A forum to discuss the latest news and ideas in nursing and healthcare.
Tuesday, March 1, 2016
“The ED is full of people who shouldn't be there. That's why the wait is so long.”
I've heard many iterations of that sentiment from patients, visitors, the general public, politicians, and even healthcare professionals more times than I care to count in my 30-plus years in emergency services.In my early days as an emergency nurse, I witnessed coworkers show obvious disdain when patients came to the ED with chief complaints that didn't fit their definition of an emergency. Unchecked, those attitudes were contagious and toxic.
Fast-forward many years, and I gained a new perspective as an emergency nurse leader with elderly parents and in-laws. Frequent ED visits became a reality. My family members' fragile health conditions rapidly worsened if their infections and other concerning symptoms weren't evaluated and managed quickly and aggressively. They simply couldn't wait for an office appointment.
I'd like to set the record straight: Our ED population represents people in need. The definition of emergency is personal, especially for those who are scared, in pain, or lack healthcare knowledge. When you have a garden-variety UTI and can't access timely care because of personal circumstances, you seek relief ASAP. Urgent care centers and medical aid units can be good options, but many aren't open 24/7, have limited capabilities, and expect payment up front, which all pose barriers.
What about “drug seekers” and challenging patients with behavioral health issues? Granted, the ED may not be the best place for them—but with the right systems in place, we can try to connect them to the services that they need.ED crowding is a complex problem with roots in the availability of health services in a particular community, care management systems, financial resources, public expectations for instant access, and many other factors. We need to stop blaming patients and focus on tangible, systemwide improvements. Many view ED care as expensive, but preventable harm from lack of timely access to that care carries a much higher price.
The ED is a safety net. No, it can't be all things to all people, but like the Statue of Liberty, it stands ready to help those in need: “Give me your tired, your poor, your huddled masses, yearning to breathe free...”.
Tuesday, November 24, 2015
The irony of nurses reporting to work while sick is obvious. Nurses are responsible for healing, not spreading infections. Presenteeism is a problem that runs deep within the healthcare community. The constant exposure to infection, stress, and fatigue lead to one almost inescapable outcome: the dreaded sick day.
A recent study from JAMA Pediatrics conducted a mixed-methods analysis of more than 500 clinicians and their self-report on presenteeism. Of those surveyed, more than 95% demonstrated the knowledge that working while sick puts patients at risk. Despite this knowledge, 83% reported working despite illness at least once that year. They didn’t want to let down their colleagues, create staffing problems, or disappoint their patients.1 However, the study conclusions show that the issue is more complex; presenteeism is shaped by sociocultural factors (peer pressure) and systems-level factors (facility policy).
Culturally, nurses are educated to work as a team, care deeply about their patients, and value their job. However, we must realize that in the long run, we are undermining all three by coming to work sick. At a systems level, attendance policies meant to assure that adequate staff are present to care for patients may inadvertently encourage presenteeism at the wrong time. This situation is especially true for those staff who push the limits on calling out sick when perhaps they really aren’t, and subsequently ride the fence on their sick time limits. Loss of income also may be an underlying reason for presenteeism-- depending on their employment status, some nurses may not get paid when they take sick time.
As the JAMA study points out, nurses and physicians hold themselves accountable for providing quality care. In the grand scheme, very few clinicians actually abuse sick days, but all too often nurses are caught between justifying their illness and endangering patients. This ethical dilemma is a difficult one, but we should err on the side of safety for our patients and ourselves by staying home. Until nurses and organizations come together to eliminate the root causes of presenteeism, we will continue to see a cycle of illness perpetuated among patients, colleagues, and professionals.
1. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: A mixed-methods analysis. JAMA Pediatr. 2015;169(9):815-21.
Monday, November 16, 2015
Flu season is ramping up. It’s a good time to cover a topic that should be second nature to all of us, but unfortunately still poses significant challenges: adherence to best practices for infection control. Research shows that while most nurses overrate their own compliance with respiratory and hand hygiene practices, they observe their colleagues practicing good hygiene less than 3/4 of the time,1 and actual compliance rates appear to be much lower; one recent study of triage nurses put median objective compliance with respiratory hygiene measures at just 22%.2
These statistics can have a very tangible and concerning impact on our patients. If a nurse accidentally infects a patient, he or she may not be aware of the long-term repercussions, since lengths of stay may be short and incubation periods vary over a period of days. Whether it’s influenza, HAIs, MRSA, or C. difficile, the simplest hygiene processes make a difference. There certainly may be human factors and workplace design barriers that are obstacles to compliance in certain work settings or environments; these are areas of much needed focus and effective intervention.
Standard precautions, PPE, infection control-- although the principles remain the same, methodologies change constantly with advances in education, research, and equipment. It’s essential to consult your facility’s infection control policies or guidelines whenever necessary to make sure you are protecting yourself, your co-workers and other patients. When it comes to the basics, such as hand and respiratory hygiene, we all need to consistently renew our commitment to what may seem to some inconsequential, routine, and even occasionally burdensome.
So this winter, let’s make a dedicated (re)commitment. Cover your mouth and nose when sneezing or coughing. Cleanse your hands frequently, including before and after every patient encounter. Apply warm water before soap. Recognize that alcohol-based rubs have their limitations (they don’t kill C. difficile), but do use them as an adjunct to handwashing. Know the risks of artificial fingernails and don’t apply them if you work in direct patient care—they can harbor pathogens that may not be eliminated by standard hand hygiene practices.
Refer to your facility policies on infection control, including the proper use of PPE. Educate yourself and empower your colleagues. Make sure posters and visual cues are prominently displayed. Read up on the latest guidelines from the CDC, INS, and IHI.3 In fact, use as many approaches as you can think of-- research suggests that a multimodal method is best for increasing and maintaining hand hygiene compliance rates due to the complex environments in which we practice.4
What are your successes and challenges in maintaining proper infection control practices in your work setting? Post a comment below and let’s keep the conversation going!
1. Delahanty KM, Myers FE. Nursing2007 infection control survey report. Nursing. 2007;37(6):28-36.
2. Martel J, Bui-Xuan EF, Carreau AM, et al. Respiratory hygiene in emergency departments: compliance, beliefs, and perceptions. Am J Infect Control. 2013 Jan;41(1):14-8.
3. CDC. Respiratory Hygiene/Cough Etiquette in Healthcare Settings. 2012. http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
4. Hebert J. Improving hand hygiene through a multimodal approach. Nurs Manage. 2015 Nov;46(11):27-30.
Monday, November 9, 2015
In October, the journal of Anesthesiology published results from a study conducted at Mass General Hospital on perioperative medication errors. Researchers found that every second operation resulted in a medication error (ME) and/or an adverse drug event (ADR). Sadly, more than one third of these errors led to observed patient harm. 1 These numbers are stunningly different from existing data on the subject, which is sparse and largely self-reported. However, these numbers are likely much closer to the true impact of ME’s and ADE’s.
Although we know the OR environment is a completely different animal than the settings most of us work in, I think there are some lessons to be learned here. How can we take this sobering information and use it to evaluate and improve patient safety across all settings?
First, honesty is paramount. Until the healthcare community can accurately track and identify patient harm, we’ll never reach optimum patient safety. Meticulously recognizing risk, documenting care, and avoiding error is part of our working lives; we follow best practices, advocate for our patients, and learn from our mistakes.
The next time the opportunity comes to participate in a new initiative or implement a new tracking method that supports patient safety in your facility, I hope that nurses will fully engage. Too often, we are slow to change as a healthcare industry, or we must overcome barriers to best practices in the real-world setting. In all cases, we can continue to embrace with enthusiasm what nurses do best—patient advocacy, caregiving with integrity, innovation, education, and documentation.
I applaud the researchers for uncovering such important information. It may be a small step, but it’s a step in the right direction, and I hope that clinicians take note and take action to actively participate in future efforts to improve patient safety, regardless of their setting.
1. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of Perioperative Medication Errors and Adverse Drug Events. Anesthesiology. 2015.
Monday, November 2, 2015
Over the years I’ve known many nurses who have had a work-related injury or strain. It’s part of the job description to be on our feet, lifting, shifting, helping, and occasionally, running. It’s such a common problem, in fact, that NPR did a six-part series earlier this year on nurses and injury.1 It’s about time that we take a good, hard look at why and how this is – and how far we’ve come.
Back injuries cause nurses to lose time from work and ultimately can be totally debilitating. The Bureau of Labor Statistics reports that 20,000 RNs experience an injury or illness involving days away from work every year.2 It’s important to know that risk is always present- ‘light’ patients can injure nurses just like the bariatric patients. And even with a team of nurses working together, the risk isn’t reduced to a safe level. "The bottom line is, there's no safe way to lift a patient manually. There's no safe way to do it with body mechanics." reported William Marras, director of the Spine Research Institute at The Ohio State University, after he and his team examined caregivers at work. Interestingly, Marras first published his findings in 1999.3 Since then, the CDC, OSHA, and other organizations such as the ANA have used these and related findings to encourage hospitals and care facilities to implement safety measures- to little avail.
I’m proud to say my hospital has installed ceiling-mounted lifts in patient rooms and has made lifting devices available to facilitate getting patients off of the floor or out of the car. Using them is now part of our nursing culture and is routine among our nursing staff. However, even in hospitals that do have lifting devices available, not every nurse may choose to use them. They might seem time-consuming, especially when the situation is urgent; there might be a lack of training on how to use the new devices, since many nurses were simply taught to ‘lift with your knees, not your back’ while in school; other times, nurses might simply feel that as caregivers, they’re tough enough to handle any situation without help.
Healthcare facilities need to make the investment in convenient and safe patient handling equipment at the point of care to protect their staff from musculoskeletal injuries of all types. However, nurses must also commit to using these devices when they are available. The issue can be a hard sell in an industry with soaring costs and an often hectic pace, but the injury and disability numbers speak for themselves. Share your workplace safety best practices in the comments below – we can all learn from one another!
1. National Public Radio. Special series: Injured nurses. 2015. www.npr.org/series/385540559/injured-nurses.
2. Bureau of Labor Statistics. Fatal Occupational Injuries and Nonfatal Occupational Injuries and Illnesses, 2008. http://www.bls.gov/iif/oshwc/osh/os/oshs2008.pdf.
3. Zwerdling, D. Even 'Proper' Technique Exposes Nurses' Spines To Dangerous Forces. 2015. www.npr.org/2015/02/11/383564180/even-proper-technique-exposes-nurses-spines-to-dangerous-forces.