The October issue of AJN is now live.

This month’s AJN Reports takes a close look at how artificial intelligence is being used in health care—and why nurses must be involved in its development and implementation.

“Current and Emerging Applications of Fecal Microbiota Transplantation” describes the use of this procedure to treat recurrent Clostridioides difficile infection, nursing management of individuals undergoing it, and its future applications. CE credit is available.

To learn more about the potential oral complications of adjuvant endocrine therapy in breast cancer survivors, the authors of the October Original Research article compared aspects of oral health in those who were taking the therapy with those who were not.

“Activism Is an Essential Nursing Role” discusses the rationale for and roots of political activism in nursing, the values that shape it, and the importance of nursing’s stance on health-related policies.

How can nurses best attend to seriously ill patients’ existential needs? Read “Perspectives on Palliative Nursing: Existential Care in Daily Nursing Practice” for an overview of key priorities.

See also the extensive health care news sections, the Journal Watch and Drug Watch sections, a Specialty Spotlight column highlighting critical care nursing, and an On the Road with AJN report from the 2023 ICN Congress.

A note on the cover: This month’s cover photo shows a robot checking a patient’s blood pressure. We chose this image to acknowledge the burgeoning conversation about artificial intelligence in health care—an area of innovation with seemingly limitless applications and still unfolding implications.

Browse and subscribe.

Some articles in this issue like the original research studies, news, and the editorial will be free to access; others will require log-in or subscription. You can subscribe to AJN, America’s most respected and oldest general interest nursing journal, for just $37.95 for a year (12 issues), so why not give it a try or give a subscription as a gift? We pay attention to appearance as well as content, and hope the cover of every issue will look good on a coffee table!

The post AI and Nursing: Recommended Reading in AJN’s October Issue appeared first on Off the Charts.

July, a month typically characterized by the relative hibernation of communicable respiratory illnesses, brought with it the U.S. Food and Drug Administration’s (FDA’s) approval of nirsevimab-alip (brand name: Beyfortus) and thus a reminder of the gearing up necessary for the respiratory disease season ahead. Nirsevimab, approved for the prevention of respiratory syncytial virus (RSV), is poised to mitigate the staggering effects of this lower respiratory tract disease. Since significant barriers remain related to distribution, accessibility, and insurance reimbursement for this drug, it is especially important for primary care RNs and nurse practitioners in clinics and medical homes to be well informed on this topic.

RSV: a significant public health burden.

Transmission electron microscopic image revealing morphologic traits exhibited by a human respiratory syncytial virus (RSV)/ CDC

RSV is primarily of concern in the youngest and most vulnerable of the pediatric population, such as those born prematurely, with chronic lung or congenital heart disease. As many of us know all too well, RSV carries significant public health burden, causing more hospitalizations than any other illness in U.S. infants and accounting for 100 to 300 deaths each year in children under five years old.

Recommendations for the new preventive antibody.

While not a vaccine by definition, nirsevimab functions similarly to one. It’s a monoclonal antibody product that provides passive immunization. The American Academy of Pediatrics (AAP) recommends that it be administered “shortly before or during” the RSV season, which roughly translates to providing the jab (via pre-filled syringe that can be administered alongside other routine immunizations) between October 1 and March 31. Local patterns of RSV activity may alter these dates slightly, so we should all keep close watch of information from the National Respiratory and Enteric Virus Surveillance System.

Per the AAP, all infants under eight months old born during or entering this first RSV season should receive the antibody. Ideally neonates will receive nirsevimab within the first week after birth during the RSV season. Infants and children who are eight through 19 months of age who are at increased risk for severe RSV disease and entering this second RSV season should also receive a dose of nirsevimab.

These recommendations are based on multicenter, placebo-controlled, randomized clinical trials (Trial 03, 04, 05) which have shown that nirsevimab confers a 75% reduction in RSV that requires medical attention, including hospitalization. The most common adverse reactions were rash, fever, and mild injection-site reactions. Considering that RSV is responsible for 2.1 million outpatient visits and 58,000 to 80,000 hospitalizations each year for children under five, nirsevimab is revolutionary. This protection lasts approximately five months, the length of a typical RSV season.

Barriers to accessibility.

Though benefits of nirsevimab are clear, actual distribution and accessibility are still murky. It is widely acknowledged that there is no existing infrastructure to ensure all pediatric patients get nirsevimab. The gaps are likely to be most profound among children who are the most vulnerable, whether due to lack of resources or high-risk medical conditions. The Centers for Disease Control and Prevention (CDC) is still working on contracts with the Vaccines for Children (VFC) program, with the goal of having nirsevimab pushed out in early October.

A crucial role for medical homes.

Few hospitals participate in the VFC program, a fact that will impede implementation of administration to neonates prior to discharge. As result, pediatric patients’ medical homes will need to lead the way in providing the injections. Communication between the infant’s place of birth and outpatient medical home will also prove critical to ensure it is clear whether a child has received nirsevimab.

Other expected barriers include the all-too-common lag in insurance payments for new products as well as coding challenges. Since nirsevimab is not a vaccine, it’ll be coded as a drug administration; codes of this nature do not include a counseling component. The AAP is lobbying for a more comprehensive code that reflects the counseling and work surrounding administration of nirsevimab—a cause we should join. This code, 96372 (injection, subcutaneous or intramuscular), is not likely to be usable until closer to the start of the RSV season.

Nirsevimab can be obtained via the Vaccine Shop. The formulation won’t change from year to year and nirsevimab has an 18-month shelf life. Expired doses will be returnable to Sanofi. The AAP offers guidance on ordering nirsevimab. Practices should start planning now in order to implement this product for the 2023-24 RSV season.

Nicole Donager DNP, CNM, FNP, teaches in the midwifery program at Shenandoah University in Virginia and practices at a primary care clinic in Missoula, Montana.

The post RSV Prophylaxis for Infants and Children: Now Available, But Is it Accessible? appeared first on Off the Charts.

Nursing students are known to have high stress levels during their nursing programs. While many researchers have explored different coping mechanisms to help nursing students cope with their stress and anxiety, not many have looked at animal interventions.

I am a huge fan of animal interventions after seeing their positive effects on patients (and staff) while I was working bedside in the hospital. Frustrated or anxious patients would usually become more accepting of care after a visit from an animal. Scared and lonely patients who were shutting down became more vibrant and open. Visitors and staff also benefitted from the visits. There were many times that as the therapy animal came down the hallway to a patient room, staff members stopped and took a moment to relax with the animal in a way that clearly refreshed them.

Becoming a therapy animal handler.

Seeing the effects of therapy animals in the hospital inspired me to pursue being a therapy animal handler myself. The hospital where I work had rabbits as part of their therapy animal program. This was a small enough animal for me to handle and care for. I picked out my first two, and I was hooked from the get-go.

The rabbits are very interactive—I like to say they are nosy. All rabbits chosen to be therapy animals are very comfortable with being petted and interacted with; they must undergo recertification every two years through Pet Partners, the volunteer organization through which we are registered. Even children and others who are afraid of dogs tend to be comfortable with them.

I currently have three registered rabbits—along with one retired old lady rabbit and two new babies that will hopefully become the next generation of therapy rabbits. They are litter box trained, live in my house, and have free time for roaming every day.

As a team, my rabbits and I have visited long-term care centers, colleges, libraries, counseling centers, the local hospital, domestic violence shelters, and recovery centers, just to name a few. My passion for animal therapy has transferred to many different areas of my life, most notably my passion for nursing education.

The stress of nursing students.

When I first started my nursing educator journey, it was hard to witness nursing students who were intensely stressed and anxious both from life challenges and nursing school curriculum with no real way to offer to help them. I could make suggestions, but ultimately I had no control over whether they carried through and made use of them or not. Usually my suggestions for coping with stress were meditation, yoga, deep breathing, and walking.

I began to wonder if the phenomena of stress and anxiety relief from animal therapy that I had noticed in outside institutions would work on nursing students. I started bringing the rabbits with me to work at least one day a week, more if I knew there was a particularly big exam on a certain day. It was a hit. The nursing students would look for me and the rabbits on exam days. Slowly, students started stopping by my office during class breaks, lunches, and in between other classes. It gave the students a chance to get their mind off of their stresses. I liked being able to connect with the students and I liked that they felt they had a safe place with the bunnies when things got too overwhelming.

Studying animal-related stress relief.

I eventually did my PhD dissertation on the effects of the animals on stress and anxiety levels of nursing students. The results confirmed what I suspected: animal therapy session do lower nursing students’ stress and anxiety levels.

I truly believe that this is one of my callings in this life. I get so much joy from being able to share my rabbits with others. They help so many people every day, I plan to continue to bring them to university with me for the foreseeable future.

By Karen (Beth) Ballenger, PhD, RN, assistant professor, Shenandoah University Eleanor Wade Custer School of Nursing

The post The Healing Power of Animals: Reducing Stress in Patients and Nursing Students appeared first on Off the Charts.

A friend’s desperation.

Photo by Ben Blennerhassett on Unsplash

It was early in the morning when I received a call from my best friend, who was crying and
distraught. She frantically rattled off her symptoms: “My stomach is on fire, I can’t sleep, nothing is relieving the discomfort, and I’m in excruciating pain.” Although she’d been feeling discomfort for the previous two weeks, at first she’d thought the intensity of her current symptoms might be from food poisoning. Given her not always healthy diet, which she and I had discussed in the past, I too at first thought she might have eaten something that set the symptoms off.

“It hurts so badly I don’t think I can take it anymore,” she told me over the phone. “I can’t stop going to the bathroom.”

She said that despite the severity of her pain, her family just thought she was being dramatic. I could sense her desperation as she sobbed over the phone. Even though she did not want to seek medical attention, I begged her to go to the nearest clinic or hospital and told her I’d meet her there.

Crohn’s disease: When nurses doubt a patient’s pain.

In the emergency department (ED) where she waited on a stretcher, she kept repeating that no one believed how much pain she was in. She lay there crying for a full hour before the nurse came with pain medicine. It was a big relief when the nurse gave my friend an intravenous dose as she calmly explained the plan of care, and I was struck by her sincere concern and commitment to making my friend feel comfortable. It is one thing for a friend to show empathy, but for a total stranger to show such compassion is something else entirely for the person on the receiving end. I felt honored in that moment to be a nurse and call this ED nurse my colleague.

The next day, my friend was admitted to a medical–surgical unit. By this point, her symptoms had temporarily resolved and she felt ready to go home. The physician and nurses recommended that before my friend left the hospital she should undergo an inpatient colonoscopy, given the severity of her symptoms. Meanwhile, I couldn’t help feeling uneasy at the way some of the nurses on the unit giggled and teased my friend about how she felt better after the pain medicine and was ready to go home; it seemed like they too did not believe my friend, just like her family.

At my persuasion, my friend at last agreed to the colonoscopy, which showed inflammation in her bowels. After three days spent by my friend in the hospital, the doctors confirmed that she had suffered a flare-up related to an inflammatory bowel disease (IBD).

Chronic illness and the burden of invisible pain.

Over the past five years, my closest friend has suffered from the type of IBD known as Crohn’s disease. I have watched the disease affect both her physical and mental health. My friend is often too self-conscious to go out to eat. She struggles with choosing foods to eat, aware that certain food groups may cause flare-ups. She struggles with her fluctuating weight and her chronic symptoms of diarrhea, abdominal pain, and fatigue. My friend’s disease has also caused other diseases, infections, and surgeries. She has been to several different hospitals and clinics in order to better manage her symptoms and gone through numerous diagnostic tests, screenings, procedures, and treatments.

Although my friend somehow always remains positive on this difficult path, her experiences give me a window into the care she receives in the hospital and elsewhere. The fact is, it can be exhausting to navigate the medical system with a chronic disease that isn’t visible at first glance to others. As nurses, we sometimes find ourselves unsure about the severity of someone’s pain. Their self-report is subjective, and we may find it difficult to understand that they can be in pain when they seem to be lying comfortably in bed. My friend has truly opened my eyes to the reality that every patient’s experience is unique.

Reflecting on compassionate nursing care.

As my friend continues to go in and out of hospitals, she always speaks about the different types of nursing care. Although she expresses concerns that many nurses are not familiar with the intense pain and severity of her symptoms, she also boasts about the nurses that go above and beyond to make sure she is comfortable. My friend’s disease and her experiences have allowed me to reflect on my own nursing practice. It is important to understand chronic diseases like Crohn’s disease and appropriate nursing interventions related to the diseases in order to provide compassionate and high quality nursing care.

Every patient has their own individual circumstances and experiences. Nurses play a crucial role in providing care and support to patients with chronic diseases. As nurses, we must show compassion and empathy when helping patients manage their chronic diseases. We must be able to communicate appropriately with different patients to address fears and concerns related to their condition, treatment, and lifestyle adjustments. Although I have a personal connection with someone who deals with this chronic disease and can empathize from her perspective, I must still work to consciously create nursing interventions that address each patient’s concerns and meet their individual needs.

Lilly Gareau, BSN, RN-BC

The post Unseen Struggles: When the Pain of Chronic Illness Meets Disbelief appeared first on Off the Charts.

The September issue of AJN is now live.

This month features two Original Research articles:

• “‘Do I See Myself?’ Exploring the Potential for Online Images to Attract a Diverse Nursing Workforce,” which  examines how online images of health care workers vary by gender and skin tone and how those representations might impact recruitment.
• “Nurse-Reported Missed Care and Its Association with Staff Demographics and the Work Environment,” which evaluates the prevalence of, types of, and reasons for nurse-reported missed care, including staff-associated factors, at one hospital.

“Exploring the Human Experience in Health Care,” the first article in a new series from health care performance improvement organization Press Ganey, discusses the emerging concept of human-centered care—and how data can be used to help deliver it.

Read “Pneumococcal Vaccination in Adults” to learn about updated pneumococcal vaccine recommendations from the Centers for Disease Control and Prevention, which include two new vaccines.

What can nurses do to protect patient safety and provide good care in light of record-high, ongoing national drug shortages? See AJN Reports to find out.

See also the extensive health care news sections, the Journal Watch and Drug Watch sections, a Specialty Spotlight column highlighting the role of the clinical nurse specialist, and the latest installments in our Strip Savvy and Nursing Research, Step by Step series.

A note on the cover: This month’s cover pictures students from the Johns Hopkins School of Nursing in Baltimore, Maryland. The school is a five-time recipient of the INSIGHT into Diversity Health Professions Higher Education Excellence in Diversity Award and a four-time recipient of the Best School for Men in Nursing award. “Achieving true health equity will require all people to feel they belong in nursing,” says Sarah L. Szanton, PhD, RN, FAAN, the school’s dean.

Browse and subscribe.

Some articles in this issue like the original research studies, news, and the editorial will be free to access; others will require log-in or subscription. You can subscribe to AJN, America’s most respected and oldest general interest nursing journal, for just $37.95 for a year (12 issues), so why not give it a try or give a subscription as a gift? We pay attention to appearance as well as content, and hope the cover of every issue will look good on a coffee table!

The post Investigating Nurse-Reported Missed Care: Recommended Reading in AJN’s September Issue appeared first on Off the Charts.

Photo by Bradyn Shock on Unsplash

When I first heard of telehealth services coming to our rural hospital, no one was a bigger skeptic than me.

Perhaps the main reason was the way I was educated as a nurse and how I learned to practice as an APRN. Honestly, I am “old school” in every way possible. My first thought was, “This is not good practice; how could it be? Won’t there be shortcuts? How about the lack of a physical exam? How can you properly physically evaluate someone over telehealth? How can you take safe care of patients and avoid missing something that’s potentially life-threatening if you can’t touch them? How could someone a thousand miles away help me way up in the mountains of the Eastern Panhandle? What could they know about the community here and their needs?”

These were just a few of the questions and concerns I had regarding telehealth coming to our rural community access hospital. When we assess our patients, we not only to listen to their heart and lungs, look into their eyes, hear their voice, feel the temperature of their skin, but we connect. We are building trust and ensuring support with looking, listening, and feeling.

The APRN in me wanted to know more about the evidence backing these services; reviewing the literature gave me hope and helped me better understand the benefits to having an extra set of “eyes” on my patients.

Filling a gap in care, saving lives.

Rural counties have fewer health care workers and specialists, critical care units, emergency facilities, and transportation options for patients to get to appointments. A recent study about videoconferencing to connect specialists in stroke centers with providers in smaller hospitals found that these “telestroke” services helped get lifesaving treatments like clot-busters to these smaller hospitals within the 60-minute national average more often.

Consider the fact that the number of potentially excess deaths (deaths among persons under age 80 in excess of the number that would be expected) differs among and within public health regions and US states. In light of this, a statistic that really hit home with me is that a substantially higher proportion of trauma patients in rural vs. urban areas die within 24 hours: 89.6% vs 64%. As you can imagine, trauma and critical patients who come to many rural EDs are transferred out if there is a bed at another facility and if they can survive the one-hour (or longer) ambulance transport.

In the rural hospital I served in, there were few in-house specialists. The nearest specialists were an hour away in each direction. There was no neurologist, no pulmonologist, hematologist/oncologist, trauma surgeon, psychiatric or mental health providers, infectious disease specialists, nephrologist, urologist, or gastroenterologist. We had a cardiologist who came once a week for office visits but did not see consults in the hospital. Many times, I had to be a little of each of those specialists in order to care for the patients who had been admitted.

In addition, we had no ICU, only an ED and medical–surgical unit. When the COVID-19 pandemic hit and we were housing ICU patients, telehealth was my saving grace. Due to the lack of hospital beds at other facilities, we had no choice but to admit these patients to offload the overwhelmed ED. At any time, day or night, I could call a specialist (pulmonology or intensivist) to help with managing these critically ill patients from afar. These providers helped us save countless lives.

A return to the time pressures of family practice.

After the pandemic, I decided to leave hospital medicine and go back to family practice. I was quickly reminded why I left family medicine all those years prior. Productivity. The lack of time with patients and the sense of feeling rushed during the day added to burnout. With EMRs and documentation requirements, too many hours were spent on the computer instead of with patients.

Providers like APRNs are required by their employers to see a specified number of patients per hour. Some APRNs are lucky to get 30 minutes per patient, but the norm for follow-up is usually 10 minutes. In rural areas, our demographics generally demand more time to fully educate and prepare patients to care for themselves and their chronic illnesses. Add in financial constraints, illiteracy, lack of resources and consultants, and you have a recipe for frequent hospital readmissions, medication/nutrition/exercise noncompliance, and increased morbidity and mortality.

Telehealth and primary care: a good fit.

In response to these pressures, I decided to open my own telehealth practice and see patients on my own terms. (I practice in Virginia, which allows APRNs full practice authority, and West Virginia, which is partial but allowed me to apply for full practice authority with my years of experience.) This meant I could take all the time I needed with patients, educate them, encourage them, and support them. Since I have patients who work six of seven days a week, most of my appointments fall on Sundays. Ninety percent of the US population has cell phones, so talking with them is not an issue if they do not have video conference availability. With the price of gas and food so high, many patients prefer this method of communication; they feel supported and are more likely to not miss appointments.

I have found two things to be true with having my own practice: I have all the time I need with my patients and they love it, and I have zero “no-shows” on practice days.

After two years of having video telehealth intensivist backup during the worldwide pandemic, I quickly changed my opinion on physical touch being a necessity during all patient evaluations. No one would argue that physical examination isn’t valuable. But it’s not always essential. Many of the patients in my current practice come for specific services such as medical weight loss, hormone replacement therapy, and chronic disease management and counseling. Some are also followed by in-person primary care providers, some I see once in person before beginning telehealth visits, and others are asked to take their blood pressure at home because of the medications they are taking. Each patient’s needs are different.

As a health care team or individual, we can make the connection whether in person, phone, or video. The space in between is not always as relevant as we may believe.

Martha Vesterlund, DNP, APRN, ANP-C, FNP-C, is an assistant professor at Shenandoah University Eleanor Wade Custer School of Nursing in Virginia and a family nurse practitioner at Compassionate Care Telehealth Services.

The post Telehealth in Rural Nursing: Embracing Change for Better Patient Outcomes appeared first on Off the Charts.

Photo by LuAnn Hunt on Unsplash

In July 2022, Velasco et al. brought attention to ongoing and systemic discriminatory policies regarding blood donation in the United States. The Food and Drug Administration (FDA) guidelines specifically targeted individuals who identify as men who have sex with men (MSM). The screening questions specifically asked men if they had sex with other men. A “yes” answer disqualified potential donors from donating blood even if they were in monogamous relationships where both partners were HIV-negative.

In December 2022, the FDA’s commissioned study (ADVANCE) wrapped, and news emerged that the study’s results prompted potential changes in the FDA-required screening policies. In a post on this blog titled Potential Changes to Blood Donation Policies for MSM in the United States, I reported the possible changes.

At the time, although we knew there would be potential change, we did not have full transparency or a final answer. Then in May 2023, the FDA updated the guidance for screening blood donors based on the results of the ADVANCE study. You can review those changes here. However, until August 7, some major blood donation centers, such as the American Red Cross, had not fully implemented the new screening guidance.

What are the current guidelines?

• All potential donors will see new non-gendered screening questions when presenting for donation.
• All potential donors, regardless of sexual orientation, will be asked the same questions and be screened for blood donation eligibility based on individual risk factors.
• The previous FDA blood donation eligibility criteria based on sexual orientation, which restricted sexually active MSM from giving blood, has been officially eliminated.

Moving forward and what to expect.

As a potential donor who was previously rejected for donation because of the screening procedures, I look forward to donating in the future. However, given the gap between the updated guidelines and the screening that actually occurs in some blood centers across the nation, potential donors should inquire about the donation center’s screening policies before attempting to donate.

This exciting change in FDA policy can profoundly affect the nation’s currently stressed blood supply. Potential donors and health care professionals must inform themselves about the current screening processes and watch the uptake of these changes to keep the blood supply safe and plentiful.

Justin Fontenot, DNP, RN, NEA-BC, FAADN, is an assistant professor of nursing at the University of Louisiana at Lafayette and the editor-in-chief of Teaching and Learning in Nursing.

The post Updated FDA Guidance on Blood Donation Screening: Where Are We Now? appeared first on Off the Charts.

Influencing patient health through advocacy.

Did you know that as nurses we have the power to influence allocation of government funds and the passage of government bills on health care? Through advocacy for federal policy and appropriations (funding), we can influence the health care of our patients. We have a voice that can be used to provide lawmakers with a new perspective on the reasons for supporting health care policy. Government policies and budget allotment affect the health of constituents.  Through legislative action, nurses can make changes that affect the lives of individuals, especially those with chronic diseases, minority background, and economic instability.

Not just for patients but for the community.

The ethical principle of beneficence means to do good. As nurses, we have the responsibility to not only do good towards our patients but to communities, expanding our focus from the nurse–patient relationship to a broader community health lens. Nurses can move from patient advocacy that makes changes for one patient to policy advocacy that makes changes for communities of patients. As nurses, we can discuss disparities seen in health care with legislatures to provide a new and personal perspective on support of different health care laws.

Drawing attention to sickle cell disease.

As a nursing doctoral student, I am interested in improving the care of children with sickle cell disease. I noted when studying the literature on the topic that there is often a lack of clarity on the true number of people in the United States living with sickle cell disease and the quality of the care that they are receiving. Through my readings, I learned about the Sickle Cell Data Collection (SCDC) program. The SCDC program is a government-funded initiative through the Centers for Disease Control and Prevention that collects data on people living with sickle cell disease with the goal of improving their quality of life, life expectancy, and overall health. Realizing the importance of the SCDC program, I collaborated with a community sickle cell organization to speak with legislators to advocate for future funding.

Getting involved in policy advocacy.

You may ask, “How can I be involved or participate in policy advocacy?” There are community organizations that provide education and a platform for policy advocacy. We can also contact our legislators to discuss proposed government bills and requests for appropriations. Opportunities for nurses to participate in policy advocacy are available for many diseases and health care concerns. Groenwald and Eldridge (2020) discuss in detail methods we can use to participate in policy development. Below are general steps that a novice can take to use advocacy to affect the lives of our patients.

1. Find what you are enthusiastic about improving for your patients.
2. Research the topic and check if there are any associated legislative bills or appropriation requests.
3. Locate community or nursing organizations with a similar focus.
4. Seek opportunities to participate in policy advocacy through organizations or contact your legislative official regarding the importance of the bill or appropriation request.

For more information on the importance of nurses participating in policy advocacy related to the Sickle Cell Data Collection program, see my article in the August issue of AJN.

Andrea Jackson, MBA, BSN, RN, is an evidence-based practice specialist at Texas Children’s Hospital in Houston. 

The post Empowering Nurses: Advocating for Better Health Care Policies and Patient Well-Being appeared first on Off the Charts.

Colorized electron micrograph showing malaria parasite (right, blue) attaching to a human red blood cell. The inset shows a detail of the attachment point.

In June and July, eight locally acquired cases of malaria were diagnosed in the U.S.—seven in Florida and one at the southern tip of Texas. Cases in the two states appear to be unrelated, and all patients are recovering. In both geographic areas, it’s likely that malaria in people with travel-related cases was transmitted by local (U.S.) mosquitoes to the people who developed the locally acquired cases.

Malaria was endemic in this country until the early 1950s, when mosquito control programs and public health campaigns brought the disease under control. Since that time, virtually all cases in the U.S—now at almost 2000 per year—have been travel related.

Malaria transmission.

Malaria is caused by several species of the Plasmodium parasite, transmitted by the bite of a female Anopheles mosquito infected by the parasite. In less than one percent of cases, transmission occurs congenitally or via transfusion, organ transplant, or unsafe needle sharing.

Why it matters.

If you’re not one of the people infected in Florida or Texas this summer, or a nearby resident, why should you care about malaria?

• Travel-related cases are increasing. The number of imported U.S. cases has steadily increased since the early 1970s. Most U.S. cases occur during the summer and fall. With increased post-COVID travel; a warming and in some locales, wetter climate; and plateauing or decreased funding for malaria control programs in many countries, conditions are ripe for an increase in malaria across the globe.
• Malaria symptoms are nonspecific. Early symptoms include fever, chills, headache, muscle aches, fatigue, and sometimes GI symptoms. The incubation period varies widely, but in most cases, symptoms occur within a month after infection. If the disease progresses without treatment, the infected person may experience impaired consciousness, seizures, shock, acute respiratory distress syndrome, acute kidney injury, abnormal bleeding, jaundice, and death.
• Many medical facilities don’t routinely stock diagnostic tests and drugs for malaria.   The CDC emphasizes that “malaria is a medical emergency” and calls for diagnosis and treatment within 24 hours. Prompt treatment can prevent progression to severe disease and limit ongoing transmission.

Staff in hospitals and emergency facilities need rapid access to microscopic examination of a blood smear by an experienced technician to determine the Plasmodium species and parasite load. PCR tests for malaria also are available, but PCR testing usually takes longer to set up than microscopy. This summer’s cases were caused by P. vivax, which usually results in less severe illness.) Newer rapid diagnostic tests for malaria are becoming more sensitive, but rapid tests are not able to identify the Plasmodium species or parasite load.

The agents most commonly used for malaria treatment in the U.S. are artemether-lumefantrine (Coartem) for uncomplicated cases, and IV artesunate for severe malaria.

The CDC urges all medical facilities to ensure that staff consider the diagnosis of malaria in cases of a fever of unknown origin and to arrange for rapid access to both accurate diagnostic tests and malaria drugs in order to quickly manage suspected cases of malaria. CDC resources for clinicians include:

• Their original CDC health alert regarding local cases.
• For diagnostic and treatment questions, the CDC’s malaria hotline, staffed by malaria clinicians.
• This CDC web page for help in acquiring IV artesunate.

Personal preventive measures.

If you plan to travel internationally, consult the CDC’s Yellow Book for detailed and up-to-date information about health and safety measures. If traveling to areas where malaria is endemic, your level of risk depends on your own health, your itinerary, your accommodations (screens? air conditioning? neither?) and modes of travel, and the season. Insect repellents and bed nets will usually be necessary, along with taking one of several possible medications as a malaria preventive. It’s safest to acquire medications in the U.S. before travel, because “fake” antimalaria drugs and drugs of dubious quality are the norm in some countries.

The post Why Should You Care About Malaria? appeared first on Off the Charts.

It hurts to move.

Staja Booker, PhD, RN

It’s 10:00, 15 hours postoperative, and your patient has eaten breakfast and is resting comfortably in bed. You ask the patient, “On a scale of zero to 10, how much pain are you having right now?” The patient replies “zero, as long as I don’t move.” The nurse documents the pain score as 0/10 and continues their rounds.

Most nurses are happy when patients report no pain. What is the nurse missing? The contextual factor called movement.

Several years ago, a research participant told me, “Ain’t no sense in getting up to hurt.” A very simple yet powerful statement began my quest to shift how we understand and assess the dynamics between pain and movement.

The realities are:

• Movement increases acute pain postoperatively, and most patients are afraid to move even when the importance of ambulation is known.
• Most patients need some type of pain medication or non-pharmacological intervention to engage in mobility-related activities.
• Movement and mobility enhance recovery and rehabilitation.
• Movement-evoked pain is as a major barrier to participating in activity-based interventions.

Movement-evoked pain is an important pain characteristic that describes pain and discomfort during active or passive motion of the affected area. Yet, despite awareness among nurses of the importance of setting function-related pain goals, most of our pain assessments are performed when the patient is resting at random times or at set intervals, or before or after activities. Rarely is pain assessed during activity or with movement at the point of care.

A movement-evoked pain assessment (also known as movement-based pain assessment) evaluates pain during movement, functional activities, or other physical tasks. At a more biological level, movement-evoked pain reveals how the nervous and motor systems are functioning together and highlights any dysfunction in pain responses. Understanding the patterns of pain at rest and during movement offers a unique opportunity to plan care with intentionality and develop a pain management plan that will control pain at its peak.

Moving the care paradigm.

Even with pain medications, the majority of postsurgical patients can expect to feel a certain level of pain with movement, especially at first. Pain goals specific to undertaking certain functions such as walking, transferring from bed to chair, or bathing/dressing that are set by the patient and clinician have long been understood as important. Despite this, we often assess pain before an activity or irrespective of the activity, then set a pain–function goal that is not congruent with the method of assessment. What differs in the model presented here is a specific and intentional goal by the nurse to assess pain during the activity. Yes, this is a shift in thinking! But new strategies are needed to tackle pain.

Since pain often occurs or increases with movement and has a significant impact on daily functional ability, a movement-evoked pain assessment can measure two critical recovery activities at once: pain and function. Movement-evoked pain assessment offers ‘real-time,’ individualized, and more precise report of pain that occurs with movement along with observation of function, such as gait, range of motion, and physical adaptations. We still remain overly focused on assessing pain intensity without consideration of the patient’s functional microenvironment.

Strategies for managing movement-evoked pain.

Movement is instrumental in recovery after surgery and good pain management can reduce pain that a patient may anticipate or experience during physical activities.

Don’t let movement-related pain overwhelm your patient. As nurses, we should:

• Ask about pain during movement or significant activities.
• Treat pain preemptively and proactively using multiple treatments and strategies.
• Educate patients on the positive and negative impact of movement on pain and pain on movement.
• Work with an interdisciplinary team to formulate a comprehensive pain management plan that addresses pain at rest, spontaneous pain, and movement-evoked pain.

The underlying goal is simple: how do we help postoperative patients get moving? To quote the advice in a James Brown song lyric, “Get up offa that thing/And shake ’till you feel better!”

(For more in-depth information on assessing and managing movement-evoked pain, see the two CE articles, “Assessing Movement-Evoked Pain” and “Overcoming Movement-Evoked Pain to Facilitate Postoperative Recovery.”)

Staja “Star” Booker, PhD, RN, is a pain researcher and faculty at the University of Florida College of Nursing where she studies how older adults experience chronic joint pain.

The post Prioritizing Assessment of Postoperative Movement-Evoked Pain appeared first on Off the Charts.

The August issue of AJN is now live.

“Nursing Care for Patients After Ostomy Surgery,” a CE feature, details the basics of pre- and postoperative care and patient education for colostomy and ileostomy—two of the most common types of ostomy surgery.

This month’s Original Research article is on nurses’ self-reported QI engagement and competence. Also see “Cultivating Quality: Reducing Tubing and Device Connections” to learn about a nurse-led QI project that explored misconnection prevention strategies.

“Fostering Race-Based Conversations in Nursing,” our latest Focus on DEI column, discusses ways to address racism and promote cultural competence.

AJN Reports examines the unintended consequences of online health care portals, noting that:

Although patient portals are designed to help with the management of personal health information, their proliferation may also be creating barriers to care for some people.

See also the extensive health care news sections, the Journal Watch and Drug Watch sections, a new installment in our series on palliative nursing, and a Reflections essay on how a school nurse compassionately cared for the author when she became pregnant at age 15—and whose kindness inspired the author to eventually become a family NP.

A note on the cover: The most recent decade was the nation’s warmest on record, and temperatures are expected to continue to rise. As such, the photo on this month’s cover of a wind power station by the sea in Zhoushan, China—with the wind turbines in the distance offering an alternative to fossil fuels—seemed an appropriate choice.

Browse and subscribe.

Some articles in this issue like the CE, news, and the editorial will be free to access; others will require log-in or subscription. You can subscribe to AJN, America’s most respected and oldest general interest nursing journal, for just $37.95 for a year (12 issues), so why not give it a try or give a subscription as a gift?

We pay attention to appearance as well as content, and work hard to make sure the cover of every issue will look good on your coffee table!

The post Recommended Reading from the August Issue of AJN appeared first on Off the Charts.

I’ve been fascinated by death as long as I remember.

Just before I turned eight, my Grampa Lewis died. The event left a lasting impression on me. He had gone to the hospital, puffy and deteriorating from kidney disease, at age 56. I remember that Dad parked the station wagon with faux wood paneling in the hospital lot and we all got out and stood there in cold December sunlight. Strict visiting hours prevailed then, and no kids were allowed, period. Dad pointed up to Grampa’s window, where he waved down at us through the glaring glass as we waved back. The youngest of four children, I was too embarrassed to admit I couldn’t locate him in the anonymous grid of windows.

At the funeral, I grappled with whether or not to look into the casket. Both available options seemed horrible—be forever haunted by a vision of dead Grampa, or guilt-ridden because I hadn’t respected him enough to look.

As a parent, I know no child should feel alone with that type of decision. But this was the 60s, when feelings weren’t discussed. Although neither an open casket or an embalmed body are traditionally Jewish, Granny must have decided she wanted it this way. At the last minute, as I hesitatingly advanced toward the casket, Dad intervened, calling me back to the comfort of his lap.

I grasped that death was permanent. Grampa was never coming back. Most of my life he’d lived two houses down, always there, smiling, opening warm arms. Shiva visitors thought they should distract me. “Have some strudel,” they urged, uncomfortable with my tears. “Show me how your Suzie Homemaker oven works.” I spurned them. Didn’t they know Grampa was dead? Forever? I had every right to be sad.

Right after Shiva, Mom sent me as proxy to nearby Los Angeles to visit family with Granny. Granny and I slept in the same seemingly giant bed. I often woke in the morning to her sobs as she read condolence cards.

“It’s okay, Granny,” I would tell her, snuggling up to her warm body, not knowing what else to do. It worked. She hugged me and smiled, soon able to get up and on with her morning routine. And my destiny as a caregiver was solidified forever. Age seven.

‘Death is just part of life.’

I ended up in Oregon for college and stayed. I voted for the nation’s first Death with Dignity Act in 1994, and again when it was challenged a couple years later. I was a nurse-midwife, passionate about women’s autonomy in reproductive health and pregnancy/birth. Choice and autonomy in dying was a no-brainer.

“Death is just part of life,” Mom always taught.

When I reached my early 50s and she was 78, she was diagnosed with ALS. “I’ve had a good life!” she insisted. When ready, she stopped eating and drinking, telling family and friends, “I have elected to die with dignity.” She stayed home with hospice, surrounded by Dad and her four children.

She died as she lived, making her own choices. Peaceful, and quietly stunning.

Frank talk in the shadow of death.

I had begun PhD studies in nursing. When I learned how few Americans die at home, even though the vast majority prefer to, I turned my focus to studying relationships between adult children and dying parents at home. I interviewed 10 dying mothers and their adult caregiving daughters in hospice at home about their relationships. They seemed comfortable—even relieved—to talk, appreciating the chance to vent, unburden, speak frankly about close bonds as they went through the taboo period of death and dying as practiced in America.

When I mentioned this research socially, people often rejected it as macabre, depressing. “It’s totally inspiring,” I’d counter. “People are getting the death they want, and family members—even if the relationship isn’t great—know they’re supporting them. Afterwards, the family heals with few regrets. It’s so much better than getting traumatized watching your loved one’s ribs and sternum crack in the ICU for no reason, when there’s no hope anyway.”

Readiness is all.

Most of us still try to avoid admitting the inevitability of death—avoid putting our affairs in order or even talking about it. I keep my papers and affairs in pretty good shape. And like my mom, I talk to my kids about death when it comes up. It’s not taboo.

“You can take care of the paperwork,” I tell one. “You’d throw up if you had to deal with body fluids.”

Or “You’re the one I want by my bed—nothing fazes you; you’ll be great. Thank you, in advance!”

I don’t think death is imminent—my work here isn’t done; I love and am grateful for my life. But when it happens, it’ll be okay.

And I practice dying.  At the end of yoga, for instance. Savasana, or corpse pose, is designed to help us practice death. Sure, it’s for total relaxation and soaking in the benefits of class; for taking a pause before the next thing in the day, yes. But it’s called “corpse pose” for a reason: To practice, to calmly prepare for, to dissolve the fear of, death.

So I lie there, tranquil, unmoving. Taking slow deep breaths in and out, extending my exhales, longer and longer.

By Diane N. Solomon, PhD, PMHNP-BC, CNM. The author has just closed her private practice as a psychiatric nurse practitioner in Portland, Oregon, to focus on writing and health policy. She serves on adjunct faculty at Oregon Health & Science University (OHSU), and on the boards of Nurse Practitioners of Oregon and the Oregon Wellness Program. She can be found at drsolomonconsulting.com and @DianeSolomonOR. Her last post for this blog was Practicing the ABCDEs of Self-Care in Pandemic Times.

The post Why I Practice Dying: A Nurse’s Perspective appeared first on Off the Charts.

Photo by Artem Kovalev on Unsplash

Two-and-a-half years ago, I experienced severe burnout in my role as a night shift charge nurse in a cardiovascular ICU. This blog post shares my personal story, highlighting the common ingredients of burnout and the challenges I faced. Through this experience, I learned valuable lessons that can benefit both nurses and the health care industry as a whole.

Where it All Began

Transitioning from a clinical nurse educator to a night shift charge nurse in a new cardiovascular ICU was an exciting opportunity for me. However, it soon became overwhelming due to various factors. These included a surgeon I didn’t see eye-to-eye with, moral and ethical dilemmas in patient care, staffing challenges, and a hostile work environment created by lateral violence from coworkers.

Strained to the Breaking Point

As my anxiety grew, I struggled to meet expectations each night. While prioritizing patient care and my night shift team, I feared for our patients’ well-being. Frequently, we were overloaded with acute post-cardiothoracic surgery patients. Despite my efforts to manage admissions responsibly, I faced constant pressure. Doubts crept in, and I lost trust in myself and my ability to provide safe care.

The emotional toll affected my eating, sleeping, and overall well-being. I couldn’t disconnect from work.  When I was at work I feared when my surgeon rounded or if I would need to call him in the middle of the night because a patient’s condition was declining. When I was off, I was worried about how the patients were doing and if there was anything I might have done wrong.  It was nothing for me to randomly start crying at any moment.

I was afraid to leave because of the financial stability this position gave me and my family. But the last thing I wanted was to be responsible for a patient’s deterioration, or worse, a patient dying. I had to get out of there. To be honest, I wasn’t even sure I wanted to be a nurse anymore.

Seeking a Solution

My story of burnout is unique to me, but it echoes stories from many other nurses. After resigning, I realized I didn’t want to be a victim of burnout. I embarked on a healing journey and learned valuable lessons about myself and the life I wanted to create. While personal shifts are important, I also believe tangible solutions within the health care environment can significantly impact patient well-being and nurse satisfaction. Instead of dwelling on problems, I embraced a mindset of seeking solutions. Here are some actionable suggestions to create a safer, healthier health care workplace.

Four Suggestions for Improvement

• Suggest an acuity-based staffing model: An acuity-based staffing model, supported by research, adjusts nurse-to-patient ratios based on patient diagnoses and acuity. This allows nurses caring for higher-acuity patients to have a reduced nurse-to-patient ratio so they can be more attentive to patients’ needs and subtle changes. A nurse with a higher nurse-to-patient ratio will have patients with stable vital signs, controlled pain, and not showing signs of distress.
• Advocate for leadership presence on night shift: Night shift nurses often face resource limitations and imbalanced skill mixes, including more novice nurses. Communicating the challenges to leadership and inviting them to experience the night shift reality can help bridge the gap between awareness and action. Trust me, leadership doesn’t always know how things really are.
• Foster accountability within the team: Encourage a culture of mutual support and self-care. Don’t just come in each day to take care of your patients. Come in each day to take care of each other. Establish a buddy system to make sure you are taking your needed breaks, using the bathroom, and staying hydrated. By caring for each other, nurses can collectively prioritize well-being.
• Provide a comprehensive orientation for new hires: Play an active role in onboarding new nurses, ensuring they feel confident, competent, and welcomed into the team. Reducing turnover is essential to improving staffing situations and maintaining the effectiveness of any new staffing model.

Drawing from my frontline experiences, I believe implementing these interventions can lead to positive changes in health care. Nurses play a pivotal role in the industry, and by offering tangible solutions, we can address the ongoing problem of burnout and improve patient care. Let’s make our voices heard and work towards a healthier future for patients and nurses.

Jenna Colelli, MSN, BSEd, RN, CCRN-K, is director of staff development for Wellington Regional Medical Center, Wellington, FL. In this role, she works to “mentor and empower nurses to care for themselves so they can better care for the patients we serve.”

The post The Face of Burnout in Nursing: My Personal Story and Lessons Learned appeared first on Off the Charts.

A mother’s grief.

Photo by Khamkéo Vilaysing on Unsplash

As a member of the spiritual care team, I received a request one morning to visit Ms. L, a patient who had just received devastating news: her son had unexpectedly died the previous night. Ms. L was recovering from a major surgery and in the process of being discharged from the hospital. The details surrounding her son’s death were unclear, but they only added to the profound sadness of the situation.

It was evident that the bond between Ms. L and her son was incredibly strong and loving. They had faced numerous physical challenges together, overcoming obstacles that strengthened their deep connection.

When I entered her room, there was a sense of familiarity about Ms. L, though I couldn’t quite place it. After I introduced myself, Ms. L turned to me, tears streaming down her face, and asked the agonizing questions that often arise in times of tragedy. “Why did this happen? Why were we subjected to so much pain? What had we done to deserve this punishment from God?” Ms. L, a devoted Catholic actively involved in her church, had always drawn strength from her religious beliefs for herself and her son.

In that moment, I found myself at a loss for words. She was grieving and in deep emotional and spiritual distress, and I had no answer that could bring her solace. Following my instincts, I embraced her, telling her how sorry I was for her loss. Tears welled up in my eyes as we shared a prayer. I listened attentively to her stories and gently inquired about the support she had from her family. It felt like the only way I could be of assistance. A sense of helplessness washed over me.

Finding a way to help.

As I left her room, I was overcome with a sense that I was failing her. Was there anything else I could have said or done to bring her comfort? It dawned on me that I, along with many other staff members, had cared for her son during his hospital stays. The realization made the situation even more personal. I reached out to the on-call priest, the unit chaplain, and the primary care team to ensure that Ms. L had access to all the support services we could offer. Clearly, the traumatic loss had presented a complex challenge.

Throughout the day, I ruminated on this experience, feeling tremendously sad and ineffectual. I searched within myself for answers to Ms. L’s questions, desperately seeking a way to alleviate her pain. However, I came up empty-handed.

Death tests our beliefs and leaves behind a void in our hearts, a frightening emptiness. Ms. L was terrified, overwhelmed by her grief. The experience of loss is deeply personal, and feelings of anger, disillusionment, sorrow, fear, and despair are natural responses to the death of a loved one. The loss can hollow us out, leaving us grasping for answers and explanations that often elude us.

For many people, faith and the belief in God and an afterlife provide solace and hope. Life is a precious gift to be celebrated, appreciated, and, sadly, acknowledged as finite. Consequently, we struggle to find the right words to comfort those who are grieving. I, too, faced this struggle.

After many hours of contemplation, I had a comforting thought. I knew that it would take Ms. L a considerable amount of time to navigate through her grief and spiritual distress. Yet it occurred to me that without each other, Ms. L and her son would have led vastly different lives. Their struggles had forged an unbreakable bond. Despite adversity, they had learned to celebrate each other. To have had such a profound connection is a truly beautiful thing. Enduring memories will both sustain Ms. L and keep her son alive in her heart. His presence will always be felt.

I’m not sure there is balm to heal the wounds caused by such a loss. There are no words that can rationalize or explain the timing of death. The best I could offer Ms. L at that time was my presence, a warm embrace, a shoulder to cry on, an ear to listen, and an expression of sorrow for this terrible loss. In doing so, I acknowledged and shared in the depths of her grief. The experience and how it affected me won’t be forgotten.

To answer my own question—what else could I have done or said?—I can only say that I acted on my instincts in that moment. I hope, on some level, it provided a measure of comfort.

Barbara Wukovits, BSN, RN, BC, is a spiritual care associate with the Spiritual Care Department on a per diem basis at Hospital for Special Surgery in New York City. Her essay, “My Pocket of Care,” was published in the September 2021 issue of AJN. 

The post Comfort in the Midst of Grief: A Spiritual Care Journey appeared first on Off the Charts.

The July issue of AJN is now live.

Among the highlights is a guest editorial by Angelina Jolie, “Addressing Health Inequities in Survivors of Domestic Violence,” which explains the importance of bruise detection technologies for patients with varying skin tones. Referencing her daughter, who is from Ethiopia, she writes:

“Even as my family has access to high-quality medical care, simple diagnoses are missed because of race and continued prioritization of white skin in medicine.”

On this topic in the same issue, see the Nurse Innovators column, “Improving Bruise Detection in Patients with Dark Skin Tone.”

A useful read about getting patients up and moving again after surgery is a CE feature article, “Overcoming Movement-Evoked Pain to Facilitate Postoperative Recovery.” which emphasizes a multifaceted approach that includes timely evaluation and comprehensive care planning.

“Improving Medication Safety in the ICU” is about a nurse-led initiative to reduce medication errors by increasing adherence to safety protocols, including compliance with barcode scanning before medication administration.

A Viewpoint addresses a possible solution to the thorny problem of how a hospital and its nurses handle patient access to medical cannabis.

See also the extensive health care news sections, the Journal Watch and Drug Watch sections, a new installment in our series on conducting research as a nurse, and a powerful essay on childhood abuse that details a counselor’s experience with an ex-patient who helps him more deeply understand that becoming who we are means relinquishing hope for a better past.

Browse and subscribe.

Some articles in this issue like the CE, news, and the editorial will be free to access; others will require log-in or subscription. You can subscribe to AJN, America’s most respected and oldest general interest nursing journal, for just $37.95 for a year (12 issues), so why not give it a try or give a subscription as a gift?

And in case it matters to you, we pay a lot of attention to appearances as well as content, and make sure the cover of every issue will look good on your coffee table!

The post In AJN’s July Issue, a Guest Editorial by Angelina Jolie and Other Essential Reading appeared first on Off the Charts.

Photo by RIDVAN AYRIK/ Pexels

In the past month, we had a couple of patients in our pediatric ICU who had suffered tragic neurological injuries and were declared medically brain-dead. In the state of California as in most states, a pronouncement of brain death is equal to a legal pronouncement of death, and the medical team then possesses legal permission to remove mechanical support from the physical body that has remained under intensive care.

In both of these cases in our ICU, the parents struggled to accept the terminal implications of brain death and pushed back to varying degrees for more time to see if their children might still somehow find a way to recover. In these types of cases, the actual moment-by-moment practice of bedside nursing care becomes complicated. How do we honor the personhood of the patient as we provide intensive care for the body prior to removing mechanical support, and at the same time gently help the parents accept that their child has medically died?

The potential for misunderstanding nursing care

The interactions nurses have with family members as we care for their brain-dead child present many opportunities for either confusion or clarity. Nurses field the barrage of family members’ questions about what one reflexive neurological twitch might mean, why we still diligently protect the skin if the patient is really gone, and why we still tell the patient what we’re about to do if they can no longer interact with the outside world.

Our desire to continue to respect the personhood of our patient by way of a tender approach can unintentionally prolong the hope of struggling parents that the patient remains fully present and just needs a little more time to ‘wake up’: “Our child isn’t dead. After all, the nurse says she doesn’t want his skin to break down, and she’s still talking to him, so why would we take out the breathing tube?”

The shared human struggle with disconnecting from the brain-dead patient

I feel the moral distress of keeping this bodily shell viable through aggressive medical interventions when the spirit has already moved on. At the same time, if I change the way I provide care by withholding some of my personal touch, I feel a sense of loss in who I am and what I value as a nurse. In this way, I find myself deeply conflicted.

But I am aware that this is not just my struggle but that of my patient’s family as well. Human beings are not wired to simply shut off our hearts at the flip of a switch or the uttering of a medical pronouncement. We value personhood and struggle with the idea of disconnecting from an individual who was once embodied by this flesh and blood that now only remains present because of mechanical support. I don’t want to be a disconnected nurse; how much more do my patients’ parents resist the idea of a final disconnection from their beloved baby?

This awareness of our shared human struggle with disconnection gives me more empathy to meet my patients’ parents where they are as they grapple with the implications of brain death. It enables me to give them the emotional safety they need to wrestle, grieve, and then perhaps slowly trust what we are telling them about their child’s condition.

Tailoring patient care with sensitivity to the family struggle with loss

If the parents remain ambivalent regarding the brain death status, it benefits everyone for me as the nurse to clearly explain the reasons for my approach to patient care. I might say, “I want to be gentle with your child’s body, and I talk to every patient I care for whether they can hear us or not. But even though I do this, I need you to understand that we do not expect your child to recover or respond again, and I am so sorry. It feels important to treat him as respectfully as I can while he remains under our care.”

Stating this as clearly as possible helps all of my verbal and nonverbal messaging to stay consistent with the entire medical team as we seek to help the parents understand and eventually accept brain death. However, in situations where the parents are particularly resistant to the idea of brain death and the case has become drawn out and with heightened moral distress for the health care team, I and other colleagues have chosen to stop talking to the patient in front of the parents in order to avoid any misunderstanding. 

My interactions all have to be in the context of broader communication with the family, built on openness, close listening, and goals of trust. Only then can the parents recognize my personalized care towards the patient as my show of deep respect but not as an indicator that the brain-dead patient might somehow still have a chance to be revived. 

We cannot overstate the importance of discernment, empathy, and patience on the part of the entire medical team when caring for brain-dead patients, but particularly bedside nurses as the ones most present with the patient and family in this extremely delicate time.

The post Honoring the Personhood of Brain-Dead Patients: A Delicate Approach appeared first on Off the Charts.

Photo by Tegan Miele/Unsplash

Find out what you need to know about the health risks of wildfire smoke and the best ways to keep you and your family or patients informed and safe—whether through use of a smartphone app, limiting outdoor activities, buying an air filtration device, or other means.

As we enter summer, wildfire season is upon us and will extend into the early fall. Wildfires in the United States have increased in frequency and severity over the past several decades. The states with the most wildfires are California, Georgia, Texas, North Carolina, Florida, Arizona, and Oklahoma. This year, as the season ramps up, Canada has experienced record-setting wildfires, with smoke causing air quality alerts and evacuations in Canada, the northeastern United States, and Europe.

The health risks of wildfire smoke.

With these fires comes poor air quality, with the main culprit being a pollutant known as particulate matter (PM) 2.5. These tiny particles or droplets in the air are 2.5 microns or less in width and are able to travel deep into the respiratory tract. Exposure to fine particles can cause short-term health effects such as eye, nose, throat and lung irritation, coughing, sneezing, runny nose, and shortness of breath. It can also affect heart and lung function, worsening heart disease and asthma, and increasing the risk for heart attack.

While some states out west have experienced wildfires and poor air quality alerts for years, the past few weeks have brought unprecedented poor air—with warnings reaching the highest level of alert—to northeastern states such as New York. During poor air events, nurses may see more patients suffering from respiratory issues in emergency rooms and outpatient clinics and patients may have more questions on what they can do to protect themselves.

A recent AJN article, “Nursing Practice and Particulate Matter Exposure,” contains more detailed information on particulate matter. Get informed by exploring the resources below on minimizing dangerous exposure, including air quality apps to track when it is unsafe to go outdoors and tips on how to stay safe. What’s working for you, and how concerned are you about this growing health risk?

Resources to Limit Exposure to Poor Air Quality

From the CDC

Protecting Yourself from Air Pollution During Physical Activity

CDC Information page on wildfire smoke with links to multiple resources

From the American Lung Association

10 Tips to Protect Yourself from Unhealthy Air

Smartphone Apps and Websites for Exposure Assessment

The American Lung Association’s State of the Air app

The EPA’s AIRNow app

The OpenAQ (“a nonprofit organization providing universal access to air quality data”) website

Patient Education Handouts

The EPA’s “Patient Education Tools—Ozone Pollution and Your Patients’ Health”

Personal Air Quality Monitor Purchasing Information

Monitors evaluated by the EPA

The post Resources for Staying Safe as Wildfires and Poor Air Quality Events Increase appeared first on Off the Charts.

Improving data collection and analysis of RRTs for quality improvement

The method we use to track rapid response team (RRT) data has evolved on our health campus at Mount Sinai Queens. Just a few years ago we were using paper logs; now we use electronic logs accessed by a QR code. The goal initially has been to become paperless and collect data to analyze our rapid responses for clinical insight. The greater data collection with the QR code process has in turn allowed for analysis, including a closer examination of diversity, equity, and inclusion (DEI) variables. 

About our rapid response team

Our RRT consists of the ICU charge nurse, ICU attending, respiratory therapist, and the nurse manager or the evening/night nursing administrator. They are called upon when there is a significant change in a patient’s condition that requires critical care expertise at the bedside. After hearing the overhead call for a rapid response, the responding ICU RN scans the RRT QR code using a smart phone. The QR code is displayed within the ICU nurses station for easy access. Depending on the type of rapid response, the responding RN can enter data into the RRT electronic log as care progresses and/or at the conclusion of the response.

Celest Mars, BSN, RN, CCRN, clinical nurse

Building a QR code–driven RRT electronic log

The QR code we developed allows the RN to enter specific information about the response type, location, medical record number, clinical team presence, interventions, outcome, and length of time off the unit. There are 63 potential data points per response entry. The QR code has simplified and made the processes of gathering information more efficient.

Loriel Lozano, BSN, RN, clinical nurse

Buy-in from stakeholders

The implementation of technology in health care can provide a deeper understanding of essential data that we can use to assist, manage, and implement in our established hospital protocols. Writes Loriel Lozano, a member of our RRT team, “As a rapid response nurse, I appreciate any additional knowledge that can enhance patient treatment. This is where the QR code comes into play. The QR code enables us to identify inefficiencies in our RRT by analyzing the data obtained from our QR code log. The use of the QR code helps our hospital and health care system achieve an elevated standard of effectiveness. It improves efficiency in our nursing practice, making it easier to log and record the rapid responses that occur throughout the shift. The QR code has revolutionized our nursing practice; it is easier to use, cost-effective, and more environmentally friendly than our previous paper log format.”

Quality improvement

Geneline Barayuga, MSN, RN, ICU/IMCU nurse manager

The transition to a QR code to collect data has given us clinical operational insights as well. For example, we now track the time the ICU nurse is off the unit. This has resulted in adjusting the way we manage our sepsis alerts. After a recent analysis during a quality improvement PDSA (plan, do, study, act), the role of the ICU RN in a sepsis alert changed, enabling the ICU nurse to remain on their unit and serve as clinical support for satellite point of care testing. Prior to the PDSA, sepsis alerts accounted for 18% of rapid response calls. This QI project resulted in approximately 28 hours annually of time added back to the ICU.

We also track the presence of the clinical team at the time the RRT arrives to the call. This has led to improved teamwork and communication, and enabled us to query clinical confidence of the primary team. The result has been an upward trend to a sustained 100% compliance of the primary team’s presence at the time of the RRT’s arrival. Additionally, with the support of the nursing education department, mock codes to build experience and confidence are now a staple.

Analysis through a DEI lens

One of the ways that the QR code has improved our DEI insights, this map illustrates ICU hospital rapid responses by home zip codes, interestingly mimicking our ED/hospital catchment area in Queens. This level of detail enables us to seek out disparities in the communities we serve, differentiated by demographics and clinical outcomes.

Jonathan Nover, MBA, RN

Today we can take a deep dive, analyzing clinical insights against patient demographics, race, language, gender identity, and zip codes. For example, we can analyze the frequency of rapid response calls for sepsis, stroke, cardiac arrest, or respiratory failure and then analyze the event frequency compared to race, gender, or language spoken, and also against hospital unit. We can compare RRT event frequency by race, gender, or language to geographic home zip codes, seeking insights for vulnerability in the communities we serve. We can investigate the length of our rapid responses, outcomes, the need to upgrade to a higher level of care, the use of reversal agents, and hypo- or hyperglycemic responses by race, gender, or language spoken. The combinations seem endless.

Next steps in ensuring equitable, inclusive, high-quality care

The QR code implementation has resulted in a better understanding of our patient population. We can identify patterns of disparity or bias that may impact specific patient populations, and seek methods to change practice, find new resources, and develop awareness to change. The QR code has created another variable in our hospital and clinicians’ mission to ensure equitable and inclusive care. Collectively, these efforts will contribute to better patient outcomes and create a more inclusive and welcoming health care.

The authors of the various sections of this post all work at Mount Sinai Queens Hospital, New York City: Celest Mars, BSN, RN, CCRN, clinical nurse (“Building a QR code–driven RRT electronic log”); Loriel Lozano, BSN, RN, clinical nurse (“Buy-in from stakeholders”); Jonathan Nover, MBA, RN, senior director of nursing, Emergency Department and Critical Care Services (“Analysis through a DEI lens”); Geneline Barayuga, MSN, RN, ICU/IMCU nurse manager (“Quality improvement”); Zachary Kee, director of patient experience. A previous post by nurses at Mount Sinai Queens addressed “Improving the Discovery and Care of Pressure Injuries in the Emergency Department.”

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Confronting fragility: a perfectionist father’s illness.

“Nurses make horrible patients,” my dad’s words echoed in my mind as I stood beside his hospital bed. Confined to this cold and sterile room, he, once a seasoned nurse, now teetered between worlds, fighting to maintain control of his crumbling body and the walls that had always surrounded him.

My father took pride in his immaculate exterior wall. He kept a well-manicured lawn and showcased three exemplary children and a life partner we referred to as our “uncle” when outside the wall. The inside structure was sharp and less forgiving. Within the confines of his perfectly controlled life, I was subjected to restrictive diets and forced to starve myself, all in pursuit of fitting his external vision of a perfect 16-year-old girl. I didn’t match his mural, but at least I had “a pretty face.”

In this hospital bed, my father’s wall became brittle and translucent. Machines whirred, extending their tentacles, both charging him with life and subtly stealing it away. Weakened by the long-term use of prednisone, his body bore the weight of cancer’s progression, leaving him moon-faced and unrecognizable. His once unblemished mural, now in ruins, left him dependent and vulnerable, requiring nursing assistance for basic tasks like toileting and bathing.

In his time of greatest vulnerability, the nurses assigned to his care—Nurse Kay, Nurse Jessica, and Nurse Tina—turned a blind eye to his suffering. They refused medications, neglected repositioning, and denied him even the most basic nursing care. Overhearing their callous remarks dismissing him as “the gay guy” shattered my faith in their advocacy. It became clear to me that if anyone would champion his cause, it would have to be me.

Becoming his nurse: a daughter’s journey,

My father became my “patient” teacher, a role reversal that defied our usual dynamic. He guided me in recording his input and output amounts, deciphering lab reports, and assisting with tasks like bedpans and urinals. I learned how to care for his raw and neglected sacral bedsore, a wound the nurses refused to acknowledge. One night, I spilled the urinal on his bed as I was attempting to slide it out from under him. A knot of shame formed in my throat. But through his own stifled cry, he taught me how to change sheets while he remained in the bed.

Each lesson chipped away at the wall between us, revealing vulnerability and fostering a deeper understanding of his plight. “I should’ve been a nurse,” I quipped, removing his soiled sheets.

Amid the chaos of raising three children of my own, a new career in nursing seemed impossible. “It’s never too late,” he replied.

His vulnerability and the blurred boundaries of our relationship inspired me to consider that I could both be a nurse and a mother. He saw my potential instead of flaws; he saw me. This revelation opened new doors as I embraced the idea of becoming a nurse.

A father’s lasting impact.

One fateful Sunday night, sitting by his bedside next to a Christmas tree, I held my father’s hand as he departed this world. The grandfather clock chimed ten times, and a few minutes later he was gone. Following his death, I spent much time going through the motions, sipping life through a straw from under the surface, as I fought against drowning in grief. In the struggle to find balance between life when he existed and life without him, I clung to the transformative experience of caring for my father. It became the driving force behind my journey to become a registered nurse, forever shaped by his lessons on humanity. Through this experience, I discovered that patience, not just patients, makes a great nurse.

Amanda Converse, BSN, RN, is a pediatric nurse in Nebraska. She writes, “When I’m not doing nurse things, I like to write and paint. I published my first children’s book last fall. I live in Waverly, NE, with my husband, three children, and two perfectly imperfect puppies.” 

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In today’s world, teenage boys are facing a crisis that often goes unnoticed: their mental health. Anxiety, depression, despair, and even suicidal thoughts plague young boys and young men alike. Shockingly, teenage boys and young men in the United States are more than twice as likely, and sometimes up to four times as likely, to die by suicide compared to their female counterparts. They are also at a higher risk of gun violence and drug overdoses. It’s time to shed light on this crucial issue that often remains overlooked by both the public and health care professionals.

The increase in youth mental health issues has garnered considerable attention in recent times, with the U.S. surgeon general calling it “the defining public health crisis of our time.” But a lot of this has focused on the struggles of adolescent girls and LGBTQ+ teens.

Undoubtedly, these issues deserve our utmost attention and support. However, it is a mistake to assume that teenage boys and young men are faring well. As someone who writes and speaks about boys and has personal experience raising four sons, I understand that male depression and anxiety often manifest as irritability, rage, or anger. Many young males turn to alcohol or drugs as a form of self-medication for undiagnosed conditions like depression, anxiety, ADHD, or bipolar disorder. It is essential to recognize that teenage boys and young men are also in need of support and understanding.

Challenging societal expectations.

Society perpetuates harmful stereotypes that discourage boys from expressing their emotional pain. By adolescence, most teenage boys have learned that it’s best to ignore physical and mental pain. The pressure to “man up,” refrain from crying, or “rub some dirt on it” creates a culture that disregards their emotional well-being. Consequently, teenage boys are more likely to avoid seeking medical care and less likely to admit to feelings of persistent sadness or hopelessness. Although they may not speak their pain aloud, this silence often leads to suicide, gun violence, or overdose. It is crucial that we break these barriers and encourage boys to acknowledge and communicate their pain.

Call to action.

To address the crisis in boys’ mental health, we must take action. It is vital to screen young males for anxiety, depression, and other mental health conditions. When necessary, connect them to local support networks. Educate yourself and others about male mental health, dispelling the misconceptions and providing a safe space for boys talk about their struggles. If you know someone experiencing suicidal thoughts, equip yourself with the knowledge and empathy to support them effectively. A highly recommended resource is Loving Someone With Suicidal Thoughts: What Family, Friends, and Partners Can Say and Do, by Stacey Freedenthal, PhD.

Our boys need us. We cannot afford to overlook their mental health any longer. By shedding light on the crisis affecting teenage boys and young men, we can provide the care, attention, and support they desperately require. Let us break the societal barriers, challenge the stereotypes, and create a world where boys feel safe to express their emotions. Together, we can make a difference in the lives of our boys, ensuring their mental well-being and helping them become the resilient, healthy men of tomorrow.

Jennifer L.W. Fink, RN, BSN, is the author of Building Boys: Raising Great Guys in a World that Misunderstands Males and The First-Time Mom’s Guide to Raising Boys: Practice Advice for Your Son’s Formative Years. She’s also the creator of BuildingBoys.net and co-host of the podcast ON BOYS: Real Talk About Parenting, Teaching, & Reaching Tomorrow’s Men.

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