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Simulations: A safe environment for student training

How can nursing students effectively learn to manage psychiatric patients without causing patient harm during training? Simulations could be the best answer, according to an article in the Pittsburgh Post-Gazette this week. The article profiled Ann Fallon, MSN, RN, APN, PMHCNS-BC, nursing instructor at The College of New Jersey, who uses a medical mannequin nicknamed Andrea Warhol to give students the experience of dealing with bipolar patients and other psychiatric conditions.

Prior to the exercise, students are taught about listening carefully, responding gently but firmly, and going through checklists to determine whether patients present a danger to themselves or others. Students are then placed in a room with the mannequin while Fallon delivers the audio portion of the simulation, which includes symptoms of bipolar disorder such as nonstop talking and resisting treatment. Fallon escalates or tones down the audio depending on whether or not the student is effective in communicating with the mannequin. Fallon often has another student act as the mannequin’s sometimes helpful, sometimes uncooperative sibling.

According to the article, students have responded well to the simulation and feel that it is an effective way to experience unmanageable patients with the opportunity to discuss how to best handle similar patients in the future. The use of mannequins and even actors in simulation allows students to practice appropriate responses to crisis situations, training which students can then draw upon in real-life situations. While no simulation can possibly address all the issues that could arise during actual patient care, exercises such as those conducted by Fallon can make students more confident when headed into real situations.

Did your training include simulations, or has your training program incorporated them? Do you feel simulations are an effective means for teaching nursing students? Leave a comment!

Poll results: Using technology to connect with patients

Last month, I posted about the ways that technology could improve patients’ communication with nurses but could also place a greater burden on nurses for round-the-clock care and feedback. To get a feel for how often nurses used technology and social media to interact with patients, we posted a poll on StrategiesForNurseManagers.com asking nurses and other healthcare professionals to weigh in.

Approximately three-quarters (74%) of those who participated in the poll responded that they did not use social networking sites such as Twitter, Facebook, or LinkedIn to interact with patients, while the remaining 26% replied that they do use those technologies for patient interaction.

While these results indicate that social networking sites have not become a place for healthcare communications, I still wonder whether nurses and other practitioners use other forms of technology, such as emails, listervs, or websites, to share information with patients and respond to questions about treatment plans. As mentioned previously, these resources have the potential to improve patient care, but they must be leveraged appropriately.

How do you communicate and follow up with patients outside of their scheduled appointment times? Leave a comment below!

Nurse burnout and patient dissatisfaction linked to longer shifts

The longer a nurse’s shift, the more dissatisfied the patient, according to a recent study from researchers at the University of Pennsylvania School of Nursing. Researchers found that nurses who worked shifts of 10 hours or longer were more likely to experience burnout and job dissatisfaction than nurses who worked shorter shifts. Of the nearly 23,000 nurses involved in the three-year study, 65% worked shifts of 12-13 hours; the percentage of nurses who reported burnout and/or intention to leave their job increased incrementally with the shift length.

Longer shifts not only had a negative impact on nurses, but also affected patients and patient outcomes. According to researchers, seven out of 10 patient outcomes were significantly and adversely affected by the longest nursing shifts. Additionally, higher percentages of patients reported that the sometimes or never received help as soon as they wanted, and nurses sometimes or never communicated well, in hospitals with higher proportions of nurses working longer shifts.

Researchers recommended that nurse management monitor the hours nurses worked, including second jobs, and consider restricting the number of consecutive hours worked. Nurse leadership should also “encourage a workplace culture that respects nurses’ days off and vacation time, promotes nurses’ prompt departure at the end of a scheduled shift, and allows nurses to refuse to work overtime without retribution,” according to researchers.

While this may all seem like common-sense advice, it is far easier said than done. There are so many factors that could prevent a nurse from leaving the moment a scheduled shift ends, and it would be difficult to enforce a policy for “prompt departure.” Likewise, if an organization is already facing nursing shortages, it’s unlikely that nurses will feel comfortable refusing overtime or taking adequate time off. However, these are issues that must be addressed to prevent nurse fatigue and job dissatisfaction that could put patients at risk. Researchers are correct in that change must come from the top, and nursing leadership must initiate the cultural shifts necessary to prevent burnout and ensure safe, high quality patient care.

What is the average length of nursing shifts at your organization? Have you ever noticed a correlation between the length of a shift and nursing fatigue? Does your organization have any policies in place to address these issues? Share your thoughts in the comments section!

Emergency preparation in the face of a hurricane

Editor’s note: This post originally appeared on the Patient Safety Monitor blog.

The anticipated impact of Hurricane Sandy undoubtedly led many hospitals on the east coast to reevaluate their emergency preparations, and now that the storm has hit, facilities will keep patient safety a priority in the aftermath. It is no small feat to assess the risks associated with a major natural disaster, from loss of power to compromised infrastructures and depletion of essential supplies. In addition to keeping existing patients safe, hospitals must also consider the possibility of an influx of new patients if the storm wreaks havoc elsewhere in the community. It is one thing to have disaster recovery plans sitting in a file somewhere, but another thing entirely to put those plans into action.

Healthcare Finance News highlighted the extensive preparations undertaken by Hackensack University Medical Center (Hackensack, N.J.) in advance of Hurricane Sandy’s arrival, noting that the hospital stockpiled medical supplies and medications, increased food and water supplies, and backed up essential equipment by generator. The hospital also deployed mobile satellite emergency vehicles to service the community. Each vehicle contains seven critical care beds with monitor-defibrillator capability, a portable digital X-ray unit, telemedicine capability, and a full functional mobile emergency department consisting of physicians, nurses, and operations personnel.  As demonstrated in Hackensack’s preparations, even the smallest details must be considered to ensure patient safety in the event of an emergency.

Sometimes even the best preparations can’t match the power of a natural disaster, and a hospital is forced to evacuate, as was the case with NYU Langone Medical Center in New York City. Although emergency generators kicked in, 90% of the hospital’s power went out and the hospital’s basement and lower floors filled with more than 10 feet of water. Approximately 1,000 physicians, nurses, residents, and medical students worked alongside firefighters and police officers to evacuate patients by the light of flashlights. Nurses carried several newborns down nine flights of stairs while performing manual respiration, since the respirators the newborns were on had stopped working in the power outage.

Hopefully the extensive preparations that many hospitals took will prove successful in the face of Hurricane Sandy. Even without the threat of a monster storm, hospitals are wise to review emergency plans and perform risk assessments on a regular basis; patients’ lives depend upon it.

Are you aware of your organization’s emergency procedures? How often do you review those procedures? Share your thoughts in the comments section.

Template for NPD administrative reports

Editor’s note: This feature is written by nursing professional development expert Adrianne E. Avillion, DEd, RN. Each week, Adrianne writes about an important issue in the area of professional development or answers questions for readers of the e-newsletter Staff Development Weekly.

Template for NPD administrative reports

We’ve been talking about evidence-based monitoring for nursing professional development (NPD) departments. How you present your evidence is critical. Whether you present your findings in writing or verbally you need to be concise and make an impact. All of us receive more than enough materials to read. We don’t have time (nor will our colleagues take the time) to read lengthy documents. The same concept goes for verbal presentations. How many times have we squirmed and kept glancing at our watches in meetings as a colleague makes what seems to be an endless report that could have been presented in a few choice sentences?

You need to use some type of template that summarizes your key findings. Using a template will also help keep all members of the NPD department “on track” when presenting information during department staff meetings. Here is an example of such a template.

Using this type of format allows you to quickly show not only how and why you made programming decisions based on available evidence but the positive impact education had on a specific patient outcome. There is no guess-work. All comments are “backed up” by evidence.

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Zombies, witches, and nurses?

As the end of October quickly approaches, children and adults alike are finalizing their choices for Halloween costumes, and it is highly likely that some variety of nurse costume will be among the options. The “naughty nurse” is an image that pervades our culture, and unfortunately detracts from the many positive images that nursing professionals strive to uphold.  According to an article in the Los Angeles Times, nurses are tied with ghosts at number eight in a list of the 10 most popular Halloween costumes. Why does the nurse costume remain a popular option year after year?

Halloween costumes run the gamut from scary to silly, as the article in the L.A. Times shows. Traditional costumes such as witches and vampires are joined by superheroes, princesses, and politicians. The holiday marks an occasion to become something or someone else for an evening, and of course it is all in good fun, but the trend towards the “sexy” or “naughty” nurse belittles the profession and in many ways mocks the work that nurses do each day. People who dress up as an Olympic athlete are typically showing their admiration of that athlete’s achievements; people who dress up as a naughty nurse are typically displaying a lack of originality.

Do you feel that the “naughty nurse” costume perpetuates a bad image for nurses? Share your thoughts in our comments section?

When disrespect becomes a safety issue

A dysfunctional culture rooted in widespread disrespect is a significant barrier to patient safety, and affects everyone in a healthcare organization, according to a pair of papers published in the journal Academic Medicine earlier this year. The papers’ authors identified six broad categories of disrespectful behavior, including degrading treatment of nurses, residents, and students, passive-aggressive behavior, and dismissive treatment of patients. Other behaviors included disrespect for system-wide policies and processes, disruptive behavior, and passive disrespect. The authors concluded that such behavior prohibits teamwork and undermines morale, which in turn threatens patient safety.

Most, if not all, organizations have at least one practitioner who seems intent on making everyone else miserable. While these disruptive practitioners may only be a small percent of the people working in a hospital or other healthcare facility, their behaviors and the influence of their attitudes can have much larger implications, as the authors of the papers point out. Nurses are particularly at risk for taking the brunt of a physician’s abuse; in several recent studies, more than 90% of nurses reported experiencing verbal abuse.

The second of the two papers focuses on creating a culture of respect. The paper’s authors call on an organizations leader, specifically the CEO, to initiate changes within an organization. However, anyone in a leadership position could address the need for change and begin working towards a cultural shift. The paper recommends five major tasks: motivate and inspire, establish preconditions for a culture of respect, lead the establishment of policies regarding disrespectful behavior, facilitate frontline worker engagement, and create a learning environment for resident and students. By recognizing that there is an issue with disruptive behavior and taking steps to eliminate those behaviors from your organization, you can begin to move towards a culture that is respectful and safe.

How has your organization addressed disruptive behavior in the past? Leave a comment and let us know!

Heading down the virtual road

An article on Advance for Nurses this week explores the dynamic between the well-informed patient and the well-educated nurse, weighing the pros and cons of patients who thoroughly research their symptoms and diagnoses prior to an appointment. On the one hand, patients who take charge of their health can be more collaborative and active in their treatment, but on the other hand these well-educated patients may challenge nurses about prescriptions and treatment options. According to the article, nurses with well-informed patients should listen carefully and establish a dialogue with patients and their families to avoid any potential aggression that might stem from disagreements about care options.

The article also points to telemedicine and the advances in technology that allow patients to communicate with nurses and other healthcare professionals easily and get quick answers to any questions they may have forgotten to ask during an appointment. It also allows nurses to monitor patients with chronic diseases more effectively.

While the internet might improve the ways in which patients can communicate with their nurses, it could also lead to increased expectations for round-the-clock care and instantaneous feedback, which might not always be possible with a hospitals’ budget and resources. Adding a virtual element to the work nurses perform daily makes for greater responsibility and accountability, especially if individual nurses are expected to maintain email communications with patients. What happens if a nurse forgets to check her email, or sees an email from a patient but does not respond quickly? Technology has the potential to improve healthcare, but it seems certain precautions should be taken when implementing telemedicine programs or when interacting with patients who have conducted extensive online research about their diagnoses.

Does your organization encourage online interaction with patients? Have you seen an increase in patient engagement in light of online communication and research? Leave us a comment below!

Medicare performance penalties and incentives are in effect

Editor’s note: This blog post originally appeared on the Patient Safety Monitor blog.

As of October 1, two provisions of the Patient Protection and Affordable Care Act will impact Medicare payments at hospitals across the country.  The Act calls for a 1% cut of Medicare payments across all eligible hospitals. The $963 million expected to result from those cuts will be placed in a fund for redistribution among hospitals that scored well over the course of a performance period that ended last June. Hospitals’ scores are based on patient satisfaction surveys and adherence to 12 quality measures.

The Centers for Medicare & Medicaid Services predicts that approximately 40% of the hospitals will receive their 1% share of the pooled money, plus additional funding, while another 500 hospitals will received their 1% share back, without additional money. Approximately 1,377 lower performing hospitals will receive less than their 1% pool funds back.

As the payment adjustments begin to impact hospitals’ finances and the penalties increase in the coming years, it will be interesting to see how these organizations react to the incentives. The intended goal, of course, is to improve quality across the board, but how different hospitals will accomplish that goal remains to be seen.


The practitioner will see you now: Physicians oppose independent nurse practitioners

The debate about who is qualified to provide primary care rages on this week, following the release of the report Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient  from the American Academy of Family Physicians (AAFP).  In the document, the AAFP advocates for a team-based approach to primary care–in which a physician leads a groups of nurses, nurse practitioners (NP), physician assistants (PA), and other healthcare professionals to provide comprehensive and high quality care –while criticizing proposals to allow NPs to practice independently.

A national shortage of primary care physicians has led to efforts to substitute independently practicing NPs for physicians, but the AAFP points out that NPs “do not have the substance of doctor training or the length of clinical experience required to be doctors.” While it is an inarguable fact that physicians receive several years of training and clinical experience beyond that of NPs, the debate centers more around whether NPs and PAs can provide the necessary healthcare services that patients require while maintaining a high quality of care, without the direct supervision of or collaboration with a physician.  Some states, such as Massachusetts, have already granted a greater degree of independence to advanced practice professionals.

While the AAFP’s argument for solving the primary care gap by instituting ideal ratios of NPs to physicians is compelling, and the model of physician-led healthcare teams does hold promise for improving the healthcare system, the report nonetheless seems to fan the flames when it comes to practitioner qualifications. NPs are referred to as “less-qualified health professionals” and “lesser-trained professionals” who are able to handle only patients with “basic,” “straightforward,” and
“uncomplicated” conditions. The language of the report does not seem to give NPs much credit when it comes to their training and education.

While the AAFP rules out the idea that two models of healthcare–physician-led teams and independently practicing NPs–could coexist harmoniously, one has to wonder whether ultimately the patient should be allowed to decide which model best meets his or her needs. Shouldn’t patients be trusted to make informed decisions about their healthcare? If a patient is aware of the amount of training an NP has received, is aware that it does not equal that of a primary care physician, and is comfortable with that concept, why shouldn’t a patient be able to seek those (potentially more convenient) services rather than hunt for a physician-led team model? The issue is complex, but a solution that allows all Americans to receive quality healthcare must be reached.

What are your thoughts on the AAFP report, and the debate about granting NPs autonomy? Share your comments with us!