Image copyright Tanya Parker

Taking the art of collage seriously.

I recently attended an art workshop at the Biggs Museum of American Art led by artist Melissa Sutherland Moss, whose work is currently on exhibit there. The award-winning artist shared her process and guided participants in creating collage art based on the themes of self-identify and reflection. With participant permission, the artwork was featured in an exhibit at the museum as a part of the Dover Citywide Black History Celebration in February.

This was not the same collaging I remembered from elementary school years. There was nothing “juvenile” about the process. In fact, the only thing that invoked nostalgia was the use of the materials (magazines, photos, and other resources) to bring my vision to fruition. My end product, shown above, was titled “Relaxation.”

A visual reflection on relaxation.

Nursing is a caring profession. We know well how to serve others (patients , families, colleagues, students), but often neglect to care for ourselves. There’s an underestimated strength in the ability to rest, “relax,” and recharge. Self-care is often an afterthought or a never-thought. It’s frequently downplayed and or dismissed. However, with self-care we are able to be a better version of ourselves and better caregivers. Relaxation can often feel like a luxury, but in fact it should be a necessity. Relaxation shouldn’t be just an expectation during vacation; it needs to be woven into everyday life.

I took stock of my relaxation efforts, and recognized that I have work to do. The artwork is a self-reminder of what represents relaxation to me and the tools needed to facilitate it. As I look at the finished artwork, I mentally commit myself to utilizing the tools suggested in the image, such as reading, meditation, making music, rest, and spending time in nature.

The whole experience was an introspective exercise in identifying what can help me gain and maintain mental health. I was inspired to continue collaging and have gone on to create another collage called “Relaxation 2.0”!

By Tanya Parker, DNP, RN, NPD-BC, NEA-BC

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The National Women’s History Alliance organizes Women’s History Month each March. This year, the theme, “Celebrating Women Who Tell Our Stories,” was picked to draw attention to  “women in every community who have devoted their lives and talents to producing art, pursuing truth, and reflecting the human condition decade after decade.” To this end, the organization has been highlighting such literary notables as Maya Angelou, Toni Morrison, Gloria Steinem, and Willa Cather, among others.

For Women’s History Month in March 2015, I wrote an editorial in AJN discussing the importance of knowing nursing history and pointing out that as a female-majority profession, nursing’s history is closely entwined with women’s history. Nurses have made significant contributions to developing the health system of this country—indeed, community health services, school health, and public health were built through the efforts of nurses.

Archival voices from nurse pioneers.

In that editorial, I drew attention to several of the more widely known nurses and their contributions. But in AJN’s archives, which date from the first issue in 1900, one can find reports of nurses’ contributions, big and small, written by those who lived them. For example, Lina Rogers, the first nurse sent by Lillian Wald as a school-based nurse, writes (to read this and the following article, click on the PDF version in the upper left of the destination page) in 1903 about her experiences during her first year; Anne Colon, a district nurse in northern Michigan, describes her foray into the deep woods to a logging camp to provide care to loggers during the 1918 influenza epidemic. And there are so many others who are unknown to most of us.

Making our work visible.

As someone who has spent over 15 years encouraging nurses to tell their “stories”—whether in scholarly reports of research and practice innovations, accounts of community health projects they’ve initiated, thought-provoking opinion pieces, and heartfelt and personal reflections—I applaud this year’s theme. As nurses, we need to ensure that our work is made visible and that our contributions are recognized. Good work and innovative projects and practice need to be shared. We need to document nursing’s legacy of contributions.

And we need to share the “other” stories, too: the ones that live in our memory of a patient who was unforgettable or of a colleague who provided support at a critical time, the ones “reflecting the human condition decade after decade.”

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She sat in my office, tissue in hand, tears rolling down her cheeks as she tried to process the news I’d just confirmed: she was pregnant, and really, really needed to not be. She was living in her brother’s small house, her seven-year-old son with her, sleeping on a sofa while trying to put her life back together after a divorce. She had chronic kidney disease, and had been told that another pregnancy could cause kidney failure.

She didn’t really believe abortion was a good thing to do, but also couldn’t imagine that God would want her to go on dialysis. For the most part I listened, asking a question here and there to help her clarify her own thoughts. Ultimately, she decided on an abortion, so I referred her to the closest clinic, several hours away from the rural town we met in.

Medication Abortion in the United States

By Robin Marty/Flickr Creative Commons

Even before the Dobbs decision overturning Roe v. Wade, abortion was difficult to access for people living in many regions of the country. TRAP (targeted regulation of abortion providers) laws forced many clinics to close, making abortion access challenging if not impossible even though every American was legally, constitutionally permitted to make her own decision.

Last year, as the Dobbs ruling eradicated that right, medication abortion with mifepristone and misoprostol had just surpassed procedures as the most common method for first-trimester abortion. The medication combination was already well-established as a safe and effective protocol—so safe that the World Health Organization (WHO) guidelines recommended it for self-managed abortions, since the risks of incomplete abortion, hemorrhage, or infection are very low. Self-managed abortion allows use of medications in the privacy of the home, inducing miscarriage.  These drugs are also used to manage early pregnancy loss, making mifepristone a critical drug for patient care that helps people avoid unnecessary procedures.

Medication Abortion and the Rights and Duties of the Nurse

Despite its two-plus decades of safety data, the status of mifepristone is uncertain as we await the imminent decision of a judge who was strategically chosen in a case brought by plaintiffs who believe abortion is morally wrong. Of course, some nurses agree, and do not want to be involved in abortion-related care. Conscience clauses provide legal protections to nurses who wish to opt out of non-emergency situations.

Ironically, many nurses are now legally compelled to deny evidence-based care that the patient desires and the nurse may believe is ethically required to provide based on the ANA Code of Ethics. The Code supports patients’ rights to self-determination in health care based on the patient’s values and beliefs and compels the nurse to uphold patient autonomy even if the nurse disagrees. Many U.S. states now deny their citizens a legal avenue to access safe abortion care, and deny nurses the right to provide it. When activist judges, governors, and state legislatures keep evidence-based care from patients for ideological reasons, everyone loses.

Accessing Medication Abortion

So, what can nurses do if mifepristone becomes harder to obtain? There are several options to consider. First, protocols have been published using misoprostol alone for medical abortion. The WHO has found the regimen to be acceptable in terms of safety and efficacy both for clinician-supported and self-managed abortion.

Nurses may be prevented from directly assisting in mifepristone provision if the United States Food and Drug Administration (FDA) decides its hands are tied by an adverse ruling and removes approval of the medication. However, nurses retain the right of free speech under the First Amendment and may decide to refer their clients to a reliable website to obtain mifepristone and misoprostol by mail for self-managed abortion or telehealth abortions.

Some people may seek advance provision of abortion medications prior to pregnancy so that they will be immediately available to them in case of need. The medications have a shelf-life of about two years and are easily accessible online; however, state laws are evolving rapidly and the legality of this option may change over time in many states. If/When/How offers a legal help line for reproductive health to answer questions with up-to-date information, state by state. Buying clubs like those already established in Mexico may allow for extralegal access outside the formal health care system. Currently, patients may access in-person medication abortion by traveling to states where it is legally provided, and nurses may refer patients who need to travel to abortion funds to help cover costs.

Implications for the Future of Nursing

Regardless of our personal views on the ethics of abortion, nurses should be wary of political interference in evidence-based patient care. It is unacceptable that clinicians, including nurses, could face loss of license or criminal penalties for providing care that meets long-established professional standards and guidelines. This year, many state legislatures are actively restricting the rights of people to make decisions about their pregnancies (and about other areas such as gender identity), and have enacted laws in direct opposition to science and evidence. If this trend continues, nurses may experience new barriers to providing care that has been part of our profession for decades, including contraception, an essential element of health care that reduces the need for abortion.

Whatever our personal beliefs may be, we need to keep our eyes on the big picture. We must follow our ethics. We must work to ensure that patients receive evidence-based care, while honoring our core principle of patient autonomy. Nursing ethics demand that care is based on scientific evidence, paired with the values and religious beliefs of the person receiving the care, not those of their care provider or state legislature. When we encounter barriers, nurses must find ways to continue to provide ethical patient care. This will take creativity and resilience. We must stay true to what drew us to nursing in the first place: meeting patients where they are and helping people reach their health and life goals.          

Laura Manns-James, PhD, CNM, WHNP-BC, CNE, FACNM, is an associate professor in the Department of Midwifery and Women’s Health, Frontier Nursing University, Versailles, KY.

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The Time to Build Assessment Skills for Dark Skin Tone is Now

As a faculty member teaching prelicensure nursing for nearly three decades and a former adult critical care nurse, I have had the opportunity to review countless nursing textbooks. Unfortunately, we have a serious curricular blind spot regarding caring for and assessing conditions in dark skin tone patients. It is time we provide equitable education and patient care to all human beings of all skin tones for safe and effective care.

Development of Descriptive Terms for Dark Skin Tone Conditions

Consensus is needed for new and revised standard definitions of the terms and protocols currently in nursing textbooks and teaching-learning materials to incorporate dark skin tone. Terms such as erythema, pink, pallor, and non-blanching are some of the terms that need new descriptions reflecting how they represent or manifest in dark skin tone.

In addition, skin assessment protocols, guidelines, images, and overall protocols—pressure injury stages, the skin color aspect of the Apgar score, the definition and description of healthy gums in foundational texts, to mention a few—will require revision to incorporate how dark skin tone manifests. Human photos/images of dark skin tone are also needed to help students and practitioners recognize, normalize, and validate common conditions.

Evidence of the Impact of Omission

The COVID-19 pandemic and the rapid demographic changes have forced us to look at what we have been doing in nursing care and to address the provision of care for all skin tones to avoid further harm to people with dark skin tone. Evidence points to dark skin tone people having higher stages of pressure injury, undetected injuries in women after sexual assault, lack of early recognition of oxygen saturation alterations, and less accurate detection of an issue with a dark skin tone newborn using Apgar score, to mention a few.

A Call for Change

Faculty and clinical nurses can start addressing the curricular and practice blind spot by intentionally including in the teaching-learning materials how and where to assess for cyanosis, pallor, jaundice, petechiae, ecchymosis, and stage 1 pressure injury in dark skin tone patients. In addition, terms, assessment findings, and images that demonstrate and describe dark skin tone occurrence need to be standardized and not othered.

As described in our article in the March issue of AJN, “Skin Assessment in Patients with Dark Skin Tone,” terms and descriptions such as post-inflammatory hyperpigmentation, bluish hue, and changes in texture and color to the surrounding skin in dark skin tone need to be centered and reinforced in nursing education and practice. In addition, our current devices (such as oxygen saturation devices) and lighting (halogen, for example) should be readily and routinely available to assess patients in learning laboratories and clinical settings.

Nurses are encouraged to avoid referring to the assessment of dark skin tone as difficult, complex, and challenging, which further contributes to stereotypes, bias, and stigmatization. Nurse academicians and clinicians should reach out to nursing textbook publishers to request more photos/images showing conditions as manifested in dark skin tone. Manikins of dark skin tone should be standard equipment used to teach-learn clinical scenarios and conditions in nursing programs and clinical settings to practice and build assessment skills.

The aim is to foster health equity for people of all skin tones in academia and clinical practice by requesting the addition and incorporation of terms, guidelines, and protocols that include and describe conditions in dark skin tone so they are understood as part of a continuum of the normal rather than as other.

Eleonor Pusey-Reid DNP, MEd, RN, is an associate professor in the School of Nursing at the MGH Institute of Health Professions in Boston. 

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1. Nurses Don’t Have to Make This Stuff Up

Photo by Kah Lok Leong on Unsplash

During a fire drill the nurse, Kathryn, was closing doors to patients’ rooms. An 86-year-old patient was talking on the phone to her daughter when Kathryn reached her room. As Kathryn started to shut the patient’s door, the woman asked, “What’s that ringing noise?”

“Don’t worry,” Kathryn said. “We’re just having a little fire drill.”

As she was leaving, Kathryn heard the woman tell her daughter, “No, everything’s just fine, dear. The hospital’s on fire but a nice little nurse just came to lock me in my room.”

Having worked as a nurse, as well as having interviewed hundreds of nurses over the years, I can attest that you don’t have to make this stuff up. Yet nurses from coast to coast right now are telling me, “There’s nothing funny happening in my life.”

Having studied the brain and humor for decades, I can tell you that if that is your belief, that will also be your reality. Telling yourself there’s nothing funny around you will wire your reticular activating system to show you just that—nothing funny.

Even during times of chaos—overwhelming patient census, lack of resources, staffing shortages—humorous material is abundant. But so often we’re caught up in “what’s next” or still thinking about “what happened” rather than being in the present.

The actual experience of humor is in the present. Are you tuned into it? Do you listen for the humor that is around you right now in this crazy, absurd, out-of-balance world? What you discover may surprise you, and it will give your brain a much-needed respite.

What humor have you recently seen or overheard that others may have missed?

2. Laughing With or Laughing At? The Power of Humor to Build Up or Tear Down

“My pain may be the source for somebody’s laugh. But my laugh must never be the source for somebody’s pain.” -Charlie Chaplin

It was the first week of the first semester of nursing school. My fellow nursing students and I had just finished lunch in our dorm’s cafeteria, and we were on our way to class, but first—a quick stop by the soft-serve ice cream machine. We stood in line and watched a young man with cerebral palsy awkwardly place his cone under the spout, press the pedal with his foot, and dump chocolate ice cream all over his arm. I’m ashamed to admit it now, but instead of making an effort to help him, a few of us actually laughed at his efforts as we watched, before we decided to skip the ice cream and head to class. In my ignorance, I’d assumed that since the young man had a physical disability, he also had a cognitive disability and wouldn’t realize we were laughing at him.

Fast-forward a few weeks—I attended a school-sponsored social event. I didn’t see anyone I knew, so I was making small talk with some other new students when the “ice cream man” showed up and made his way over to our group. He began talking about his classes and his aspirations. He was so articulate and funny. My face grew hot with shame as I realized that he had to have known that day in the cafeteria that we were laughing at him.

To this day I don’t know if he recognized me, but I wish I’d had the guts to apologize to him. Instead, embarrassed, I made excuses and headed back to the dorm, vowing never to hurt anyone with my laughter again.

Now I make my living by showing people how to find humor amidst their pain. It’s my sincere belief that nurses who can’t laugh—leave. I encourage them to laugh at the good, the bad, and the ugly in health care. But whether it’s a patient, a doctor, a family member, or a colleague, may our laughter never be at someone else’s expense.

Have you ever laughed at someone only later to regret it? Have you ever been the recipient of painful laughter? What did you take away from the experience?

Karyn Buxman, MSN, DAIS, CHP, CSP, CPAE, is a nurse and a speaker, author, and consultant with a focus on studying the importance of humor in nursing. “Her mission is to transform lives through the power of humor and laughter.” 

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“Nurses do the big things, but I am thankful for all the small things: for bringing peace in the eye of the storm…for providing us coordinates when we felt lost…for making us laugh—for doing the things that we remember, the things that last years later.”—Holly Bills in this month’s Reflections article, “The Little Things Nurses Do”

The March issue of AJN is now live. Here’s what’s new. Some articles may be free only to subscribers.

CE: Tumor Lysis Syndrome: An Oncologic Emergency

What nurses need to know about preventing and treating this serious condition, including recognizing its clinical presentation, identifying at-risk patients, and monitoring and managing symptoms and laboratory values.

Original Research: Impact of a Bedside Activity Device on the Functional Status of Hospitalized Older Adults: A Randomized Controlled Trial

This pilot study evaluated the use of a device equipped with exergames—interactive video games that incorporate physical exercise—in preventing functional decline and increasing patients’ independence in basic activities of daily living.

Skin Assessment in Patients with Dark Skin Tone

The authors provide basic information about the assessment of dark skin tone and call for action in academia and professional practice to ensure the performance of effective skin assessments in all patients.

Nursing Research, Step by Step: Efficacy Randomized Controlled Trials

This article, one in a series on clinical research by nurses, describes the process of selecting the intervention, choosing experimental and control groups, determining study outcomes, and applying blinding and randomization.

Knot the Best Scenario: A Case of a Knotted Nasogastric Tube

This report presents the real case of an older adult whose nasogastric tube became knotted, causing difficulty in its removal, and discusses key takeaways for clinicians.

There’s much more in our March issue, including:

• A Focus on DEI column on the benefits of a diverse nursing workforce.
• A Specialty Spotlight on medical–surgical nursing.
• A Professional Development article on how to write powerful letters of recommendation.

Click here to browse the table of contents and explore the issue on our website.

A note on the cover.

On this month’s cover is Vanishing Capes, a painting by artist and retired nurse Therese Cipiti Herron. The work spotlights a relic of nursing history: the nurse’s cape. “The uniform no longer worn is historically recognizable by the last generation of nurses still alive today,” she says.

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Staying connected to something greater.

Photo courtesy of Pexels/Pixabay.

In a world that is constantly asking more of us, how can we stay connected to ourselves, to something greater, to a sense of meaning and purpose in our lives? This question guides most of my work, and my personal practices. Across years of conducting mixed-methods research to explore the role of spirituality among people with cancer, I am constantly presented with ways where our connection to spirit is challenged, and ways that we can remain connected amidst the very real pain, challenge, busyness, stress, and burnout of this modern world.

Making time and space for spirituality may seem elusive or impractical, especially when considering the limitations on our time and capacities. Along with co-authors Katie Addicott, MSN, FNP-C, ACHPN, and William E. Rosa, PhD, MBE, AGPCNP-BC, FAANP, FAAN, my hope for this recent piece in the American Journal of Nursing is to highlight simple, practical, and enjoyable ways to incorporate spirituality into everyday life and everyday nursing care, with the intention of supporting our own well-being and the well-being of patients and families we work with.

Defining spirituality 

While various definitions have been offered, “spirituality” generally refers to a human experience of connection with self, others, nature and/or a higher power, and a sense of meaning or purpose. Put more simply, spirituality can be seen as our essential relationship with life—how we understand, make meaning of, and relate to events in our lives.

As you might expect, experiences of spirituality vary greatly from person to person, and are expressed through beliefs, values, rituals, traditions, and practices. It is also important to highlight that many people do not identify with the word “spirituality” at all. I use the term in a broad and inclusive way, acknowledging unique experiences of connection and meaning or purpose in each of our lives.

What is spiritual care? 

The immense experiences of suffering, grief, loneliness, and burnout among nurses today call for a reexamination not only of our care delivery systems, but also of the personal frameworks through which we approach our nursing practice. Evidence supports addressing spirituality as part of holistic palliative care nursing, yet we need to be careful that spiritual care doesn’t become another item on our to-do lists, but rather is practiced as an embodied way of being, part of our daily lives and moment-to-moment activities.

Cornerstones of spiritual care include presence, intentionality, and compassion.

• Presence is a practice of approaching others in a way that acknowledges and honors their holistic nature, and focuses on creating an interpersonal environment of authenticity.
• Intentionality includes holding a desire for the greatest good.
• Compassion involves bearing witness to another person’s lived experiences, seeking to understand their suffering, and acting in alignment with an intention to reduce suffering.

Attending to spiritual care is a core component of palliative nursing, as reflected in the Clinical Practice Guidelines for Quality Palliative Care from the National Coalition for Hospice and Palliative Care. Notably, these guidelines define the role of spiritual care in practice, such as assessing spiritual histories and screening for spiritual concerns, and they highlight the importance of nurses tending to our sense of spirituality as part of our professional role. Tending to our own spiritual care needs is a central part of sustaining our palliative nursing work and showing up from a place of authentic presence, intention, and compassion.

Putting spiritual care into practice

Despite limitations and practical barriers, there are many ways that we can bring spiritual care into our everyday lives and nursing practice. First, we can take a bit of time to tend to our own unique sense of spirituality. Some suggestions for putting this into practice include: being present with loved ones, engaging in contemplative practices, meditation, prayer (secular or religious), creating and/or viewing art, engaging in service activities for positive social change, practicing mindful exercise/movement, seeking pastoral care, counseling, and/or therapy, participating in rituals or ceremonies, and spending time in nature.

Moving from a place of self-awareness, it can then be useful to practice assessing spiritual care and spiritual care needs regularly within our nursing care environments. Various resources and guides are available to do this. Identifying which spiritual care resources are available can be especially useful when needs are identified, within ourselves and within the patients and families we work with. Building relationships with spiritual care specialists (chaplains, if available, or mental health clinicians) can be helpful as well so that we know that support is available when needed.

Palliative nursing and ‘a deep examination of priorities.’

Jaxx and Megan

As our schedules and to-do lists continue to fill up, the need for a connection to something greater may be more relevant than ever. Within my work in palliative nursing, I recognize that being close to suffering and mortality requires a high level of self-knowledge and self-care, and it also brings numerous gifts that have enhanced my life beyond measure. One of the greatest gifts brought by recognizing our shared relationship with suffering and mortality is a deep examination of priorities, which has the capacity to transform the way we live. By recognizing that suffering is a universal human experience, this shared vulnerability can connect us more deeply with the patients and families we serve and with the deeper roots of our nursing work.

I want to take a moment to honor the courage it takes to engage in palliative nursing today, and the ways our presence really can make a difference. Spiritual care starts with us.

Megan Miller, PhD, RN, is an assistant professor at the University of Wisconsin–Madison School of Nursing. Contact author: Megan Miller, miller89@wisc.edu. This text was deeply informed through collaboration with Katie Addicott, MSN, FNP-C, ACHPN, and William E. Rosa, PhD, MBE, AGPCNP-BC, FAANP, FAAN. Megan would like to offer gratitude and acknowledgement for their thoughtful contributions to this piece.

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Remembering an influential article.

Patricia Speck

Timing is everything. Forensic nursing service through telehealth is possible today, as reported in a recent Kaiser Health News story, but it wasn’t always that way. Fifty years ago, Ann W. Burgess, a psychiatric–mental health nurse working in the emergency room, wrote a paper with a sociologist colleague about what she was seeing in patients who complained of being raped. “The Rape Victim in the Emergency Ward” (pdf), published in AJN, was reported nationally and informed 1970s kitchen table conversations about what rape is, is not, and when “no means no.”

Naming the trauma and its effects.

The ideas in this article were new at the time. Burgess wrote that sexual assault causes acute emotional trauma, requiring time for recovery, and she named phases of what she eventually called “rape trauma syndrome.” Prior to the article, victims of sexual assault often did not report the assault, and when they did they waited hours for a newly minted physician intern who had been punished with “rape-duty.” These physicians had no knowledge about what to do.

In accordance with societal views at the time, victims were often blamed for their rape—the way you dress, how you act, if you were drinking. Even if you were bloodied and bruised, society assumed that if you were raped, you had “asked for it.”

Beverly H. Bowns, a nurse practitioner faculty at the University of Tennessee Health Science Center, is likely to have read the article and known we can do better. She wrote a grant, received federal funds, and brought stakeholders together to train the first three nurse practitioners to be on call to respond to police and to meet assault victims at a newly established Title X family planning clinic. The three NPs were trained by forensic scientists to collect evidence using the Vitullo Kit and provide medical prophylaxis for disease and pregnancy in a compassionate way to the traumatized woman.

That was 1973. The new role was immediately very successful, as evidenced by increasing reports, but it would be almost 20 years before nurses doing this work were given the name of forensic nurses.

Making forensic nursing a specialty.

In 1995, the ANA designated the role of the forensic nurse a specialty, covering a number of subspecialty practices such as psychiatric-mental health, emergency, death investigation, child and elder maltreatment, and violence against women, both sexual and domestic. In 1996, the term sexual assault nurse examiner or SANE was adopted by the forensic nurse subspecialty special interest group and the ‘sexual assault nurse clinician’ became an ‘examiner.’

In the early days, patients would travel hours for the services of a forensic nurse caring for crime victims and the accused. Victims in rural communities were often sent into the night to a regional program in an unfamiliar city several hours away. Is it any wonder that they would turn around and go home?

The role grew and so did the number of graduate programs that offered specialty tracks in forensic nursing. These were the forensic nurse leaders in the 1990s and early 2000s. Nurses in subspecialties such as SANEs received training through continuing education coursework. However, sustaining the RN in the role was more difficult. Many suffered significant provider fatigue and burnout. Hospitals didn’t see financial benefit in having a program either, and many SANE programs folded.

Growing awareness and recognition of sexual crimes has gradually increased the demand for forensic nurses with sexual assault training. Other populations, such as victims of sex trafficking, have benefited as the number of SANEs increased. Policy makers changed child sexual abuse and minor sex trafficking reporting through Title X family clinics, legislators began to use the term forensic nurse in grants, and academic institutions were adopting Forensic Nursing Certification Board core competencies that defined content for all undergraduate and graduate forensic nurse programs of study.

A role for telehealth, and continuing limitations.

By 2012, the Department of Justice was meeting to consider funding for telehealth by forensic nurses. During the COVID-19 pandemic, telehealth was rapidly accepted by the medical community. Nursing compact states had also increased in number, enabling many nurses to cross state lines as traveling nurses.

Unfortunately, timing is everything and compact status is not enjoyed by advanced practice nurses. Because of this, the use of telehealth is limited in states that are not part of the nursing compact. Regardless of compact status, sexual assault evaluation using telehealth may be synchronous or asynchronous, may be a telephone consult or use technology that transmits encrypted protected health information. With the compact states now allowing RNs to practice in other compact states, SANE RN practice challenges will come. All states distinguish between RN and advanced practice using a license from the state’s board of nursing. The APN license is based on education foundations of the three P’s—physiology, pharmacology, and health assessment (focused on creation of a differential diagnosis).

Confounding the problem is continuing education training that encourages RNs to offer an ‘opinion’ as to cause of injury when asked about ‘medical certainty,’ which is a legal term. RNs do not have licensed authority to offer a differential diagnosis or predict medical certainty without extensive knowledge of the literature. What RNs do best is assess the patient, document, describe, quote, recognize and refer potential medical sequelae, all by following protocols.

Telehealth is a new layer of complexity, and advanced practice nurse leaders who are certified advanced forensic nurses supervising RN SANE practices must become proactive in protecting the RN using new technology with protocols that highlight what the RN SANE does best. These programs offer comprehensive services, including access to experienced forensic nurses and on occasion to certified advanced forensic nurses with graduate preparation.

The advantage of having bedside RNs trained as SANEs is the best hope for increasing access to care following sexual assaults and rapes. Systems continue to evolve and risks to RN SANE practice are continually present. But with remote assessments, the basic premise remains the same. When a person experiences sexual assault, there needs to be a local provider with protocols and technological access to an experienced forensic nurse with specialized training in the care of the sexual assault victim. The future of such practice will depend on a well-developed system of certified and advanced forensic nurse providers. Timing is everything.

Patricia Speck, DNSc, CRNP, FNP-BC, AFN-C, DF-IAFN, FAAFS, DF-AFN, FAAN, is a professor and coordinator of advanced forensic nursing in the Department of Family, Community, and Health Systems at the University of Alabama at Birmingham School of Nursing. 

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Limited English proficiency and adverse event risk.

As a native San Franciscan, I grew up surrounded by bilingual people who represented cultures from all over the world. It is a privilege for me to be surrounded by such rich diversity, but many patients who are limited English proficient (LEP) are at risk for adverse events once they enter a health care setting. Identifying a patient’s preferred language at the initial point of entry can ensure that resources are available to support the patient as they navigate the health care system. Medical interpreters are vital to our LEP patients and serve as a bridge for translating both language and other crucial cross-cultural elements of communication.

Letting patients and families know their rights.

Providing interpreting services reduces health inequities for LEP patients and is also required by Title VI of the U.S. Civil Rights Act (1964). This law states that hospitals that receive funding from the U.S. Department of Health and Human Services must notify LEP patients of the availability of free interpreting services, which should not include their own friends and family. As nurses, we must advocate for our patients who may not be aware of their rights and may have fears about perceived consequences if they admit to not being proficient in English. Perform a quick scan of your clinical environment and patient paperwork—is it LEP friendly?

I am a nurse at an academic medical center that provides tertiary care to adults and children from all over the world. We have patients who speak “rare” languages and we are often challenged to coordinate services with an interpreter who is in high demand and often serving the entire country. I collaborated with interpreting services and a pediatric surgery work group to identify that patients with specialized interpreting needs should be scheduled as the first case of the day and provided a separate appointment with an interpreter to complete the consent, especially for complex surgeries. In this work group, it was also identified that health care staff could benefit from learning about best practices for when they work with a medical translator. We can offer phone, video, and in-person interpreting services based on the level of patient need.

Certified medical interpreters.

By Rihards Sergis/Unsplash

Certified medical interpreters are highly skilled can ensure a lower risk of medical errors for our LEP patients. For any conversation that goes beyond “non-vital” activities of daily living, a certified interpreter is required. If staff are bilingual, they may apply for certification to act as interpreters for their own patients.

Certified medical interpreters are screened for linguistic competence, which means they are fluent in the source and target language and have the ability to interpret speech from one language to another. They are trained to interpret verbal and nonverbal communication, which can reduce the risk of bias, misunderstandings, confusion, and frustration. This is why using friends and family to translate can be dangerous. Certified medical interpreters are trained to be impartial and not let their own values, beliefs, and opinions interfere in the communication process.

The pediatric surgery work group identified a need to educate clinicians on how to access and schedule interpreting services as well as best practices once an interpreter is present. I created an e-learning module to help disseminate these tips to all clinicians who interacted with patients regularly.

Tips and best practices.

These tips and best practices can be helpful for you, your patient, and the interpreter to ensure a successful interaction:

• Document and identify the patient’s preferred language for health care in the electronic health record as a shared resource for all team members.
• Use a tool to assist the patient and staff in identifying their preferred language (see example).
• If an in-person interpreter is not available, test the audio and microphone of the device you will be using.
• Try to let the interpreter know what to expect before starting the conversation.
• Assume, and insist, that everything said in the encounter by anyone present will be interpreted.
• Speak to the patient, not the interpreter: Use the second person (“Do you….?”), not the third person (“Does she….?”). You are not talking at the patient, but with the patient.
• Attempt to normalize the experience for the patient. Face them and maintain eye contact.
• Be careful with humor and idiomatic expressions—they probably won’t translate well.
• Keep a comfortable pace that allows time for interpretation (consecutive or simultaneous). Speak slowly, rather than loudly.
• Use an appropriate level of language complexity. Lack of English proficiency is not an indication of low cognition; avoid assumptions about a lack of formal education.
• Cultural considerations: a patient nodding, saying “yes,” or smiling may indicate listening or respect rather than understanding. Gestures vary in meaning from culture to culture.
• Organize your thoughts before speaking. Sentence fragments, complex sentences, and changing your mind mid-sentence can be confusing.
• Be prepared to repeat, rephrase, and summarize. Be patient.
• Ask patients to “teach back” what was said to assess for understanding, as you do with your English-speaking patients.
• For any important conversations that the nurse charts about, document that an interpreter was used and identify the interpreter, either by name or the ID code they give you.

Anjal Pong, DNP, MSN, RN, NPD-BC, is a nursing professional development specialist at the Center for Nursing Excellence and Innovation, University of California, San Francisco (UCSF). She has had over 20 years of clinical experience in the operating room, been a leader for the Evidence-Based Practice Nursing Fellowship Program, and served as coach for the professional development shared-governance council.

The post Collaborating with Medical Interpreters: Best Practices for LEP Patients appeared first on Off the Charts.

Carrying the burden of depression as a nurse.

As I read Anna’s (not her real name) description of how much effort it took to drag herself into work, how much she felt like a burden to her family, and her fear of being “found out,” tears welled up.

“I know,” I said to myself.

I was analyzing an interview transcript for a qualitative study of psychiatric-mental health nurses (PMHNs) who have experienced mental illness. More specifically, my colleagues and I wanted to know how their illnesses impacted their work as nurses.

I have been a PMHN for over 40 years, with an even longer experience of a mental illness. I recognized many of the participants’ stories in my study as my own, but none affected me the way hers did. An alarm bell inside my head went off. If I couldn’t create a clear boundary in my mind between Anna’s experiences and my own, I might be at risk of unduly influencing the study results.

Reflecting on shared experiences of depression.

I was grateful that a colleague was also analyzing these transcripts; to minimize the effects of my own potential bias, I took the opportunity to write down my thoughts and feelings in my reflexivity journal. This is a tool used by qualitative researchers to examine ways their perspective could affect the research process by introducing bias. In addition to having more than one person conduct data analysis, keeping a reflexivity journal lessens the chance of attributing one’s own thoughts and feelings to study participants.

Journaling took me down memory lane—a road, in part, of hardship and despair. I recognized Anna’s exhaustion, guilt, and shame related to depression. You may be able to get to work, but emotionally connecting with patients is almost impossible. After your shift ends, you have no energy to engage with your family, which leads to guilt. Mental illness is highly stigmatized and can result in a person’s internalization of that stigma. Putting up a front that everything is “fine” takes a tremendous toll on the body, mind, and spirit.

But for all the pain and suffering that Anna’s story illustrated, it didn’t end there. She fought back, got into treatment, and most importantly, used her experiences to help her patients. Her accounts of interactions with patients were what touched me the most.

Applying the lessons of personal experience to practice.

Photo by Volkan Olmez on Unsplash

Anna never disclosed to patients that she had a mental illness. She didn’t have to in order to convey her empathy and understanding of their suffering. She had the words to articulate their pain when they didn’t. She didn’t minimize their complaints about drug side effects because she had experienced them too. Anna offered hope to her patients that they could recover because she had recovered. In the mental health field, recovered doesn’t necessarily mean cured. Being in recovery means that one can still experience symptoms of a mental illness but live a productive, meaningful life.

Acceptance: humbling and empowering.

Unlike Anna, I didn’t have the insight or readiness to accept my illness until after I left clinical practice. Even though I was in treatment, I saw myself as superior to patients. It wasn’t until I began teaching undergraduate psychiatric nursing and got involved with the National Alliance on Mental Illness (NAMI) that I began my recovery journey. I self-disclosed to my students because I wanted to counteract the negative image the public casts on people with mental illnesses. I gave students the words to describe feeling like a burden or feeling hopeless, language they then used when their patients had a hard time expressing themselves. I also, with great humility, admitted my biases. Having academic degrees and work experience as a psychiatric nurse didn’t make me a better person than anyone else with a mental illness. “Those people” I once referred to became “us.”

When first writing this piece, I felt I had wasted the opportunity to use my lived experience to help patients when I was in clinical practice. Upon further reflection, however, I’ve come to believe that my experience may have made a difference after all.

I will be forever grateful to the nurses, including Anna, who shared their stories with us for our study. They not only touched the lives of their patients, they touched mine, too. As hard as it was to relive darkness from the past, it gave me a profound appreciation for the present. My data analysis is complete, and I have removed my researcher’s hat. The fact that my story could intertwine with their stories is no longer an issue. It is our story.

Susan Brammer, PhD, RN, CNE, FAAN, is a professor educator at the College of Nursing at the University of Cincinnati. She has been a psychiatric-mental health nurse for over 40 years. Her professional experience, volunteer work with the National Alliance on Mental Illness (NAMI) and American Psychiatric Nurses Association (APNA), and lived experience with mental illness, has led to a lifelong passion for advocacy and stigma reduction.

The post When Studying Mental Illness in Nurses Means Studying Yourself appeared first on Off the Charts.

“Workplace violence has become a familiar threat for those employed in a health care environment.”—Miranda Squire and Karen Hessler in this month’s Original Research article, “Patient-to-Nurse Violence During One-to-One Assignments: A Silent Epidemic”

The February issue of AJN is now live. Here’s what’s new. Some articles may be free only to subscribers.

AJN Reports: What’s the Future of Hospital at Home in the United States?

Programs offering this promising acute care model have proliferated since 2020, but payment and regulatory structures to address equity, oversight, and sustainability are needed.

CE: Caring for Patients After Ileostomy Surgery

A review of postoperative care following ileostomy, including hydration, medication, and nutritional management.

Original Research: Patient-to-Nurse Violence During One-to-One Assignments: A Silent Epidemic

This qualitative cross-sectional study investigated workplace violence from the perspective of nurses and nursing assistants working one-to-one assignments who experienced violent encounters with patients or visitors.

Supporting Family Caregivers: No Longer Home Alone: Managing Older Adults’ Chronic Pain: Lower-Risk Interventions

This article—part of a series published in collaboration with the AARP Public Policy Institute—discusses evidence-based, lower-risk strategies to control pain and describes how nurses can engage
family caregivers in using them.

Perspectives on Palliative Nursing: Spiritual Care as a Core Component of Palliative Nursing

The authors highlight the relevance of spiritual care to palliative nursing and offer practical tips to incorporate spiritual care into everyday nursing practice.

There’s much more in our February issue, including:

• A Viewpoint on recognizing the role of the adult-gerontology NP.
• A Focus on DEI column on ableism in health care.
• A Specialty Spotlight on perianesthesia nursing.

Click here to browse the table of contents and explore the issue on our website.

A note on the cover.

On this month’s cover, providers with DispatchHealth, an in-home health care company, attend to a patient. Founded in 2015, the company offers services throughout the country, including hospital-level care for conditions like pneumonia, heart failure, and chronic obstructive pulmonary disease. DispatchHealth is one of a growing number of companies offering hospital-at-home care, a model that has shown promise in improving patient outcomes and satisfaction and in reducing costs.

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Although currently living upstate, I’ve closely followed news of Mayor Eric Adams’ policy for removing residents who appear mentally ill on city streets. As a nurse with a background in health care administration, I find this policy ethically problematic. As a PhD candidate studying how organizations collaborate to transition patients lacking homes at discharge, I know the complexities of implementing this policy.

Mayor Adams is proposing a close read of section 9.58 of Article 9 of the New York State Mental Hygiene law, which is the state’s legislation pertaining to involuntary hospitalization of people experiencing acute mental illness. To “939” someone, as it is often informally termed, means to place them under involuntary psychiatric hospitalization because they pose an imminent threat to themselves or others; ‘imminent threat’ is usually interpreted to mean active suicidal ideations or homicidal threats or actions. What Mayor Adams proposes is to allow peace officers and mobile outreach units to apply a wider interpretation of this clause such that it includes any behavior that might threaten an individual’s ability to take care of their daily living needs.

I believe that housing first policies are the bare minimum for giving a person with serious mental illness or any significant chronic disease a chance at achieving well-being. But with thousands of New Yorkers living on the streets, many with serious mental illness, Mayor Adams’ argument for intervention based on an individual’s capacity to care for themselves, even in the absence of tangible solutions to the housing crisis, might at least provide individuals in psychiatric crisis with better access to necessary stabilizing treatments. At the same time, the influx of potentially lower-acuity patients into emergency departments could exacerbate the shortcomings of our hospital-to-community care transitions systems.

What happens after admission?

Photo credit: Luke Stackpoole/Unsplash

When I worked as a nurse in New York City, it wasn’t uncommon to walk past recently discharged people wearing hospital bands and yellow socks asking for change on street corners adjacent to the hospital. I often felt a sense of guilt that we couldn’t find a place for them when they no longer required hospital-level care, and bewilderment about what the incredibly complex process of successful community transition might entail—or if it was even possible, in some cases.

Mayor Adams’ policy places a heavy responsibility on hospital administrators, who will have to strategize ways to better transition the influx of people with serious mental illness to hospitals under this policy. Once these individuals make their way through various clinical paths toward discharge, what happens? Discharging medically complex people who lack homes is time-consuming, leading to longer discharge delays than for housed counterparts, higher rates of readmissions, and increased costs.

The need for cross-sector collaboration.

I’ve been studying cross-sector collaboration in the city of Buffalo, where I currently live. Care fragmentation is most extreme in patients experiencing high social complexity, like homelessness, alongside medical needs. I work in a cross-sector network of providers to sustain a 13-bed medical respite unit for men experiencing homelessness at hospital discharge. This is a care transitions unit intended for patients with care needs that might be managed in a home-based setting, like extensive wound care by visiting nurses, but lack a home for this treatment.

In our project, we have found that helping our patients transition from hospital to shelter-based medical respite requires cross-sector collaboration that includes intricate, case-by-case communication between providers across the care continuum.

The success of our team in facilitating care transitions to our medical respite unit depends on several factors related to communication and relationships, themes prominent in the framework that is central to my own dissertation research, relational coordination theory. In weekly case conferences, representatives from the discharging hospitals, homeless shelter, academic partners, home health agencies, primary care, and behavioral health care meet to discuss our patient roster, new referrals, and troubleshooting. But even after almost three years of working together to launch and sustain our program, we still struggle together when faced with problem-solving and the intensity of communication it requires—something that we are always refining our shared cross-sector structure, process, and protocols to improve.

Cross-sector collaboration has been much studied, but its effectiveness remains difficult to measure, and we don’t often understand its actual impact. There are many barriers to its successful implementation, such as time, lack of infrastructure, vast differences between the roles and cultures of organizations, and fear of reputational impact. These challenges are common within the walls of the hospital, but imagine them spanning multiple boundaries between organizations that serve clients in different capacities and lack incentives or tools to systematically coordinate.

My point here is that even in a small group of providers with established relationships, cross-sector collaboration, which is vital to the success of patients with serious mental illness, homelessness, and other care complexities, is challenging and requires ongoing improvement strategies from intake to discharge to permanent housing and beyond. While Mayor Adams’ policy clearly outlines steps that exhibit cross-sector elements for the intake of people who may be at risk of undue harm to themselves, his initiative stops at their drop-off at the hospital. And while he is calling for increased accountability for hospitals to share information with community-based agencies at hospital discharge, a more developed and intentional strategy that appropriately addresses cross-sector needs spanning the care continuum for successful community transition is a necessary care threshold that all New Yorkers deserve.

Amanda Anderson, MPA, MSN, RN, is a PhD candidate and research project assistant at the State University of New York University at Buffalo School of Nursing and a fellow in Clinical Scholars, a national leadership program supported by the Robert Wood Johnson Foundation. She is also on the editorial board of AJN.

The post Cross-Sector Collaboration and the New York City Involuntary Hospitalization Policy appeared first on Off the Charts.

“Black patients’ hair is often neglected due to lack of appropriate products and a predominantly non-Black health care staff unfamiliar with caring for hair different than their own.”

Click image to expand; see link in text for a pdf of the full tip sheet.

Irene Friedman, MS, RN, and Michelle Sison, MSN, RN, noticed that hair care for Black patients needed improvement at their hospital. In response, they developed a Tip Sheet for Care of Textured Hair as an initiative in line with the goals of their hospital’s nursing diversity, equity, and inclusion (DEI) Magnet core council. They have generously made this downloadable pdf available to AJN to share with readers who would like to make use of it in their own hospitals.

This two-page document also includes recommended hair care products and QR code links to videos to instruct staff on how to care for textured hair.

To learn more about why and how Friedman and Sison developed this tool, read their December 2022 Viewpoint in AJN, “Equitable Patient Care Includes Equitable Hair Care.“

The post A Tip Sheet for Care of Textured Hair in Hospitalized Patients appeared first on Off the Charts.

“I pleaded with her to go to the hospital.” Don’s voice is suffused with sadness as he sits at the bedside of his dying 39-year-old partner, Clarisse. “She was terrified of medical tests and procedures. By the time she saw a doctor the cancer had spread. She was so overwhelmed she refused any treatments.”

Over the year I’ve had several patients like Clarisse; younger people who refused to seek medical care or declined treatments that might have cured them. Some were depressed, others worried about the financial burden. But there was a common thread: all were intensely distrustful, avoidant, and afraid.

Depressive thoughts, distrust, avoidance, and fear are all common features of post-traumatic stress disorder (PTSD) and every one of these patients had either been diagnosed with PTSD or would have if they’d sought psychological care.

Effects of PTSD in patient response to health care.

Clarisse had survived childhood sexual abuse at the hands of one of her mother’s boyfriends. This had left her intensely sensitive to intrusions into her personal space, terrified of being touched or probed by medical staff, and distrustful of men and authority figures. There were a number other common effects of PTSD evident in my work with Clarisse.

• Hypervigilance, which is a state of extreme alertness to threats and danger that keeps someone feeling unsafe and on guard. Imagine the experience of a hypervigilant person who awaits an exam, procedure, or test in the waiting room of a fast-paced clinic or hospital.
• Hyperarousal refers to a pattern in which a person’s nervous system kicks into high gear (fight-flight-freeze or collapse) when in the presence of trauma reminders (triggers). This can cause intense emotional and behavioral reactions and can make it difficult to take in information. Possible trauma reminders for someone with a history of sexual violence include things like being examined, being naked, ruptures in boundaries, being in the dark, loss of control, procedures which inflict discomfort, emotions or sensations like fear or a racing heart, and thoughts or beliefs such as “I’m not safe.”
• Negative thoughts and beliefs about one’s self, the world, or others, which can lead to a negativity bias in which one expects worst-case scenarios or assumes dire motives in others or in large systems. For Clarisse this had resulted in a sense of futility about medical care and catastrophic beliefs that it might actually harm, even kill her.

Poor support networks and other factors.

Some people with PTSD have poor support networks with few, if any, caregivers due to histories of relational stress or social isolation. Ganzel (2018) points out that “patient–staff collaboration and patient care may be compromised because patients struggling with trauma histories are more likely to be anxious, depressed, distrustful, angry, and/or avoidant of trauma reminders, which may include medical settings and medical personnel.”

Patients experiencing fear and vulnerability associated with post-traumatic stress may not adhere to medical recommendations and may have difficulty processing information intended to help them assess treatment options. Some may dissociate or zone out when overwhelmed; others may engage in fight-or-flight behaviors such as arguing or leaving the room.

Signs of trauma-related distress in patients.

For medical professionals encountering patients like Clarisse, it’s important to know that PTSD can affect anyone and that people often conceal trauma histories due to shame, stigma, or wanting to distance themselves from painful memories.

If a nurse fails to recognize signs of trauma-related distress, such patients may be negatively labeled as unintelligent, argumentative, in denial, or as having poor insight, coping, or emotion-regulation skills. Below are possible signs of acute trauma-related distress associated with medical care compiled by the Beacon Program at the University of North Carolina:

• Patient is highly anxious, agitated, or “jumpy”
• Appears tearful during exams, with no obvious cause
• Physically withdraws, or becomes very quiet or “frozen”
• Has difficulty concentrating, is very distractible, or seems disoriented
• Minimizes symptoms that might require an intrusive exam
• Cancels appointments or refuses needed care
• Exhibits strong emotional reactions to relatively benign interactions (e.g., crying, panic, irritability, anger)
• Experiences flashbacks or dissociates during appointments

Trauma-informed care.

If a patient is experiencing any of these, or other symptoms suggestive of trauma activation, it’s important to slow down and find ways to enhance a patient’s sense of safety, connection, and control. The Beacon Program offers these tips:

• Ask the patient if they would like to take a break
• Ask if they would like a safe family member or friend to be present
• Prepare the patient ahead of time for the exam by telling them exactly what you are going to do before you do it
• While performing exams tell the patient what you are doing step by step
• Ask for permission to touch the patient and check in during exam to make sure they are still okay with you touching them
• Be present and attentive

When working with patients like Clarisse there are plenty of things nurses cannot control and for which they are not responsible. We cannot force people with histories of psychological trauma to seek care or adhere to recommendations, but we can learn how triggers work, what trauma-related distress looks like, and how to respond.

Even the best care will not guarantee that hospice clinicians like me will no longer see patients like Clarisse now and then. But if we all practice in a trauma-informed way, maybe this will become less likely.

The author of this post, Scott Janssen, MA, MSW, LCSW, is a clinical social worker with UNC Health Care Hospice in Chapel Hill, North Carolina, and a member of the National Hospice and Palliative Care Organization’s Trauma-Informed Care Workgroup. His writing has appeared in publications that include the Journal of Palliative Medicine, Psychotherapy Networker, Washington Post, Reader’s Digest, and HuffPost.

(For an in-depth look at trauma-informed nursing care, read “Trauma-Informed Care in Nursing Practice,” a CE feature article that’s currently free to read.) 

The post Death by PTSD: When Patients Are Afraid of Health Care appeared first on Off the Charts.

(This post is by an author of AJN‘s January CE feature, “Evidence-Based Practice for Peripheral Intravenous Catheter Management.”)

Questioning the status quo.

As a former critical care nurse and now a vascular access nurse researcher, I’ve had the good fortune to travel widely and work with nurses from around the globe on multiple projects. As a researcher, part of my role is to question clinical practices we often take for granted and to ask, “Is this the best way? Could there be a better way?” Identifying practice that may not always be evidence-based is how research often begins.

Prior to the Covid-19 pandemic, I undertook a two-month fellowship in the US and visited several hospitals where, time and again, I noticed the majority of hospital patients had a peripheral intravenous catheter (PIVC) in place, but many were not in use. When I asked the nursing and medical staff why patients had a PIVC that was not in use, I was repeatedly told, “Every patient needs an IV, just in case.” When I pointed out that some patients had two or three PIVCs not in use, or a central venous access device as well, it became obvious that this is a common problem.

An ‘idle’ catheter is a PIVC that has not been used for the previous 24 hours and has no plans for use for the next 24 hours. Following treatment, a PIVC may be left in place until someone remembers to remove it. Shockingly, up to one-fourth of PIVCs are inserted but never used. It’s time to question the ‘just in case’ PIVC.

Staff time and convenience.

Having a PIVC in situ may give you a sense of control, that if an emergency occurs the patient will have ready intravenous (IV) access. If the patient is medically unstable or needs short-term IV therapy, having a patent PIVC in place is important.

However, a stable patient will almost never require emergency access, and appropriate vascular access can be inserted when it is needed. A PIVC that has already been indwelling for more than a day or so without use may not function effectively when you try to access it, requiring a new PIVC to be inserted and fewer veins available for access. That means two or more IV insertion attempts, which is a waste of staff time and hospital resources, as well as painful for the patient.

Bloodstream infection risk.

Bloodstream infection is usually considered to be caused by more invasive central vascular access devices. If you think that PIVCs are a benign device and rarely lead to bloodstream infection, I urge you to reconsider. The rates of PIVC-associated bloodstream infection are often unknown and rarely quantified. But there is increasing evidence that PIVCs pose just as much risk as central devices, which makes sense. After all, any vascular access device is a portal straight into the bloodstream. Furthermore, PIVCs are often treated with less care than central devices. My team did a global prevalence audit of PIVCs and identified one in five PIVC dressings were soiled or loose: a red flag for potential infection.

Vessel health and preservation.

Vessel health and preservation is increasingly on the nurse’s radar. And rightly so. Veins are a limited resource, from infancy to advanced years. Many patients require multiple insertion attempts to achieve functional vascular access, and each insertion attempt can leave veins bruised and nonviable. If a PIVC is inserted and not used, this is a waste of viable veins that may be needed for urgent care at a later time. Nurses should be advocates for the patient and speak up when routine IV cannulation is not in the patient’s best interests.

A little critical thinking goes a long way.

A PIVC should not be the default option for every patient. There are many ways nurse can advocate for patients’ vessel health. Here are some suggestions:

• Think twice before inserting an IV.
• Use ultrasound guidance for patients with known difficult intravenous access.
• Consult a pharmacist to spread out intravenous medication times so that one IV is sufficient, even with drug incompatibilities, or to identify alternate drug administration options.
• And every day, question if the PIVC can come out. Consider if the patient can manage with oral medications and fluids. Do some local audits and see how many patients in your unit have a PIVC that hasn’t been used recently.
• Follow up patients who have a PIVC inserted to monitor infections or other complications.
• If your hospital policy insists that every patient have a PIVC inserted, regardless of indication, challenge it.

‘Just in case’ is not good enough. Let’s aim to do better.

Gillian Ray-Barruel, PhD, RN, MACN, is a senior research fellow at the Herston Infectious Diseases Institute and the University of Queensland School of Nursing, Midwifery and Social Work in Brisbane, Queensland, Australia; an adjunct senior research fellow at the Griffith University School of Nursing and Midwifery; education director at the Alliance for Vascular Access Teaching and Research (AVATAR); and associate editor of Infection, Disease and Health.

The post Every Patient Needs an IV, or Do They? appeared first on Off the Charts.

“Growing, evolving, and progressing are part of the natural order of things. In my almost 40 years as an RN, I have seen enormous evolution and elevation of nurses in the delivery of health care.”—AJN editor-in-chief Carl Kirton in this month’s editorial, “Evolution in a New Year”

The January issue of AJN is now live. Here’s what’s new. Some articles may be free only to subscribers.

The Year in Review: 2022

The top health care, clinical, and policy news stories of the year, plus stories to watch in 2023.

Original Research: Practice Variations in Documenting Neurologic Examinations in Non-Neuroscience ICUs

This study explored existing practices for documenting neurologic examinations by RNs and providers in medical, surgical, and cardiovascular ICUs, which don’t routinely admit patients with a primary neurologic injury.

CE: Evidence-Based Practice for Peripheral Intravenous Catheter Management

The authors discuss the evidence for the appropriate use of short PIVCs in hospitalized patients, assess the ongoing need for PIVCs, provide recommendations for alternative options, and argue for promptly removing a PIVC that is no longer in use.

Ethical Care for Patients with Self-Managed Abortion After Roe

A review of patient privacy as it relates to self-managed abortion, ethical reporting requirements for nurses, and best practices for treating complications of self-managed abortion using a harm reduction framework, with a focus on protecting patients’ rights.

Addressing CAUTIs with an External Female Catheter

After identifying catheter-associated urinary tract infections in bedbound female patients, a team of clinical nurse specialists initiated an intervention using external female catheters to achieve better outcomes, at a significantly lower cost.

Book of the Year Awards 2022

AJN selects the most valuable texts of the year.

There’s much more in our January issue, including:

• An AJN Reports on global hunger.
• A Focus on DEI column on why diversity, equity, and inclusion are important for nursing.
• A Specialty Spotlight on infusion nursing.

Click here to browse the table of contents and explore the issue on our website.

A note on the cover.

On this month’s cover is Memento Mori, an embroidery by Colorado nurse and textile artist Paula Giovanini-Morris. The piece was inspired by her experiences working during the COVID-19 pandemic. Three years into the pandemic, COVID-19 has claimed 1.1 million lives in the United States and 6.6 million globally. It has also dramatically affected the health care landscape, with nationwide nursing shortages driven by an exodus from acute care and a lack of nursing faculty and clinical sites to prepare the next generation. For more on the current state of nursing, see “Acute Care Workforce Under Stress,” the lead story in AJN’s annual “Year in Review.”

The post January Issue: Best Practices for PIVC Management, CAUTI Prevention, More appeared first on Off the Charts.

Critical blood shortages persist.

Blood supply shortages heightened by the effects of the Covid-19 pandemic continue to persist in the United States. Major blood suppliers report that this is the lowest level of blood supply they’ve experienced in a decade. Despite this, the Food and Drug Administration (FDA) continues to uphold a longstanding ban on donations from men who have sex with men (MSM), even those who are HIV-negative and in monogamous relationships. The current ban, revised in 2020 due to blood shortages during the pandemic, recommends deferrals for all men who report having sex with men within the last three months.

In early January of this year, the American Medical Association (AMA) sent a strong message to the FDA recommending a change in the current practices. After much external debate, the FDA recently took a significant step by initiating a national pilot study to examine these deferral policies. This study, entitled Assessing Donor Variability and New Concepts in Eligibility (ADVANCE), aimed to guide the FDA in revising the current screening questionnaire and deferral practices. Since the study’s conclusion in September, news outlets have reported that the FDA is considering revising the questionnaire to shift its focus to individual risk, based on the findings of the ADVANCE study. It has been reported that the FDA anticipates new guidance in the next few months.

More transparency needed.

By Matty Flicks/via Pxhere

While this news is encouraging, many questions remain. The FDA is mainly silent about the specific findings of the ADVANCE study. Nursing and medical researchers should review the results and offer feedback directly to the FDA. There must be more transparency about the internal work group composition assigned to policy revision decision-making. In other words, we should ask, are nurses at the table? If not, who is?

Some sources have reported that the FDA will likely change the question from “did you have sex with men who have sex with men in the last three months” to inquiries mostly related to new sexual partners during the previous three months. This option might allow MSM in monogamous relationships to donate blood only if there were no other sexual partners in the last three months. While this is promising, what happens to men who recently entered new relationships and who are also HIV-negative? Will they be excluded from donation, should the screening policies change, as many predict they will? Additionally, HIV-negative MSM who had more than one sexual partner in the last three months would be excluded. While there is no perfect solution, it is clear that the FDA still has work to do in terms of exclusionary policies related to MSM.

The FDA plans to release more details soon, including specific results of the ADVANCE study. Health care professionals should continue monitoring this situation, as these changes will affect practice and blood supply shortages. Blood shortages affect everyone in the general public. While many people are not explicitly aware of these exclusionary policies, it is essential to provide education.

Nurses can position themselves to advocate for LGBTQIA+ people, knowing that this situation involving LGBTQIA+ people is an issue that can affect every American. The next few months will be critical as nurses and others prepare to review the specific details of these changes. Nurses should begin planning the various avenues for responding to the FDA while demanding a seat at the table and a voice to advocate for humanity.

Justin Fontenot, DNP, RN, NEA-BC, FAADN, is an assistant professor of nursing in the LHC Group • Myers School of Nursing at the University of Louisiana at Lafayette.

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In my experience, nursing students often have an intense drive, intelligence, curiosity, and resilience to get them through the two years of the specialty courses in our BSN program. But sometimes the strain of the many demands and new experiences can be overwhelming, and over the years I have had numerous students come to my office for reassuring words and a safe space to reveal their struggles.

Amidst the rigors of nursing school (and their nursing careers to come), it’s important that students find a way to balance studying with self-care. We all wear masks in our lives; in fact, they are essential. Here are some of the masks that I’ve noticed students adopt when they feel particularly under pressure.

Always smiling.

When I was a student almost 20 years ago, I was stressed more days than I was happy. While everyone has a different temperament, I know I was not alone in this. As an educator, I’ve noticed that some students seem to be always smiling, as if the smile is frozen on their faces. There are some real advantages to friendly, caring smiles from a nurse, in that they can help build rapport with patients who are in a vulnerable position. But in some cases, by always smiling, the students may be trying to live up to an expectation they think others have for them. Under the bluff of the mask, the individual might be feeling overwhelmed by practical challenges while struggling with strong emotions they don’t know how to acknowledge or name.

Concerned.

Some students, on the other hand, always look concerned or worried. The look is a cross between a scowl and deep concentration. While it is important to be focused on the many new things they are learning, it is also important for students (and their teachers) to check in with themselves from time to time, to notice the tensions in their face and body, learn to take a deep breath in the midst of all the activity and demands.

We are very good at teaching skills like critical thinking. While a caring and concerned quality is at the core of nursing practice, we may also need to teach our students to become introspective about their own vulnerability if they are going to be able to give of the caring self to others. If we see that a student consistently has a concerned look on their face, it may be a good idea to take a minute to ask them if everything is okay. Let them share with you any negative thoughts or fears they may be experiencing. Clear the air, so to speak, and move forward with positivity.

I am fine.

Photo by Emma Simpson/Unsplash

This mask is the facial expression that contradicts the student’s words when she tells you, “I am fine.” The expression may be one of gloominess or flatness. I always teach my first-semester students that when they are doing a patient assessment, make sure that the patient’s verbal and body language are congruent. The same goes for our students. Does the normally peppy student seem off in a way that’s concerning? Is the quiet student who is keeping their head down even quieter than normal? Are their grades in a slow decline, yet they tell you they are okay?

This is the student I invite to my office for a chat. Sometimes I ask if anything is going on in their personal life that could be affecting them in school. I ask if they are having trouble in a particular class, or all classes equally. I have had past students who were so consumed with the work they needed to do in another class that they did not have enough time or energy left to devote to getting work completed in my class. I work with the individual to set a plan of action. I then follow up with them the next week to review how the changes are helping, or not, and to determine if additional changes need to be put into place.

A little attention goes a long way.

Not all students need or want help like this. Nor are all facial expressions a matter of comment. People are all different, and different styles are just fine. But today’s students face particular stresses, and noticing when one of them might need a little help in reorienting themself may make a difference at a crucial point in their nursing school years.

Lenore Cortez, MSN, RNC, is a clinical senior instructor of nursing at Angelo State University, San Angelo, Texas. She also writes a mental health blog called Chocolates and Tissues.

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In March 2020, Mount Sinai Queens, like many other hospitals, was overrun with patients with COVID-19. Despite layers of PPE, plus anxiety, exhaustion, and communication overload, the will to not only survive but thrive sustained the breath behind every mask. Heroes of all types were saving and soothing lives, and still are.

Outside the big front door of our hospital is a bustling ED ramp. To the left were two 18-wheel refrigeration trucks, the sight of which could take your breath away. To the far right were two 30-foot inflatable enclosed tents propped up to help the ED off-load abundant overcrowding inside. These were constant reminders that we were living through a once-in-100-year-pandemic.

An ER nurse’s creative response to a grim time.

The health care workers at the hospital weren’t the only ones subjected to these grim sights; so were our Astoria neighbors, who lived on the same block facing the ED ramp. We’ve always prided ourselves on the collaborative work we do for and with this community, including health fairs, screenings, and partnering with them on community boards. So one of us, an ED nurse named Fionnuala Quiqley (Nuala), decided to do something about it.

Nuala is a skilled and passionate ED nurse with more than 14 years of experience. She is also a neighbor—her home is very near our hospital. In October 2020, Nuala knew the struggle and pain of the staff and surrounding hospital neighbors from the cumulative weight of the successive waves of COVID-19. The freezer trucks and tents and the volume of patients in need were overwhelming.

Nuala wanted to create something in that space that was more peaceful to look at. Along with some volunteers from a local church, she cleared out an overgrown tree pit near the ED ramp and built a rock garden. She asked a friend to bring river rocks from her house upstate. She bought paints and paintbrushes and laid them out on the ED break room table for staff during their meal break to invite them to take part in an arts and crafts activity.

A place to just breathe.

The staff took to the rock painting and the #emergencyrocks hashtag was born on Instagram. Rocks of all sizes, shapes, colors, and messages of motivation were created in our break room, shellacked to protect them from the weather, and placed in the rock garden. Instagram lit up with support from around the community and hospital staff. The garden became a place to drop your painted rock, drop your mask, drop your guard, and just breathe.

Two years later, in October 2022, we held a grand reopening of what is now called the “Rock Garden of Hope” to celebrate our staff and neighbors who transformed rocks into colorful art to help heal our community and ourselves. The garden is a homegrown memorial that pays tribute to all health care workers who cared for those who had COVID-19. The rocks now have a forever home, minus the long-gone freezer truck and pop-up tents.

Nuala wrote on her first @emergencyrocks Instagram post: “If you build it, they will paint. Health Care Hero Workers, painting one smile at a time. Be the reason someone smiles today!” We at Mount Sinai Queens could not agree with her more.

By Jill Goldstein, MA, MS RN, VP nursing support services and deputy chief nursing officer, Mt. Sinai Queens; Fionnuala Quigley , BSN, RN, CEN, CPEN, clinical nurse, emergency department, Mt. Sinai Queens; Ana M. Rodriguez, LCSW, director community affairs, patient relations and volunteer services, Mt. Sinai Queens. 

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The U.S. Food & Drug Administration (FDA) recently approved the sale of over-the-counter (OTC) hearing aids for people with mild to moderate hearing loss (not severe hearing loss), beginning Oct. 17, 2022. What should nurses know about these devices?

Margaret Wallhagen

Hearing loss is one of the most common chronic conditions, becomes increasingly prevalent across the life span, and is far from benign. This latter fact is often not appreciated, but hearing loss is associated with a range of negative psychosocial concerns such as isolation and depression, as well as many health-related conditions, including falls, delirium, and cognitive decline.

For a long time, I’ve been passionate about raising awareness about hearing loss and its impact on people, their families, society, and the health care they receive, as well as promoting hearing health care access. One intervention that can mitigate some of the impact of hearing loss is the use of hearing aids. The focus of this brief blog post is on a new opportunity for people to access this technology that those of us in health care should be aware of.

Cost as a barrier to use of hearing aids.

Prescription hearing aids, while far from perfect, can help, and usually do make hearing less effortful. Unfortunately, many individuals who are eligible for or could benefit from hearing aids do not have them or do not use them. There are a variety of reasons for this, including perceived stigma surrounding wearing aids or hearing problems.

One potentially modifiable factor is cost. Hearing aids can be expensive, ranging in price per single device from about $1,000 to as high as $4,000 and varying greatly from clinic to clinic or location to location. The cost of prescription hearing aids relates to the hearing aid’s capabilities—like directionality —and is often a “bundled” price, covering the services of the hearing specialist. Cost remains a significant barrier for many.

Unfortunately, Medicare does not cover either hearing aids or hearing health care services, and many insurance companies do not include hearing aids as one of their benefits. Although efforts have been made to modify Medicare, these have, to date, not been successful. This lack stimulated the movement to allow for OTC hearing aids.

OTC hearing aids for mild to moderate hearing loss.

After several reports recommended the development of OTC hearing aids that were regulated and thus safe, Senators Warren and Grassley put forth the Over-the-Counter Hearing Aid Act of 2017 (S.670). The act directed the FDA to develop a class of OTC hearing aids for mild to moderate hearing loss in adults. The pandemic and other demands delayed the process, but these are now finally arriving on the market.

What’s different about these devices compared with the types of devices that could previously be purchased over the counter? Devices that amplify sound but are not approved or regulated by the FDA for treatment of hearing loss have been sold for some time and are not allowed to be marketed as “hearing aids.” These devices varied significantly in quality and functions and could be dangerous if they overly amplified sound.

By contrast, the new OTC hearing aids must meet specific FDA criteria (safe and effective for those with mild to moderate hearing loss and meeting certain packaging and instruction standards) before reaching the market. The intent of this new class of hearing aids is to provide access to individuals who do not wish to see an audiologist or cannot afford to pay for prescription hearing aids. It is also anticipated that their availability will drive down the cost of all hearing aids.

Much is still not known about the devices that began coming onto the market in recent weeks, but it’s important for nurses and other health care providers to become familiar with them so we can answer questions when patients ask about them or so that we can suggest that someone try them if they have difficulty hearing. It is important to be clear that these new devices are designed for individuals with “mild to moderate” hearing loss, as perceived by the person buying the devices. They are not designed for persons with significant loss or for those under the age of 18.

Technical challenges of use.

In addition, individuals buying these on their own will need to be able to fit the device and make any necessary adjustments by following the information provided by the manufacturer. Thus, it’s very important that the buyer carefully read the directions and feel comfortable following them.

Uncertainty about cost.

Reviews of currently available devices at the National Council of Aging website suggested that at least some OTC aids may be available for considerably less than is currently paid for prescription hearing aids. Even with a significant savings, these devices may still not be within reach for people without a lot of resources.

Size considerations.

These new devices will come in various sizes. Many buyers are likely to go for the “small and invisible” types; unfortunately, these may not be able to address their hearing loss or have the functions they need. The level and type of hearing loss, not the size of the device, should drive selection.

Informed purchasing is crucial.

It will be extremely important for those who wish to use these devices to be well informed. There should be a clear return policy. Plus, individuals should not purchase OTC hearing aids if they have any ear symptoms, pain, unilateral or sudden-onset hearing loss, or if they may have significant wax accumulation that could hinder their hearing. Any significant symptom warrants follow-up with a health care provider or audiologist. Further, those who do not find OTC hearing aids helpful, have more than mild to moderate loss, or have difficulty dealing with these new devices should seek the services of a professional audiologist.

OTC hearing aids offer a new opportunity to promote hearing health care—they can fill an important need and may help individuals address their hearing difficulties sooner than later. It’s important for those of us in health care to ensure that the persons we work with are informed and stay updated on this new offering as its use becomes more widespread.

By Margaret Wallhagen, PhD, GNP-BC, AGSF, FGSA, FAAN, professor, Department of Physiological Nursing, and director, University of California San Francisco Hartford Center of Gerontological Nursing Excellence.

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