you can choose for your career,” DeRider said. “The choices are endless, and I think that’s what’s so attractive about becoming a nurse; there’s always a portion of the medical field that you can learn something about and there’s always your portion of the medical field that you become passionate about and an expert of.”

But with the love of work and numerous career paths within the field comes heartfelt stories that impact nurses.

DeRider said the most touching experience as a nurse came in 2004 and 2005 while caring for an 18-month-old girl with terminal cancer.

“To know that you’ve had the opportunity to support a family during their most difficult moments and be part of that experience is an honor,” DeRider said. “I know this sounds very awkward for some, but for a parent to allow a nurse — total stranger — in on your most intimate family moments; hold your hand, laugh with you, cry with and for you, and most importantly, love (their) baby as well … there’s no greater experience than that.”

And for her care, DeRider said she has been rewarded countless times by patients and their families with gifts like a simple thank-you card.

“I actually keep each and every one of them, including pictures colored by kids who, by now, are adults,” DeRider said. “I figure that if you’ve taken the time to say ‘thank you’ and what I meant to you, I can keep that to remember you by as well.”

For DeRider, the time spent being a nurse will never match her love and commitment to the job.

“Nobody goes in to nursing because they love the long hours, weekends, holidays and overnights. It’s not a fallback career and requires much dedication. It’s by far (not) a glamorous career, but we’re the thread that ties together the physician and the patient,” DeRider said.

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