11/21/16

How to Care for Grandma and Grandpa? Nursing Innovations Forge New Paths


 To improve and refine the quality of health care that the elderly receive in America will require not only more health care workers but professionals that are trained in geriatric care and understand the specific needs of the elderly. Currently, only approximately 2% of nurses are trained in geriatric care.

One participant in the geriatric care scene is the John A. Hartford Foundation a philanthropic organization which advocates on behalf of the elderly. Since 1996 they have been emphasizing the importance of nurses and nursing in elevating the care of the elderly. The foundation created a number of initiatives to increase the quality medical care the elderly receive. One is the Hartford Institute of Geriatric Nursing.  The vision statement realizes that education, research, and policy are key factors in moving best practice to standard practice but more importantly, education, research, and policy must translate or affect nursing practice. It is affiliated with the New York University College of Nursing and during its existence has been a pioneer in many areas of geriatric nursing.

Let’s take a hypothetical grandparent who goes to the hospital via the emergency department. What would an ideal care situation look like?

If the hospital was part of the Nurses Improving Care for Healthsystem Elders(NICHE)  it would have a set of protocols staff would follow for elderly patients. These protocols would focus on the areas of care that affect the elderly the most. Staff would try and avoid the use of restraints to prevent falls. They would take concerted action to avoid pressure ulcers, and would manage pain to avoid delirium and sleep disorders. The hospital would have a Geriatric Resource Nurse that staff could consult. If Grandma had to stay in the hospital her ward might be a Acute Care for the Elderly(ACE) unit where the physical environment is specifically designed to prevent functional decline with a less institutional like atmosphere.. Nurses would have resources like ‘Try This’ available at the bedside through technology. The goal for Grandma would be to avoid preventable adverse events, especially in terms of proper interventions and prescription treatments. Hopefully Grandma’s stay would be short and she would not have to return to the hospital again, and with comprehensive post stay transition care could return to her own home.

Currently over 300 hospitals are part of the NICHE network. NICHE is not a program per se. It provides the support, tools, and principles to bring about a change in hospital culture towards the goal of patient centered care for specifically for the elderly. Hospitals first complete the Geriatric Institutional Assessment Profile(GIAP) to find out where their organization can make changes to progress towards that goal.

The ‘Try This’ bedside resource is centered around conditions specific to the elderly population and consist of two pages; the first page describing the importance of the condition and the second page an assessment that can be administered in a short time. There is also a book available called Geriatric Nursing Protocols for Best Practice. It is presently in its third edition and is also available for use at the bedside to enable nurses to find information quickly.

The Foundation also created the Building Academic Geriatric Nursing Capacity. Celebrating its tenth year this initiative partnered with nursing schools and the American Academy of Nursing. The goal is to support the next generation of nursing scholars, researchers and most importantly future nurses. In 2004 the Atlantic Philanthropies also became a partner and there are now 9 Hartford Centers of Geriatric Nursing Excellence, which are educational institutions that are committed leaders in geriatric nursing maintenance and expansion.

There is a movement to formally prepare nursing students in geriatric care by changing and adding to the curriculum of nursing programs. For instance in Minnesota 10 nursing schools have set a goal for increasing geriatric topics in their curricula. It is called the West Central Initiative.

 Highlighting excellence in geriatric nursing will help advance its importance nationally. The Foundation partnered with the AACN and has awards for curriculum excellence in the baccalaureate program that increases student competence in aging. For example, one award recipient Valparaiso College of Nursing integrated geriatric content into every course. One required course is called the Aging Process. The goal of this course was to change students’ attitudes towards the elderly. This is accomplished by students role playing an elderly person for a day to establish empathy and understanding. Students also make wellness presentations to healthy older adults. In their senior year they work with the elderly in extended care or rehabilitation units of hospitals. These activities create a comprehensive compassionate education of aging and geriatric medical care. In partnership with AONE, the foundation also created and award for hospitals that strive towards best practices in geriatric care. Recognition of excellence can be a motivating factor in change at the institutional level.

In the area of policy development the Foundation has initiated forums to create the opportunity for discussion on geriatric care.

Strategic partnerships enable leveraging of resources to attain a larger goal or greater impact. One example of this is the Foundation’s partnership with the American Nurses’ Association, American Nurses Credentialing Center(ANCC) and Atlantic Philanthropies. Called Nurse Competence in Aging, the focus of this partnership was to increase geriatric competence(comprised of skill knowledge and attitude) of nurse specialists , with a three part approach. The first is working through the 57 respective specialty organizations to assist in their involvement in pursuing best practices. A list of the activities of each association is online at http://download.journals.elsevierhealth.com/pdfs/journals/0197-4572/PIIS0197457207003163.pdf. If a specialty organization acquires funding through the NCA initiative it becomes a Specialty Nursing Association Partner in Geriatrics(SNAPG).

The initiative also encourages nurse specialists to acquire certification in geriatric care, to validate competence in that area. 

At present too many assumptions are made about the medical care of the elderly. What may be good care for a younger person may not be ideal for someone older. Care for this age group must include more input from the patient. The initiatives discussed in this article show there is a steady increase in resources for all nurses who realize the importance of geriatric competence.






10/26/16

Nursing Innovations Forge New Paths

Nurses enable health through both clinical judgment and technical knowledge. Yet their immeasurable skills such as the ability to support and comfort produce measurable results. For example,

Nurses are teachers of theirs peers and patients. Good nurses look at the whole person or patient. Nurses communicate, execute, and innovate, all with an attitude of caring. Nurses are the most trusted of the health care professionals. Nurses apply their knowledge with compassion to a positive measurable end.

These immeasurable skills that nurses possess will bring the solution to the next great challenge the US health care system faces: the aging of the baby boomers. Around 2030 there will be over 70 million people 65 or older. The fastest growing segment of the population is the oldest at 85+ years. Although people are living longer it’s not necessarily better. As they age they usually need more health care. Half of hospital patients are 65 or older. Two thirds of the elderly will need long term care at some point in their life. The average 75 year old has three chronic conditions and 4 or more prescriptions. 42% of people age 85 or older have Alzheimer’s disease. It’s so easy to list statistics but how to make those later years truly golden? It is nurses who will lead the way. Why? There are reasons other than those already listed. First of all there are more nurses than any other health care professional. Secondly, nurses are aging along with the baby boomers. Half of all nurses will be 50 or older by 2020. This will enable them to empathize with the possible challenges baby boomers face as they age.


The present health care system is unprepared for the aging of the baby boomers. They are not alone in their assessment. Reform is necessary. The foundation of that reform will be a change in attitude towards the elderly and a change in attitude in provision of care. Research by the RAND Group and UCLA shows the elderly gradually receive less care than they actually need. Resident clinics utilizing the Assessing Care of Vulnerable Elders (ACOVE) initiative shows that even the basic assessments for preventive measures are lacking in many of these clinics. The evaluation of the performance of resident MDs at over 2000 patients in 52 clinics showed that screening for at risk medical or physical conditions, for example mobility function status, or memory was at unacceptably low percentages. There was also few electronic medical records or reminder systems in place.

Current Medicare payment guidelines do not include long term care services, coordination or collaboration of providers, ongoing monitoring of chronic conditions, or any service provided by non MDs.

Nurse led innovations are changing how the elderly receive care. The goal is to maintain independence and dignity while ensuring the perils of aging are taken in stride. This change in perspective towards the care of the elderly will also include an active participation of both patient and caregiver. It is a fact that patient and caregiver engagement leads to better medical outcomes and greater patient satisfaction.

A number of nurse led innovations from the Raise the Voice initiative of the American Academy of Nursing are directed at the elderly population using strategies to prevent hospitalization for acute episodes or to keep seniors in their homes and communities as long as safely possible. These nurses, called Edge Runners are enablers and facilitators. For instance, in the Caregiver Skill Building Intervention caregivers are taught coping skills to deal with their patient’s behavior. The goal is to ward off caregiver burnout and depression. If successful, nursing home placement for the patient is delayed by 1-5 years.

In the SeniorWise program the focus is to keep seniors with MCI or Alzheimer’s mentally fit and happy for as long as possible, by the modification of risk factors, improving memory and other interventions.

The success of the Senior ASSIST Program(Assisting Seniors to Stay Independent through Services and Teaching) is measure in how long their clients stay in the program which is often many years. A geriatric trained RN makes home visits and teaches the senior to manage their health. The RN also coordinates with the senior’s doctor and helps them access other health services. This program is an important bridge to the time when an elderly person would qualify for Medicare services.

Health care worker roles will need to be changed. Change includes expansion such as allowing NPs to practice to the full extent of their licenses and revamping roles of many health care workers.  Ways also need to be explored to broaden the responsibility of workers at different levels of training.

One common factor of successful innovations in delivery of health care to the elderly is interdisciplinary teams and coordination of care. Again nurses have led the way here. 

So far we have seen that a shift in attitude towards care of the elderly must include their input.  Any interventions, strategies, or care must focus on prevention and maintenance of good health or management of chronic conditions to avoid acute episodes that require emergency care or hospitalization. The development of interdisciplinary teams can ensure that seniors can remain in the community and stay independent as long as possible. The team must include the senior’s health goals as the center of their care plan.


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9/20/16

“Keeping a Wiser Workforce”*

Over 50% of workers are age 50 or over in the nation.(1) The graying of America’s working population is approaching and with it the understanding that knowledge transfer will be a much discussed challenge. Indeed organizations like the American Association of Retired Persons (AARP) are looking at various industries and the impact the retirement of the baby boomers will have on the workforce. The transition in technical knowledge based professions will be affected the most which includes nursing.

Although there is a current artificial unemployment situation in the nursing profession this is short term. Issues of profitability and companies wanting to stay financially viable means teaching institutions have reduced expenses. For hospitals, training new nurses costs money so there is a reluctance to hire. But it is expensive to replace a nurse who has long tenure. However, when demand for services and nurse retirement peak, medical centers may find themselves unprepared due to current cutbacks.

This blog has in the past outlined the unfolding nurse shortage. There are well qualified applicants for nursing schools but lack of space and faculty means they are turned away. Nurse turnover and retention of new graduates are problems. All of these factors only exacerbate the challenge of keeping nurses employed and fulfilled long enough for them to gain experience and hopefully in some cases further education.

Many of the factors that contribute to the challenge can be solved if experienced nurses stay in the profession.

So why do those nurses exit the profession? A significant reason is stress, caused by such factors as inadequate staffing levels, physically demanding work which can cause injury, work life balance especially if there is eldercare, or feeling undervalued or unappreciated, due to lack of support.

What are health care organizations doing to address experienced nurse retention?

The Robert Wood Johnson Foundation decided to examine the challenge and began with a white paper in 2006 that outlined possible evidence based solutions that could be implemented to retain older nurses.

In 2007 the Foundation started the program by funding the Wisdom at Work Retaining Experienced Nurses Initiative. They chose 13 health care organizations to receive 18 month grants of $75,000 to examine the solution to the challenge in a work environment. The 13 were selected by the following criteria: They were organizations recognized nationally for nursing, design, or technology achievements and they already had retention programs in place. Their programs focused on one of three areas: workplace design/ ergonomics, staffing/human resources,(change in organizational culture), or using technology to improve work process.

Nursing can be physically demanding especially when patient movement is involved, and there is always risk of injury. Many of the programs that fell into the ergonomics category were aimed at reducing the impact of patient movement with lift teams and other strategies. A few of the programs involved nurse input.

The human resource or staffing programs had adequate staffing levels as a key component. A couple initiatives involved experienced nurses controlling the admission process. One program kept nurses on their own units rather than shifting them to unfamiliar units. 2 involved increasing nurse wellness and job satisfaction. Another implemented a virtual ICU that experienced nurses could monitor from several locations.

In 2007, the Foundation examined case studies of top performing companies in terms of staff retention of older workers. 7 companies were selected 4 of which were health care organizations. All 7 organizations have been awarded distinctions such as Fortune 500 List of 100 best companies or American AARP’s Best Employers for Workers over 50. The next few paragraphs will summarize their successes.

Bon Secours Health System in Richmond, Virginia’s mission statement that workers remain for life is not merely lip service, but is executed through timely ongoing efficient communication. This communication involves staff input through surveys and feedback. They monitor patient satisfaction, quality outcomes as well as financial performance. They encourage flexible work and retirement arrangements, innovative benefits and professional development.

Monongalia Hospital in West Virginia has focused on strengthening the nursing culture in its medical centre with the goal of excellent patient care. Nurses were involved in the planning the design of the new addition to the hospital, an unprecedented involvement of staff in decision making. Monongalia understood that quality patient care involves nursing input, and to leverage nursing skill they use technology.

At Scripps Health in San Diego workplace culture and benefits are organized and adapted according to the differing life cycles of its nurses. There is a system wide forecasting of employment needs which is kept current. There are focused retention strategies to prevent talent loss, one of which is their mentoring program. Each employee decides how to achieve professional success and Scripps helps them get there. There are differing benefits for employees to select depending on their needs such as eldercare benefits and phased retirement options.

Carondelet Health Network in Arizona was always competing for staff with Phoenix and California and relied on contract labor to hire nurses. Executives decided to invest in the professional development of nurses as a way of retaining staff. They created an on site BSN program with paid tuition. They also partnered with a local university to offer a free MSN program as well with the stipulation that after graduation the nurses would serve as adjunct faculty. Retention has increased and the use of contract nurses has decreased.

Retention strategies must be able to be replicated nationally to be effective. This can occur if there is a system wide commitment to understanding the value of experienced nurses. This cultural shift must be supported by planning and making the business case for investing in strategies, and learning from other medical centers’ best practices. Feedback and data must be collected diligently on a regular basis. It may be that hospitals will collect data such as quantifying the value of experienced nurses. Other professions have done that and so can health care. Organizations must be open minded as situations change and not be tempted to apply temporary Band aid solutions.

If experienced workers stay in the profession and advance to leadership roles for example, the nurses entering the workforce will more easily acquire critical thinking skills and will be able to approach clinical situations in ‘the context of broader outcomes’(2). Leadership in medical organizations need to recognize this is a pressing issue and be proactive in keeping valuable veteran nurses.

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9/9/16

The Unnamed Frustration, Fatigue, and Anxiety (1)

Consider these medical situations that nurses have been involved in:

A child is admitted to ER with possible symptoms of abuse. A doctor allows the patient to be discharged despite the nurse’s intuition about the situation. The child returns to the ER 2 days later dead on arrival. (2)


A patient was in severe enough pain to be crying out. Increased ammonia levels caused him mental confusion. The doctors wanted to monitor his mental state and ordered that pain medication be withheld. Twelve hours later he died. (3)


Readers could list many more situations like this in the various settings where nurses practice. These situations involve peers, patients, caregivers, and administration. The resultant feelings of frustration and helplessness have given rise to the term moral distress. Factors included in this phrase are cognitive dissonance, and psychological disequilibrium. But behind those fancy scientific terms lie the real crux of the matter. The nurse feels helpless, angry, and dissatisfied. Moral distress occurs when a nurse reaches a moral decision but is unable to execute her values, training, and knowledge. In other words the nursing goal is stymied and now a less than ideal outcome must be accepted. The nurse is impacted because she/he is the most involved in care, sees the consequences first hand, and because ethics are the basis of the nursing profession.


There are many reasons why a nurse might be unable to carry out maximum nursing care. Some factors are external, some internal. Nurse must collaborate with doctors and other professional colleagues. Nurses must deal with employer policy and sometimes consider cost of care. Another factor contributing to constraint are advances in technology which can increase life expectancy, but also affects the trajectory of chronic disease. Health care is expensive and medical centers have budget requirements which affect staffing levels. Nurses are pressed for time. There could be culture and values mismatch or challenges between patients, caregivers and nurses.


Moral distress in nurses is often created when there are 2 conflicting principles. For example, nurses must often choose between honoring patient autonomy and giving the best nursing care which to some extent relies on patient compliance. What if the patient is non compliant? Nurses must sometimes weigh legality and morality, for example, doctors might order tests because of the perceived possibility of legal action, but the nurse believes they are unnecessary.


Nurse researchers have developed a way to measure moral distress in nurses using the Moral Distress scale. It measures frequency and intensity of moral distress, using a Likert scale of 0-6. The most frequent situation that causes moral distress in nurses is unnecessary patient suffering, or circumstances that constrain action to relieve patient suffering.


One study researched risk factors and early warning signs of situations that could lead to possible moral distress. The researchers reasoned that if the situation could be identified early enough it could be solved in a proactive instead of an after the fact reactive manner. Moral distress in nurses would be avoided and the quality of care would be better. Medical centers would benefit from dealing with moral distress of medical staff to increase the likelihood of better work engagement and job satisfaction.


In the study the risk factors that can lead to moral distress were classified in the following categories: Individual risk factors were patient vulnerability listed as decreased mental functioning or psychiatric condition, elderly or very young, developmentally delayed, English as a second language, no relatives, homeless. End of life, suffering, and failed treatment are also individual risk factors.


Family risk factors can include the family being against the treatment plan, family uncertainty, stubbornness or unrealistic expectations, caregiver disagreement, caregivers not honoring patient wishes, denying comfort care or family indifference.


There are risk factors at the professional level which include team conflict, unethical behavior, over optimism by peers, stubbornness, fear of litigation, ignoring patient wishes or advance directives.


Risks exist at the system level as well with polices either vague or strict, limited resources, and lack of professional collaboration.


Helping nurses identify risk factors and early indicators of situations that could escalate into ethical dilemmas will avert moral distress. As indicated in this space in a previous article, nursing intuition is a scientifically valid phenomenon. Empowering nurses to proactively manage patient situations where moral distress can occur would be beneficial to everyone involved.


The early indications of a possible ethical dilemma are categorized as follows: Signs of conflict, which can include arguing between family members or medical staff, family expressing anger and mistrust of the staff, and nurses objecting to either prescribed treatment or family decisions. Patient suffering is another indication, for example unrelieved discomfort, or pain from different treatments and their complications, anxiety, and labored breathing.


Poor communication and unrealistic expectations from either patient or family are also early indications of possible ethical challenges. Ethical violations include not honoring patient autonomy, right to information, and standard of care. If the patient is treated without respect, or fraud is committed these are also signs of an ethical challenge.
Signs of nurse distress include the nurse believing treatment is futile, expressing concern over patient suffering, feeling powerless in the organizational structure of the medical center, and feeling regret that the nurse didn’t advocate enough for the patient.


Moral distress must be addressed both at the institutional and individual level.  For institutions moral distress is a factor in nurse burnout, turnover, and nurse retention. This can only exacerbate the upcoming lack of health care providers in the near future. But more importantly, moral distress affects nurses’ perception of themselves and the care they provide. Could it alter a nurse’s professional self image?  Can nurses compartmentalize self perception so that moral compromise in one’s professional life does not impact one’s ‘true’ self? Can nurses end up acting for pragmatic reasons alone due to moral distress?


The purpose of this space is always to end on a hopeful note, however. There is hope that nurses are identifying and coping positively with moral distress. Moral distress situations can prompt nurses to take action and become more assertive in changing their workplace to increase understanding of these situations. The self awareness that comes from reflection on one’s practice can lead to professional self development, and strength of character. Of course this is not going to occur without some changes at the employer level. Part 2 will deal with those innovative people and institutions that have pioneered the nursing professional championing ethics in the workplace.


6/13/16

Debrief, How to Handle All the Stress as a Nurse

Depending on where you work, the nursing career can be one of the most strenuous of all professions.

ER nurses are no exception, in fact, unless the shift is quiet, it's a collision of chaos from start to finish. (And honestly, how often is there a dead shift?)

The life and times of the career ER nurse is generally short. After all, it's much easier to have the predictability or the relative ordered chaos in some of the quieter units.

Nonetheless, ER nurses, and all nurses in general, need to have some type of outlet. Let me rephrase that, a healthy type of outlet. Self-medicating problems or stress is a slippery downward spiral. If you're not mindful about the alerts in your body the stress can shut you down.

And to get it out in the opening, regular (or heck just any) therapy qualified registered psychologist can do wonders to keep you sane and healthy mentally. Physical health is another key to ensure longevity and to extend, literally, the years on your life.

What are some testing tricks that you can share with others on how to deal with the ongoing stress, the incredible stories, and the incredible trauma you face in a normal work week?


6/1/16

Coloring Therapy for the Hospital


The current rage in art therapy models is the coloring book craze, particularly the adult coloring book market, which has exploded over the past couple of years with new titles. Some coloring books are marketed with 'art therapy' label suggesting coloring is a viable means to not only calm the mind, but offer therapeutic benefits as well. Art therapy is a useful tool to help caregivers, therapists, and other health care providers. Certain patients who do routine mindfulness exercises have been reported to experience benefits. Whether that's  directly because of self-identified 'art therapy' coloring books, is debatable. Mind you, the Mayo Clinic has noted the benefits:

Nobody can discount the craze that is the current norm. Coloring books benefit both the patient in a therapeutic way, but also help anybody de-stress. Given their popularity, eventually there may be something to color for everybody. The top coloring books on the market right now, apart from the classic books from the 'pioneers' of the adult coloring book craze, include coloring swear words, the perennial animal books, and the monotonous patterns of zentangles and mandalas.

 One of our sponsors for this blog is releasing their first book soon as well, this one with a religious focus. We've seen an advance copy and it's certainly beautiful! Details are below.

 What kind of things do you routinely try to do as a positive unwinding tool from a hectic shift?

 __________


 This is a post from one of our sponsors, RoBarry Publications. Their upcoming inaugural publication is a Christian adult coloring book called, "Soul Coats: Restoration". Visit them on Facebook as well.

5/17/16

Have you ever, or how many times, thought about quitting nursing?

Let's be frank, you've seen a lot of $hit. And there are days when you just want to throw in the towel. High stress jobs that require a high level of competency routinely put people over the edge. In a case of nursing there aren't very many professions where wonky hours, high trauma, sometimes questionable pay, unruly patients, unruly coworkers, etc., all collide to make for a challenging career.

It may be not be therapy, but what are some stories or scenarios that nearly made you end your career as a nurse?