Nursing

The Social Media Challenge in Nursing

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These days, your social life is never farther than your desktop, laptop or phone. Through a variety of devices and social platforms, not only can you stay in touch with all your friends from college, but also the ones from high school, grade school, Sunday school and your gym.

Unfortunately all of this intermingling of social spheres often leads to an information seep, where what you plan for only some people to see is in fact seen by many others. Information that was meant only for family, say, can often be easily seen by acquaintances, coworkers, or clients. Once you’ve shared information online, it can be disseminated across the globe with a quick click of a button or sometimes, simply doing nothing. No matter what the privacy settings are on your social media account, if a friend’s settings do not carry the same restrictions, there’s no telling who has access to your information.

All of this presents two big challenges to nurses who use social media. First, patients, family members and co-workers may find information that you’d prefer they not have. Second, even complaining about a tough day at work could put you at risk for violating the Health Insurance Portability and Accountability Act (HIPAA).

For the generation that has grown up with websites such as MySpace, YouTube, Facebook and Twitter, social media has become as ubiquitous as email. So it is easy to lose sight of the fact that sharing work challenges for a limited audience may become global information depending on the discretion of the audience and individual privacy settings. The expression “if you don’t want it all over the internet, don’t put it anywhere on the internet,” holds true for every venture into social media. That includes one-on-one conversations.

When Congress enacted HIPAA in 1996, it did so primarily to enforce an ethical responsibility to protect the privacy of patients and their information. A posting from a nurse on Facebook about a difficult day with the patient in room 213 because she “just couldn’t make him happy,” could result in discipline if not outright dismissal from the job. If a patient, family member or any other private citizen can see the nurse’s employer from her profile and knows the name of the person in room 213 on that day, the patient has been identified. Job loss is a real threat, and what one nurse may think is a harmless complaint about an unnerving day could land her on the unemployment line for violating a Federal mandate.

Hospital and healthcare organizations have adopted internal policies regarding the use of social media and although most of them ban any use of the electronic social venues during work hours, there are professional advantages to using social media. Discussions on research, new technology, practice and professional development can all be accomplished through social media forums. A nurse’s professional online presence may foster network building and lay the groundwork for mentoring relationships. And as this article indicates, smartphones are increasingly being used for things like quickly looking up drug interactions.

Words of caution….
One big disadvantage of maintaining any type of line presence is that you have little control over who can find you. Patients and family members who have read your last name on your badge, might suddenly start following your Twitter feed or send you a friend request on Facebook. The decision to allow this is entirely personal, but blurring the lines of patient-to-nurse care might present challenges with an employer and make future interactions with patient difficult. In the same vein, just as a patient can read public postings, so can an employer. The expression “discretion is the better part of valor” may be a good guide when nurses use social media.

Whistle-Blowers Summon Moral Courage

Posted in Nurse Safety, Nursing, Nursing News

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Whistle-blowing is both a morally important choice and one that is frequently very difficult. This article on Nurse.com explains that it can be a long and difficult process, that can chip away at a whistle-blowers’ sense of self-worth. They may be shunned by peers or lose their job. It’s not uncommon for people who have been through the whole process to say that if it happened again they’d just look away.

This despite the fact that studies have shown that whistle-blowing is the most important resource for detecting and reporting corporate fraud.

The ANA defines whistle-blowing as is the act of going outside a place of employment to report serious problems, such as those that endanger patients.

Nurses have a responsibility to report these kinds of problems, even when doing so is far from easy. The article lays out some of the things that are important to know, including knowing your options and knowing about organizations like the Whistleblower Support Fund.

Ideally, all organizations swiftly would resolve circumstances that threaten patient or worker health, or are otherwise unethical or illegal. The facility already would have mechanisms through which problems are reported and analyzed so they can be prevented in the future.

“Any place where a nurse works … there’s a responsibility to have a culture of safety as opposed to a conspiracy of silence,” said Cynthia Haney, JD, senior policy fellow for the ANA. Nurses, she added, have a vital role in shaping and supporting this type of environment, known as a “Just Culture.”

Most people know up front how their supervisors will address a serious problem, Murray said.

“They either provide the resources and demonstrate concern for what the individual has brought forward, or they do everything they can to dismiss it, change the topic and ask the individual to let it go,” Murray said. “Most people who go outside have reached a plateau where they’re so frustrated and have endured so much hardship that they don’t see any other option.”

Yet navigating “outside” isn’t easy, either.

Know your options

Multiple government agencies, partners, laws and regulations might come into play.

Among these:

The False Claims Act allows people with direct knowledge of fraudulent claims made by any entity receiving federal funds, such as Medicaid and Medicare, to pursue action. Because most hospitals and nursing facilities, as well as many private physician practices, participate in these federal programs, “it’s really a powerful tool for fighting fraud and abuse,” Haney said.

Anyone with evidence of fraud against a federal agency can seek the aid of an attorney specializing in “qui tam” cases, said Nayna Philipsen, RN, JD, PhD, CFE, FACCE, director of program development and assistant to the dean for legal affairs at Coppin State University’s Helene Fuld School of Nursing in Baltimore. “Qui tam” refers to someone else’s suing on behalf of the government and recovering a substantial portion of funds if the suit is successful.

The Occupational Safety and Health Administration addresses workplace safety. Issues such as exposure to hazardous materials and use of personal protection equipment fall under OSHA’s jurisdiction. Federal law related to job safety includes a protection called the “general duty clause,” which requires employers to provide safe environments for workers. That clause, Haney said, has been extended to include protection against circumstances that create hostile or threatening work environments.

The Affordable Care Act protects whistle-blowers in healthcare settings when patients’ consumer rights under the law are violated, Haney said. For instance, it protects nurses who report insurance company abuses or discrimination against patients with government-subsidized coverage.

The National Labor Relations Board can protect employees, both union and nonunion, who engage in certain “concerted activities,” such as discussing concerns related to safety — false charting and record tampering, for example — or other workplace conditions with colleagues.

Quality improvement organizations. In each state these are designed to ensure the effectiveness, economy and quality of care delivered by providers serving Medicare beneficiaries. These organizations address various complaints related to patient well-being, such as unneeded treatment, and concerns regarding healthcare law and appropriateness of care and billing.

State professional boards. These monitor professional behavior and are charged with protecting public welfare. When two nurses in Winkler County, Texas, thought a physician was providing unsafe patient care, they turned to the Texas Medical Board.

Arduous ordeals

The Texas nurses’ action was just the start of their journey. The two women were fired by the hospital that employed them, and county officials pursued felony charges of misuse of official information against them. The charge against one nurse was dropped, and the other was acquitted. They eventually accepted a $750,000 settlement in a lawsuit stemming from the incident.

Because whistle-blowing can be a long and grueling process, depression is common among whistle-blowers, said Don Soeken, LCSW-C, PhD, a former whistle-blower and founder and president of the nonprofit Whistleblower Support Fund. “They’re facing a terrible onslaught on their minds and bodies because society is set up so you have to have a job” to support yourself and your family, he said. Soeken asks potential whistle-blowers: “Do you have a family that can help support you?”

It’s hard for potential whistle-blowers to imagine the immensity of the challenge they face, said Soeken, who helped launch an Internet archive that catalogues and preserves details of past whistle-blowing cases to inform future whistle-blowers. “What you have are David and Goliath stories,” Soeken said, noting the government, corporations and other organizations can hire top lawyers and tap a wealth of research resources.

Still, Soeken said, whistle-blowers persist because their moral and ethical beliefs override a sense of self-preservation. “They’re almost like soldiers going into war,” he said. “They pay a high price. They do a great service. What we have to worry about is: What are we going to do to help them survive?”

The ABC’s of the Health Care Law

Posted in Nursing, Nursing News

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The future of the Affordable Care Act is uncertain. The Supreme Court has heard arguments about whether or not the ACA is constitutional or not, and will be announcing their decision in June.

Meanwhile, the ACA itself is quite complex. Gina Kolata of the New York Times spoke with Jonathan Oberlander, an expert in the field, about the law and its future.

Mr. Oberlander starts by explaining what the ACA is, exactly. He calls it “a series of policies and regulations and subsidies and mandates.” He explains that that’s the reason it’s so complex — it has many different parts to it. Rather that starting from scratch, it is building on an “incoherent” medical system, and trying to patch the holes.

That’s not to say that he thinks that the ACA itself is also incoherent — he says that if it is implemented, it would be the biggest thing since Medicaid and Medicare in 1965, and that “it brings us closer to the ideal that all Americans should have access to care regardless of income or health status.”

Can the act be carried out without requiring almost everyone to buy health insurance?

That would be a serious wound, but it would not be fatal. There are many parts of the act, including the expansion of Medicaid, that could be implemented and that have little to do with the mandate. But without the mandate, the Affordable Care Act would cover fewer people and would not be as effective. And it will raise questions about the stability of the health insurance exchanges.

My guess is that if the whole law is thrown out we will see a return to incrementalism, doing small things like expanding Medicaid by a little bit or giving very modest tax credits to some uninsured. Or we will see federalism — turning things over to the states. Or doing nothing, which has been our default for much of the past century.

How you can have health insurance exchanges without a mandate? Wouldn’t the healthy shun them until they become sick, forcing the exchanges to charge prohibitive rates?

There are other things that you can do, but chances are Congress won’t do them. You can tell the insurers that they can charge a penalty to people who do not sign up at first and try to enroll later. It could be like what happens with Medicare prescription drug coverage — if you try to sign up after you are eligible, you pay a higher premium for the rest of your life.

So if the mandate is thrown out, what about other kinds of insurance? Medicare is deducted from my paycheck, right?

One of the things that even the conservative justices said is that tax-financed national health insurance is permissible. That’s why Medicare is O.K. It is a tax, and Congress has the authority to raise revenue. The mandate would require people to purchase private insurance.

In fairness to the Obama administration, at the time the Affordable Care Act was proposed there was an overwhelming legal consensus that the mandate was constitutional. The idea has been around for decades — it was originally a conservative Republican idea as an alternative to national health insurance — and few had raised serious constitutional issues.

If the law stands more or less intact, when will we see some big changes? So far, what has happened seems less than transformative.

June will be the big earthquake. (That is when the Supreme Court will announce its decision.) The next big month is November, with the election. If the law survives those two big challenges, legal and political, the big year is 2014. That is when most of the major changes go into effect.

States will be required to expand Medicaid. All Americans making up to 138 percent of the poverty line — that’s about $15,000 today for an individual — will be eligible for Medicaid. Historically, Medicaid has been linked to demography. It is not enough to be poor. In most states you have to be a pregnant woman, a child, elderly or disabled to be eligible. The A.C.A. will change that.

In addition, insurance subsidies will be made available to help the uninsured and some workers in small businesses buy private insurance through insurance exchanges. Small businesses can buy insurance there, too.

Insurers will be prohibited from denying coverage or charging higher premiums to persons with pre-existing conditions. And most Americans will be required to obtain — and larger businesses will be required to offer — health insurance or pay a penalty.

Doesn’t the Affordable Care Act contain a lot of proposals to get costs under control, like comparative effectiveness studies and reimbursing doctors based on their performance? Will such ideas help contain the cost of medical care?

Most of these ideas are wishful thinking. The evidence is either mixed or just not there that these reforms will rein in spending. They are a sort of faith-based cost control. Other options are more painful, and at the moment there may not be any method for controlling spending that is politically feasible.

The A.C.A.’s capacity to produce reliable cost containment has been exaggerated. Its Medicare savings are significant — it will save an estimated $500 billion in the next decade by slowing payments to hospitals and private insurance plans that contract with Medicare. Outside of Medicare, the cost containment is less impressive.

Do you foresee big changes in the near future — politically difficult decisions that will rein in costs?

I’m a Red Sox fan, so I believe in miracles. But in the short term, the answer is no. We will build on our existing system — it’s what we have, and it is too difficult to move away from it. Two or three decades from now, nobody knows.

Helping Obese Diabetes Patients Stay Mobile

Posted in Nursing, Nursing News, Obesity

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The Look AHEAD trial funded by the National Institutes of Health has found that lifestyle changes have been effective in reducing disability in people with type 2 diabetes.

This article appearing on Nurse.com indicates that the risk of losing mobility in overweight or obese adults with type 2 diabetes was nearly halved with weight loss and increased physical fitness.

Look AHEAD (Action to Health in Diabetes) is a randomized clinical trial that is intended to figure out whether losing weight has an effect on the risk of developing cardiovascular diseases in overweight and obese people who have type 2 diabetes.

The study found that a group of these adults who attended meetings to help them achieve and maintain weight loss through diet and exercise were much more mobile than those who did not receive this intervention. Mobility is important for quality of life, allowing them to live independently rather than in a nursing home, for example, and also helps reduce healthcare costs.

Beginning in 2001, a total of 5,145 participants were randomly assigned to either an intensive lifestyle intervention group (ILI) or a diabetes support and education group (DSE). Participants receiving the intervention attended group and individual meetings to achieve and maintain weight loss through decreased caloric intake and increased physical activity. The DSE group attended three meetings each year that provided general education on diet, activity and social support.

To assess mobility and disability, participants rated their ability to carry out activities with or without limitations. Included were vigorous activities such as running and lifting heavy objects and moderate ones such as pushing a vacuum cleaner or playing golf. Participants also separately rated their ability to climb a flight of stairs; bend, kneel or stoop; walk more than a mile; and walk one block. Both groups were weighed annually and completed a treadmill fitness test at baseline, after one year and at the end of four years.

After four years of the study, participants in the ILI group experienced a 48% reduction in mobility-related disability compared with the DSE group, and 20.6% of ILI participants reported severe disability compared with 26.2% of participants in the DSE group. Likewise, 38.5% of those in the ILI group reported good mobility, whereas the rate was 31.9% in the DSE group. Weight loss was a slightly stronger predictor of better mobility than improved fitness, but both contributed significantly to the observed reduction in risk.

“This study highlights the value of finding ways to help adults with type 2 diabetes keep moving as they age,” Mary Evans, PhD, project scientist for the study, said in the news release. “We know that when adults lose mobility, it becomes difficult for them to live on their own, and they are more likely to develop more serious health problems, increasing their healthcare costs.”

Healthcare Providers Have Feelings, Too

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

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While this Op-Ed that appeared in the New York Times is written from the perspective of a doctor, a lot of it applies to various healthcare providers who have more information than the patient does.

The doctor, Danielle Ofri, writes of a patient she calls Julia, with whom she had a lot in common; both were about the same age, both were mothers with two young children. They were even about the same height and the same build.

But only one was facing a death sentence. Julia had a serious heart condition that meant she would die, fairly soon.

Ofri writes of the recent findings that physicians are not always open or honest with patients within this context. An article in the journal Health Affairs found that more than one in 10 physicians had told a patient something that was not true within the past year, and almost one in five had failed to reveal a medical error. More than half had put a more positive spin on a prognosis than was warranted.

Ofri expresses some surprise that the numbers are so low, but also questions how nefarious the reasons behind those numbers actually are. While she knows that she should have gone ahead and told everything to her patient, her own emotions got in the way.

When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.

It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.

When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.

I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.

Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming …” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.

Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.

I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

Most C.diff Infections Not From Hospitals

Posted in Nursing, Nursing News

Image of antibiotics courtesy of somegeekintn via Flickr

The U.S. Centers for Disease Control and Prevention reported in its March 6 issue of the Morbidity and Mortality Weekly Report that 75 percent of all C.difficile infections originated outside of a hospital setting, and that more than half of patients with C.diff infections treated by hospitals had the infection upon admission.

As nurses know, a C.diff infection can have life-threatening consequences, especially now. There has been a 400 percent increase in the number of deaths since 1999. From 1999 to 2000, an estimated 3,000 people died from the infection; from 2006 to 2007, the number jumped to 14,000 deaths, with 90 percent of the deaths occurring in the 65 and over population.

The numbers finally appear to be leveling off, according to research headed by L. Clifford McDonald, M.D., a medical epidemiologist with the CDC. In his team’s analysis of data from the Emerging Infections Program from 2010, and the number of C.diff cases reported to the National Healthcare Safety Network, the researchers concluded that although 94 percent of the outbreaks occurred in patients receiving healthcare, 75 percent of the C.diff cases occurred in non-hospitalized patients. The 52 percent of already infected patients coming into the hospital pose a significant intrahospital transmission risk to other patients.

The good news is that C.diff targeted prevention programs can be effective.

The researchers studied data from prevention programs in three states: Illinois, Massachusetts and New York. These programs were adopted by a total of 71 hospitals in those states, for eight months each. The data across the three prevention programs demonstrated a 20 percent decrease in infections during the study period. Dr. McDonald and his team concluded that better prevention programs, which begin with a more discerning approach to prescribing antibiotics, need to be implemented “in all health-care settings” including outside the hospital, since 75 percent of the infections are not, as previously believed, initiating in acute care facilities.

In a media briefing, Dr. McDonald outlined six steps endorsed by the CDC to prevent C.diff infections:
1. Prescribing antibiotics with care;
2. Testing for C.diff in patients who develop diarrhea while taking antibiotics or who develop diarrhea several months after an antibiotic protocol;
3. Isolating the patient;
4. Wearing gowns and gloves during patient care, even if the caregiver is only in the room for a short time;
5. Cleaning the room with bleach or another spore-killing disinfectant that has been approved by the Environmental Protection Agency after patient’s treatment has ended;
6. If a patient is transferred to a new facility, notifying that facility of the infection and treatment.

Dr. McDonald also stressed using prevention strategies “across the continuum of health-care,” not simply at one site where the patient is treated. The importance of prevention programs cannot be stressed enough as in addition to the implications for patients’ health, insurance companies have instituted non-reimbursement policies for nosocomial infections such as C.difficile.

Trading Overalls for Nursing Scrubs

Posted in Nursing, Nursing Jobs, Nursing News

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Nursing has traditionally been a field that is dominated by women. While men were still only about 7% of all nurses in 2008, that’s more than double the percentage from 1980. And the numbers continue to increase..

And as nursing remains an unusually strong profession in an economy where it can be very difficult to find a job, more men are finding that when they lose their jobs, nursing might be a viable alternative.

The New York Times profiles three such men: Kurt Edwards, David Pomerville and Timothy Henk. Mr Edwards, 49, was fired from his job at a Farmer Jack store in 2007. Mr. Pomerville, 57 lost his job as automotive vibration engineer in 2009. Mr. Henk, 32, took a buyout from Ford in 2007.

All three of them are now working as nurses, and making more money than they did in their old jobs.

The amount of schooling required to be a nurse depends on the level of nursing a student chooses to pursue. Mr. Henk went through Wayne State’s four-year program to obtain a bachelor of science in nursing and then took a licensing exam to become a registered nurse, or R.N. Other levels of nursing include the C.N.A., or certified nurse’s aide, which can require as little as eight weeks of training plus a certification exam, and L.P.N., or licensed practical nurse, which requires one or two years of schooling and a licensing exam.

All of that assumes acceptance in a nursing program. The American Association of Colleges of Nursing said more than 67,000 applicants were turned away in 2010 for lack of faculty or classroom space — not a good sign with a national nursing shortage projected to be as high as 500,000 by 2025.

Mr. Henk now works in the critical care unit at Beaumont Hospital in Royal Oak, Mich. He makes about $50,000 annually for a 36-hour workweek, though Ford’s health insurance was better.

The choice to make this switch was probably least likely for Mr. Edwards, the former grocery worker. He dropped out of college and spent four years in the Army as a paratrooper with the 82nd Airborne Division. He found his unionized warehouse job after a stint working for his father, an accountant.

“You have this plan, this goal,” he said. “I was going to be at this warehouse; all the guys were retiring with great benefits. I was part of the middle class, and I was going to make it.”

When it became clear that he would not make it to retirement there, someone he was dating suggested nursing.

Though he wrote it off as woman’s work at first, he realized he was getting a bit old for manual labor. So he returned to school, living on unemployment checks and occasional groceries from by his mother. He spent the last four months of his L.P.N. training with no electricity because he could not afford to pay any bills except rent.

Once he finished, the Sheffield Manor administrator, LaKeshia Bell, pretty much hired him on the spot. “They are like a hot commodity,” she said. “A male presence actually helps us in the facility.” At 5 feet 9 inches tall and 220 pounds, Mr. Edwards lifts patients as easily as he stacked boxes.

But he still appears to be a rarity. Just 7 percent of employed registered nurses are men, according to a 2008 Department of Health and Human Services survey. It did not count licensed practical nurses. Still, the percentage of people certified in nursing in some way who are men has risen to 9.6 percent since 2000 from 6.2 percent before, according to the department.

Ms. Bell noted that new nurses coming from manufacturing had unusual adjustments to make. When dealing with parts on the factory floor, she said, repetition is a major part of the job. “These are not parts. They’re people, so you can’t just have a set regimen like in a plant setting,” she said.

That cultural shift goes both ways. Mr. Edwards’s supervisor, Yvonne Gipson, provided an example. “I mean Kurt is not an ugly man, O.K.?” she said. “You got all these female workers, and they’re all looking at him like, ‘Oh! Potential husband!’ So, yes, it does change.” Her voice trailed off, erupting into peals of laughter as Mr. Edwards slipped a $20 bill into her pocket.

While these success stories point to opportunity, Michigan’s unemployment rate is still 9 percent. And Nelson Lichtenstein, director of the Center for the Study of Work, Labor and Democracy at the University of California, Santa Barbara, says history is a cruel taskmaster when it comes to struggling industries.

“When one industry goes in decline and another comes to the fore, you don’t have a one-to-one employment replacement at all,” he said. “It takes a decade, two decades. In the meantime, some people find their careers are ended, ruined, and they never get them back.”

For these new nurses, the advantage is the demand in Michigan. Mr. Edwards knows he is lucky. “You know I wake up every day and I’m very proud,” he said. “I’m looking in the mirror. I’m happy. I’m proud. I’m saying, you know, this turned out great. The lights are on!”

Recommendations for Annual Exams Are Changing

Posted in Nursing, Nursing Jobs, Nursing News

It’s been drummed into us women for decades — annual Pap smears and mammograms, especially once you’ve reached a certain age, are Good Things. If you’re responsible, you go to your annual exam.

However, more and more research is indicating that annual exams are unnecessary and can actually cause more problems than they solve. In her “Well” blog, Tara Parker Pope notes that national guidelines are urging less frequent screening for breast and cervical cancer, while other factors such as the declining use of menopause hormones and longer-term birth control methods also contribute to less of a need to visit a doctor annually.

Some women are so used to the idea of the necessity of an annual visit, though, that being told otherwise is unsettling. Especially if the annual visit led to lifesaving treatment. Miriam Richards, a 52-year old nurse in Raleigh, North Carolina, says that she worries that this is the wrong message. “I think it’s a bad road to go down because I feel like women, especially young girls, need to stay vigilant.”

But medical experts continue to preach that when it comes to cancer screening, more is not necessarily better. For years, women were advised to start mammography screening at 40; then, in 2009, the United States Preventive Services Task Force raised the recommended age to 50 — and specified every two years, rather than annually.

Last week, the task force and medical groups, including the American Cancer Society, recommended cervical cancer screening with the Pap smear no more than every three years, and said women should not begin screening until age 21. In the past, screening was recommended every one to two years, within a few years of becoming sexually active.

The concern is that more frequent cancer screening, whether of the breast or the cervix, leads to more false positive results — and unnecessary, intrusive and painful biopsies that lead to stress, discomfort and, in the case of cervical cancer screening, bleeding and future risks for women in pregnancy.

The changing landscape of cancer screening is certain to have an effect on women’s health care, although nobody is certain what it will be. Women have long been the most frequent users of health care, particularly for pregnancy care and pediatric visits for their children. But even when pregnancy and pediatric care are removed from the equation, women are still 33 percent more likely to visit the doctor, according to the Centers for Disease Control and Prevention. The rate of doctor visits for annual exams and preventive services for women is double that of men.

And importantly, gynecologists often use the annual visit to bring up nonreproductive issues: smoking, weight gain, high blood pressure, depression.

“I understand the strong relationship that has been formed with a woman’s doctors during what may be her annual visits,” said Dr. Wanda Nicholson, a member of the preventive services task force and associate professor at University of North Carolina at Chapel Hill. ”But our recommendation addresses only cervical cancer screening. It’s not meant to alter or change women’s ability to access their clinicians to discuss other concerns.”

Dr. Susan Love says that while annual doctor visits may feel reassuring, there is no evidence that they yield better health outcomes.

“There is no data that yearly physicals do anything,” said Dr. Love, a breast cancer researcher and prominent women’s health advocate in Santa Monica, Calif.

“In the current health care system, you rarely have the same doctor forever. And so the relationship you build in the 15 minutes you have will be for naught when you actually get sick.”

Giving Patients a Voice in Clinical Trials

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

Deborah Watkins Bruner Ph.D., RN, FAAN, is a nurse who has always been interested in oncology patients. In an article in the Atlanta Journal-Constitution, she says, “Standing as a young student in the ICU watching patients on monitors at life’s end was my first experience with death and dying. As a nurse, I wondered how to make that experience as best as possible.”

She is now the associate director of cancer outcomes research at Winship Cancer Institute, and also a professor at two different institutions professor of radiation oncology at Emory’s School of Medicine and professor at the Nell Hodgson Woodruff School of Nursing.

She says in the article that back when she started in 1978, there weren’t dedicated cancer units. She would go ahead and spend time with even the most serious cases, sometimes just sitting with them if they had nobody else, saying that she found it a “privelege” to be with them at the end of their lives, even though she was not a hospice nurse.

She has remained concerned with issues of cancer patients beyond the purely medical; quality of life is important, too.

An internationally recognized oncology nurse researcher, Bruner is the first and only nurse to lead one of the National Cancer Institute’s national clinical oncology research groups. She is the principal investigator for the Radiation Therapy Oncology Group’s community clinical oncology program, a consortium that studies how to minimize the side effects of cancer therapies and improve patients’ quality of life.

Bruner has focused her research on improving outcomes for cancer patients and increasing the knowledge about sexual dysfunction after cancer therapies.

“There has been a real lack of attention to the female quality of life and sexual function after treatment for cervical, endometrial and ovarian cancers,” she said. “Those patients have been underserved. They go through tremendous changes after chemotherapy and radiation, and the disparity in the research between males and females concerns me.”

She has been a staunch proponent of the need for patient-reported outcomes in cancer clinical trials. For years, symptoms and side effects have been reported by doctors. While doctors can report accurately and directly on results that show up in lab reports or imaging, that doesn’t tell the whole story.

“There’s not a test for every symptom. Pain is one example where the only real assessment has to come from the patient,” Bruner said. “Nausea, urinary or bowel problems and sexual dysfunction are others.

“Cancer patients will tell their doctors the two or three most important side effects and symptoms resulting from their cancer treatment, but then they will tell the nurse 15 other things that they didn’t want to bother the doctor with. Without a full report from the doctor and the patient, we can’t locate the best therapeutic targets.”

Doctors report adverse symptoms in clinical trials through the CTCAE (Common Terminology Criteria for Adverse Events) form, a widely accepted oncology standard and classification of symptoms. Bruner has helped to develop a patient version — the PRO (patient-reported outcomes)-CTCAE that would serve as a companion report to give clinicians a fuller picture. Her form is being tested in several national trials.

“PRO-CTCAE will give a voice to patients in every clinical trial,” she said. “Previously, we have been seriously under-reporting symptoms, and without accurate reporting we can’t develop the best interventions.”

If a drug causes pain, for example, a way to alleviate the symptom must be found or a different drug needs to be used.

“Nursing science was made to inform this kind of work,” she said. “When I became a gynecological clinical nurse specialist and asked patients about sexual dysfunction, I began to look at the evidence. There was no good research on the patient experience in the ’70s, so I became adamant about providing that evidence.”

Bruner, who is leading two National Institutes of Health studies and one National Cancer Institute clinical trial, is the first nurse to hold a Woodruff professorship at Emory since it was established in 1979.

“Emory is a perfect match for me. The interest in collaboration here is phenomenal and the cancer control work [is] stellar. I’m honored to be a part of it,” she said.

Emory is developing a model that implements new research directly into its cancer survivorship clinics and gathers feedback from its clinics to include in research.

From her experience with oncology patients as a student to her current role in research, Bruner is still listening and helping patients live with cancer.

“Nurses always focus on quality of life,” she said.

Importance of Letters of Reference for New Grads

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

When new nursing school graduates are out looking for jobs, interviews are frequently the deciding factor as to whether they will be hired or not. But in this article on Nurse.com about the importance of letters of recommendation, one person who makes these kinds of decisions, Linda Bell RN-C, says that she is given pause if a reference letter does not match up with an excellent interview. “Then I’ll wait and see other candidates,” she says. “I have to see a solid level of professionalism when the candidate was a student.”

Recruiters are looking for qualities similar to the ones that were important in nursing school, such as respect for the profession of nursing, cultural competence, reliability, and the ability to perform in high-stress situations. These sorts of attributes can be highlighted in effective letters of recommendation.

Today’s competitive job market gives recruiters a choice to hire seasoned nurses instead of new graduates, but some still choose to hire new nurses. Anna Tigar, RN, an experienced nurse manager who supervises a fast-paced, 17-bed medical unit at NSLIJ Health System/Lenox Hill, said she is proud to uphold a policy of hiring new graduates.

“New grads deserve a break and a chance to succeed, and I like being able to role model my nurses for them,” Tigar said. “The qualities I’m looking for are initiative, commitment to safe practice, great character, personal ethics and potential for leadership because all of this makes a great nurse in the end. I don’t care if you ace all your exams. I may look over 100 letters a year so if I don’t see those qualities spelled out, I’ll pass on to the next person.”

But nursing graduates are not expected to perform as expert nurses. “I’m willing to teach skills, and for new grads [those include] time management and setting priorities, but I won’t teach you how to conduct yourself as a professional and compassionate RN,” Bell said.

Students should remember that letter writing is important on many levels. A prompt thank you note after an interview is an expected courtesy and a simple way for applicants to stand out from a large pool of qualified graduates.

“It’s a nice touch to receive a letter back from candidates,” Bell said, “because I do spend a lot of time with them, at least an hour and sometimes, two hours.”

Network strategy

In the past, many nursing students had job offers lined up before or directly after graduation. But today, months may pass as new graduates wait for their applications to be processed and interviews granted, so innovative pathways to practice, such as nurse residency programs or externships, should be considered. Such programs are highly competitive, and solid letters of recommendation have the potential to help new graduates secure a position.

Geraldine Varrassi, RN, EdD, nurse educator at NSLIJ Health System/Lenox Hill, oversees the Hillman Nurse Residency Program, a unique opportunity for students who have not yet passed the NCLEX to team up, full time, with a volunteer RN for eight weeks. She stressed the importance of the letters of reference as an integral part of the admissions process.

“This is a highly competitive program, with [more than] 300 applicants a year,” Varrassi said. “We choose 20 students and our criteria are very high. Make no mistake, after the GPA is reviewed, we read through every reference letter and only then would we offer an interview. The letters of reference are extremely important and you should start thinking about them as part of your network experience in nursing, and that begins the first day that you enter the program.”

Forming and maintaining professional relationships with instructors is an important step to securing letters of reference and is an important workplace skill. Varrassi shared some basic points students should follow.

“The way to obtain a positive reference letter is stay in touch with professors, not on a daily basis, but drop them an email, let them know how you are progressing in your courses, send a holiday card,” Varrassi said. “You may want to use this person again, even after you graduate, so it should be an ongoing relationship. Ideally, the letters are written by someone who knows you well, not the clinical instructor you had last month. I want to see that they are familiar with your achievements.”