One of my roles as a senior editor at AJN is to edit and maintain AJN’s blog. We try to publish a new post two to three times each week.

A percentage of these are original first-person nursing stories and perspectives by nurses in various specialties, from critical care to community health to oncology to school nursing. I often think of these as the lifeblood of the blog, the posts that can really reach people at the feeling level, and I am always grateful to receive them—from regular or first-time authors. These posts can be heartbreaking or gently humorous, or both. The range of styles and voices is wide.

Other equally important posts are those by nurses with an argument to make about an urgent issue in practice or policy. Some of these give rise to a certain amount of debate and stimulate further discussion in the nursing community.

In addition, a fair number of short posts are by AJN editors, in some cases bringing to bear their own clinical or personal experience as they address a matter of concern like nurse staffing, or providing essential context about why they think you should read an article found in that month’s issue.

As we’ve done in the past near the start of a new year, here’s a small selection of some of the most popular of the many posts we published the previous year. As we know, the progress of the pandemic took many twists and turns in 2021, and many posts were published to offer timely updates on vaccines, treatments, and the various policy and workplace issues faced by the public—and by nurses in particular. The short list below includes only the most-read posts by guest authors, and can’t possibly represent the wide range of topics covered month to month on this blog.

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Top Guest Posts of 2021

A Plea for Help in Making Nursing Sustainable
“Please. We are so weary but we want to keep our heart for this profession. We want to keep our heart for you and your loved ones when you land in our hospitals. But we are hurting and we cannot continue this way.”

Understanding Imposter Syndrome Among Nurses
“Self-doubt, uncomfortable feelings, and anxiety at times of transition, both in the workplace and in school, are normal.”

Who Cares for the Nurses Who Care for You?
“Disaster planning should identify provisions for disaster pay, paycheck protection, and loan and mortgage forgiveness, as well as extended job or disability protection for those who become sick while taking care of others.”

The First Injection
“I have never forgotten the support and belief the instructor provided to me almost 40 years ago. As a fragile student, I could have easily given up that day.”

‘But Where Are You Really From?’
“Amidst all these patients, I continue to practice what being a person of diversity has taught me: to show grace instead of taking offense with the patient who snaps at me, to have compassion because I know they are fighting their own battles—and equally important, to share humor with patients and coworkers when appropriate.”

The post AJN’s Top 5 Guest Blog Posts of 2021 appeared first on Off the Charts.

r. nial bradshaw / flickr creative commons

This month’s CE feature article, Diagnosing and Managing Migraine, is one I’m sure many readers will relate to, and perhaps even find some answers in for their own headaches.

Like many women, I could count on experiencing at least one each month—classic menstrual migraines—that would begin with a visual aura of wavy lines that made reading or driving impossible. Sometimes, taking acetaminophen or ibuprofen right at the onset of the aura and relaxing/lying down, could prevent it from progressing further.

Otherwise, I would become overly sensitive to lights and sounds and develop a pounding headache and nausea that made me retreat to a dark, quiet room for several hours until the headache passed.

The most debilitating type of primary headache.

The authors note that “90% of the U.S. population will develop a headache within their lifetime.” Migraine, the most debilitating type of primary headache (that is, when the headache is the disorder as opposed to being secondary to other causes), occurs in about 12% of the population. I was surprised that while prevalence is fairly equally distributed among boys and girls prior until puberty (2.5 or 2.4 percent), it changes dramatically post-puberty:

“The greatest difference between the sexes occurred between the ages of 20 and 40, when migraine prevalence was 1.5 to 2.9 times higher in women than in men. After age 42, the prevalence remained twice as high in women as in men.”

A comprehensive clinical review for nurses.

The article is a comprehensive clinical review and includes a review of treatment and medications as well as prophylactic measures and patient education to anticipate and forestall a migraine headache. There’s also a section on pediatric migraine, which can manifest as abdominal pain—underscoring how difficult diagnosis can be.

You can read this article for free—and earn CE credit. This article was part of a series we published by authors from the University of Texas Southwestern Medical Center in Dallas. The other articles, Hypertensive Emergences: A Review in the October issue, and Acute Ischemic Stroke in the September issue, are also free to read and offer CE credit.

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The likelihood of hyponatremia and hypokalemia rose with increasing thiazide doses.

This effect varied based on the type of thiazide—the likelihood was highest with chlorthalidone and lowest with hydrochlorothiazide. Syncope and falls were significantly more common in patients taking thiazide diuretics. Thiazide use was the strongest independent predictor of syncope and falls, even after correction for the presence of hyponatremia and hypokalemia. Increasing age was also an independent risk factor for syncope and falls, and there was a trend for male sex being protective.

This Journal Watch article is from the January issue of AJN, which can be found here.

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As a psychiatric NP, I’m required to ask patients about the drugs they are currently taking, whether legally or illegally. This is important information to know regarding patients’ overall health, as well as for deciding which medication is safe to prescribe for them. With the recent changes in cannabis legalization, more and more patients who report using medical or recreational marijuana are being seen in health care environments.

More patients using cannabis products.

Staying knowledgeable of the effects, adverse effects, and potential interactions of marijuana is therefore critical for those of us caring for patients. Yet there isn’t much focus on marijuana education in the general training of health care professionals and cannabis is often not included in drug guidebooks.

A survey of primary care physicians, NPs, and physician assistants found that more than 30% believed that medical cannabis interacted with medical therapies and 50% did not feel  comfortable answering patients’ questions about medical cannabis.

As health care providers we need to do better than this. If you find yourself in a similar situation where you are caring for patients you know use marijuana products but don’t feel confident in your knowledge level about such products, check out AJN’s November Nursing Resources column. Here you will find links to information on the current evidence, legislation, and various nursing organization positions related to marijuana use, as well as useful patient information.

Christine Moffa, PhD, APRN, PMHNP-BC

Senior Clinical Editor, American Journal of Nursing

The post Nursing Resources: A Helpful Guide on Marijuana and Marijuana Products appeared first on Off the Charts.

A historically challenging problem presents ‘an urgent task for the nursing profession.’

“Every epidemic of the past has produced improbable facts, confusing rumors, and conspiracy theories,” observed Nancy Tomes, PhD, a history professor at Stony Brook University. She was presenting a lecture at an online meeting of the New York Academy of Medicine in late October. Tomes examined the way misinformation and disinformation during the current pandemic echoes that of past public health crises, from the 1665 outbreak of the bubonic plague in London to the global HIV/AIDS pandemic.

“Misinformation, epidemics, and media revolutions have historically gone hand in hand,” she pointed out, adding:

“One of the most distressing aspects of the COVID-19 pandemic has been the damage done by the easy circulation of false and misleading information.”

Social media as a vector for the spread of disinformation.

The widespread dissemination of such information during the current crisis has been facilitated by the near-omnipresence of social media. This month’s Ethical Issues column in AJN focuses on the way some nurses are engaging in misinformation about COVID on social media (and other) platforms. In “Nurses Spreading Misinformation” (free until January 15), author Pamela Grace, PhD, RN, FAAN, argues that immediate action and education are needed.

“Correcting unethical behavior on social media is an urgent task for the nursing profession. It’s critically important that we help nurses prioritize professional values over personal ones when posting or disseminating health information in any arena.”

She notes that “[i]n a majority of cases, the spread of disinformation by nurses is not intentional and may be the result of trying to facilitate patient or societal good and avoid harm.” The person simply grasps onto an idea or piece of information or theory that makes sense to them; at other times, however, “misinformation might be spread knowingly, because of firmly held beliefs . . . ”

Holding nurses accountable for the information they provide.

Whatever the motive, Grace argues, “all nurses must rigorously evaluate the validity and completeness of their knowledge. We must question how we know what we think we know.”

The ethical urgency of doing so was made clear with the publication of a recent policy brief from the National Council of State Boards of Nursing and several leading nursing organizations. According to “Policy Statement: Dissemination of Non-scientific and Misleading COVID-19 Information by Nurses”:

“When identifying themselves by their profession, nurses are professionally accountable for the information they provide to the public. Any nurse who violates their state nurse practice act or threatens the health and safety of the public through the dissemination of misleading or incorrect information pertaining to COVID-19, vaccines and associated treatment through verbal or written methods including social media may be disciplined by their board of nursing. Nurses are urged to recognize that dissemination of misinformation not only jeopardizes the health and well-being of the public, but may place their license and career in jeopardy as well.”

Strategies for responding to disinformation by nurses.

In her article, Grace provides general strategies for addressing misinformation, as well as specific recommendations for educators and nurse leaders and managers: “All of us need to be alert to problematic postings and address these from all available angles.”

Transparency aids credibility.

She also highlights the need for transparency, particularly during uncertain or quickly developing health crises:

“There are, of course, times when new findings emerge, revealing that the evidence we have is incomplete or even faulty, so it’s important to be transparent about the strength of our knowledge. When reliable knowledge is not available, transparency about what is known and not known is critical.”

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(This post is a reshare of AJN‘s January issue editorial; to browse the rest of the issue, visit our website, ajnonline.)

Last January, our cover was an artist’s rendering of the planet Earth as a SARS-CoV-2 virus molecule. In my accompanying editorial, I wrote that it was “unfathomable that over 275,000 Americans have died from COVID-19” and that the number would likely increase. Now here we are, a year later, with another COVID-19 cover. The white flags in the cover photo, installed on the National Mall in Washington, DC, by artist Suzanne Brennan Firstenberg, represent each person who has died from the virus. Sadly, according to the Centers for Disease Control and Prevention (CDC), as of November 28 this number had reached 776,070—well over double last year’s tally. The flags offer a stark visual image of the magnitude of our loss.

What’s especially startling is that the United States leads all countries in both deaths and confirmed cases. The World Health Organization reports that, as of November 29, U.S. confirmed COVID-19 cases totaled 47,837,599; India was second with 34,580,832. Globally, 5,200,267 people have died from the disease. It’s disheartening that the United States has lost so many people and could lose so many more, given that vaccines are available.

There was hope that the two vaccines that received emergency use authorization from the Food and Drug Administration last December would bring the pandemic under control. And in the early days of 2021, when the vaccines became available in communities, people scrambled to find appointment times and waited in long lines to be vaccinated. But that initial urgency petered out amid safety concerns, misinformation, and political posturing, and health officials had to resort to advertising campaigns and rewards to encourage vaccinations among the 47 million still unvaccinated adults.

At year’s end, we’ve seen demonstrations against vaccination mandates in many states and termination of unvaccinated personnel in many sectors (including health care, in which it’s estimated that 30% of health care workers are unvaccinated). Challenges to vaccine mandates are being pursued in the courts, and time will tell if statutes to ensure the public good will prevail over individual freedom to make health decisions. In the meantime, hospitalizations and deaths from COVID-19 continue, mostly among the unvaccinated. And as we begin 2022, there is an uptick in breakthrough cases in vaccinated individuals, especially among those with comorbid conditions and in areas where there are high numbers of cases (a reason to continue masking in those places, the CDC says)—as well as the threat of new variants.

The past year didn’t bring resolution of most of the issues that plagued us in 2020: social inequities and civil unrest, increased gun violence, substance abuse, climate disasters. In November, the CDC released another heartbreaking statistic for 2021: drug overdoses increased by 28.5% over 2020, up from 78,056 to over 100,300.

For nurses and other health care workers, the year has been especially difficult. The Lost on the Frontline initiative from Kaiser Health News and the Guardian estimates that more than 3,600 U.S. health care workers died in the first 12 months of the pandemic. After a second year of being overwhelmed by caring for people who could have prevented their illness through vaccination and being the target of angry patients and families, nurses are leaving hospital positions. Many are doing so reluctantly, saying they just can’t do it anymore. As noted in the Atlantic, “Health-care workers aren’t quitting because they can’t handle their jobs. They’re quitting because they can’t handle being unable to do their jobs.” And as we’ve reported in prior issues of AJN, a similar trend is happening in public health and long-term care settings.

On a positive note, children ages five years and up are now able to receive the vaccine and the CDC has recommended booster shots to increase potentially waning immunity in adults vaccinated more than six months ago. It is hoped this will help drive cases down. Innovations and revelations that came about because of the pandemic, like increased autonomy for NPs, more opportunities to access care via telehealth, new partnerships between academia and practice settings (see this month’s Special Feature), and heightened awareness of how critical nurses are to a functioning health system, will perhaps drive badly needed system changes. There is reason to hope that 2022 will be a better year.

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“Innovations and revelations that came about because of the pandemic . . . will perhaps drive badly needed system changes. There is reason to hope that 2022 will be a better year.”—editor-in-chief Shawn Kennedy in her January editorial, “2021: A Year of Hope and Heartbreak”

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

Original Research: Nurses’ Experiences of Caring for Patients and Families During the COVID-19 Pandemic: Communication Challenges

This qualitative descriptive study examined nurses’ perceptions and experiences of communicating with patients and families under the pandemic’s socially restrictive practices and policies.

In the News: The Year in Review: 2021

The top health care, clinical, and social justice news stories of the year, plus stories to watch in 2022. Also see our coverage of nursing and COVID-19, the pandemic’s hidden toll, and the climate crisis.

CE: Diagnosing and Managing Migraine

An overview of migraine pathophysiology, prevalence, risk factors, assessment, and acute and prophylactic treatment in the outpatient primary care setting.

Policy and Politics: Understanding the Language of Health Reform

The authors define key terms, such as public option, single payer, and universal health care; outline health care–related elements of the American Rescue Plan Act; and offer suggestions to support nursing advocacy.

Book of the Year Awards 2021

The most valuable texts of the year in multiple categories, as chosen by AJN’s panel of judges.

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

• A Viewpoint on the use of war language during the pandemic.
• An AJN Reports on alternative-to-discipline programs for nurses with substance use disorders.
• A Special Feature on nursing student involvement in COVID-19 vaccination clinics.

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

A note on the cover.

This month’s cover features a photo of In America: Remember, a September 2021 art installation that memorialized the U.S. victims of COVID-19. Artist Suzanne Brennan Firstenberg, along with a team of volunteers, placed nearly 700,000 white flags on the National Mall in Washington, DC—one for each death.

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In 1987, Mary Mallison, editor of AJN, posed a provocative question in her editorial: “How can you bear to be a nurse?” She offered several questions that the public often asks nurses, and provided clever (and sometimes powerful) responses that nurses could use to correct the public’s misunderstanding. A few examples:

How can you be a nurse? How can you bear the sight of blood?
Wait until you slide a catheter into a tiny vein just before it collapses. The flashback of blood you see will make you sing.

How can you be a nurse? How can you bear the sight and smell of feces?
Wait until you’ve been anxious about the diarrhea that nothing has stopped in an AIDS patient. Finally, your strategies work and you see and smell normal stool. You’ll welcome that smell.

How can you be a nurse? So many of your patients are so old, so sick, these days. How can you bear the thought that, in the end, your care may make no difference?
Wait until you’ve used your hands and eyes and voice to dispel terror, to show a helpless person that his life is respected, that he has dignity. Your caring helps him care about himself. His helplessness forces you to think about the brevity of your own life.

This editorial is probably my all-time favorite, as it is for many nursing colleagues. Today, however, witnessing all that nurses are experiencing, I find myself rhetorically asking practicing nurses the same question Mallison posed then: How can you bear to be a nurse? But the challenges today seem infinitely more daunting, and my responses inadequate:

How can you be a nurse? How can you take care of patients who reject all that you’re trying to do, and call you a liar for telling them that they have COVID?
How can you be a nurse? How can you watch more patients die than recover?
How can you be a nurse? How can you maintain compassion in the face of violence, abuse, anger, resistance?
How can you be a nurse? How can you reconcile the possibility of endangering your own family while working to save others?

Nurses have always been heroes.

Despite differences in the times we live in now, much of the wisdom offered in Mallison’s editorial is apt today:

“No easy answers. . . . You have days of frustration, nights of despair, terrible angers. Your highs and lows are peaks and chasms, not hills and valleys. The defeats come more than often enough to keep you humble: the problems you can’t untangle, the lives that seep away too fast, the meanings that elude your understanding. But you keep working at it, learning from it, knowing the next peak lies ahead.”

And while I don’t have answers, I can tell each of you what your heroism as a nurse means to the lives you are touching: to the patients even if they don’t recover; to the family members who know their loved one didn’t die alone; to those of us—out here—your colleagues who know what you are going through, who have also faced enormous challenges but none such as these, and who are in awe of what you are doing. Thank you.

Joanne Disch, PhD, RN, FAAN, professor ad honorem, University of Minnesota School of Nursing, Minneapolis.

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By Giulia May/Unsplash

In a recent Schwartz Rounds session at my hospital, the facilitators centered the discussion around the theme, “The Gift of Feedback.” As I listened to the panelists share their experiences, I recalled two recent exchanges with colleagues I’ve developed positive working relationships with over the years.

One was with a hardworking care partner (CP) who has been in our unit for about six years. The other exchange was with an attending physician who had been a well-respected leader in our PICU long before my 11 years working there. I find both to be very kind and very professional.

Asking a care partner for feedback.

As one of the more experienced bedside nurses in our unit, about once every four to six weeks I fill the role of relief charge nurse. I’ve done it enough over the years to feel decently comfortable in the role, but I do it so infrequently that each time I find myself relearning aspects of the role.

The charge nurse always sits in the same station as the care partner who manages the front desk. This individual gets a close-up view of how all the different relief charge nurses handle the role. One day towards the end of a busy shift, I turned to the care partner to ask for feedback. Since he got to see many different styles of leadership and and observe which approaches were more effective for managing communication and patient flow, I was curious about any suggestions he might have about how I could do the relief charge nurse role better.

Those who know me know that I am a mild-mannered person. Although I asked for this feedback in an open, nonthreatening way, the CP hesitated. After a few moments of silence, he told me that he was always reluctant to give feedback because he didn’t know if what he said might be misunderstood. I tried to reassure him that I trusted his perspective and genuinely wanted to learn from his observations, but in the end he declined to offer any thoughts.

Being asked by a physician for feedback.

In the other exchange, I was the bedside nurse in a patient room, working along with our resource nurse for the day to stabilize a trauma patient who had come in overnight. It was unclear to all of us whether this patient had suffered a head injury after falling off a table at home, per the story given by the caregiver, or had been abused.

The attending was in the room, attempting to insert an arterial line into the patient. As the attending was finishing up, the caregiver arrived and entered the room, very emotional and distraught. She asked the attending for a medical update, and the attending provided a gentle, thoughtful explanation regarding the patient’s injuries and prognosis.

The attending had to walk the fine line of not suggesting any outright suspicion of abuse while also hinting that more people would need to talk to her in days ahead to better understand what happened at home. The caregiver wept, nodded her understanding, and left to rest in her car for awhile.

After she was gone, the attending turned to me and the other nurse and asked, “Do you have any thoughts?”

It took me a moment to register that this very experienced attending physician wanted to know how we felt about the way he handled the conversation. I was so taken aback by his openness to our feedback that I fumbled for thoughts. And in truth, I felt that he’d handled the conversation incredibly well and I didn’t have much constructive criticism to provide. I knew him as a very humble and gracious colleague, but somewhere in my subconscious remained a hesitation—as “just a bedside nurse”—to give him the requested feedback, even if it were positive.

Things left unsaid.

In reflecting on my conversation with the care partner, I wished I had found a way to communicate to him that his honest feedback truly would have been a gift. I wanted to grow and improve in the relief charge nurse role, and I felt sad that I couldn’t elicit his suggestions on how I could do so.

In the same vein, I realize now that my hesitancy in providing any thoughtful feedback to our attending physician deprived him of the same gift, even though I felt he did an excellent job navigating his communication with the caregiver and I didn’t have much to add.

A mentality of hierarchy can undermine openness.

These two encounters remind me that there is a general mentality of hierarchy I believe we all continue to battle when it comes to providing feedback to one another in our work. Even if the actual conversation before us is characterized by humility, openness, and trust, there still seems to be a mental struggle to overcome in recognizing that I can safely give legitimate feedback to this person, regardless of our positions.

The two encounters also remind me of how important it is for us to develop our communication skills so that we can clearly articulate our thoughts without tripping ourselves up. Looking ahead, I don’t want to give up on this CP based on the thought, “Well, he was uncomfortable and that didn’t produce results, so I just won’t ask anymore.” I want to go back and ask him again for feedback as I continue to cultivate a safe and trusted working relationship with him.

And I want to be better prepared to offer feedback to others when they ask.

We need practice and we won’t always get it just right—all the more reason to cultivate a grace-filled environment in which to practice offering this invaluable gift of feedback.

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On November 30, a 15-year-old sophomore at Oxford High School in Michigan killed four students and injured seven others. Both the student and his parents are presently incarcerated and charged with numerous crimes.

In the days following this tragic event, questions arose regarding what the parents and school might have done to prevent this from happening. The parents are facing charges of involuntary manslaughter and a federal lawsuit, perhaps the first of others to follow, has been filed against the school district alleging that more could have and should have been done.

Warning signs and preventive actions.

With each school shooting we again find ourselves asking ourselves what can be learned in terms of warning signs and actions that could be taken. The September Mental Health Matters column in AJN, which I co-authored with Arlene Holmes—whose son James was responsible for the mass shootings in Aurora, Colorado, in 2012—highlighted warning signs that might indicate potential violence by someone experiencing mental health problems.

What can be learned from the events that unfolded in Oxford that could be applied to a similar scenario, perhaps heading off another tragedy? The following checklist compiled by Sandy Hook Promise, a nonprofit organization that aims to educate youth to prevent gun violence, includes warning signs that someone could be experiencing mental health issues in need of immediate and supportive intervention:

1. Suddenly withdrawing from friends, family, and activities (including online or via social media)
2. Bullying, especially if targeted towards differences in race, religion, gender or sexual orientation
3. Excessive irritability, lack of patience, or becoming angry quickly
4. Experiencing chronic loneliness or social isolation
5. Expressing persistent thoughts of harming themselves or someone else
6. Making direct threats toward a place, another person, or themselves
7. Bragging about access to guns or weapons
8. Recruiting accomplices or audiences for an attack
9. Directly expressing a threat as a plan

In addition to the above, having access to guns or weapons, being a victim of possible abuse and/or neglect, or directly asking for help should also raise a red flag.

Educating teachers and staff on warning signs.

The Oxford shootings took place in a school, which is unfortunately such a common location that the term “school shooting” has become part of our everyday vocabulary. Teachers have a front row seat to child and adolescent behaviors. If a school has not done so, I would encourage conducting sessions for faculty and staff on a regular basis regarding what is normal and what might be pathological behavior in this population, including signs and symptoms that herald the need for immediate intervention with any student.

The teachers at Oxford are to be commended for bringing their concerns to the school’s attention. But a teacher’s reach only goes so far. As a former high school teacher, I know that a school has the last word and can make a determination to suspend any student for certain behaviors, as well as require a student to take leave until the student meets the criteria the school puts in place in order to return. In the above case, since the student had no prior behavior problems, he was allowed to stay. However, we should know by now that just because someone has no prior behavior issues or record is no guarantee that they will remain harmless.

Removing a student from the classroom and the school until such time as a thorough evaluation and appropriate treatment can be conducted by a licensed mental health practitioner is not only the prudent thing to do to protect the school community, but is also beneficial to the student in question to help him or her to address some of the issues that are creating the concerns and problems. If they don’t already have one, it would be advisable for schools to develop an action plan addressing how and when to send students who have exhibited concerning behaviors home—and not be afraid to act upon it if need be.

As we now unfortunately know, no school is immune to the potential for mass shootings. While preventing all future shootings from happening is impossible, there are things that can be done to mitigate and/or prevent future incidents, even when doing so requires some difficult choices and measures.

Donna Sabella, MEd, MSN, PhD, PMHNP-BCPhD, is a psychiatric mental health NP, a professor at the Pennsylvania College of Health Sciences in Lancaster, and the coordinator of AJN’s Mental Health Matters column.

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We now know just how vulnerable older adults in long-term care have been during the pandemic. COVID-19, especially in the pandemic’s early months, cost many their lives far too early. Even today we are seeing the disease bring premature death to the elderly, especially at facilities with lower staff vaccination rates. Just two days ago, NBC news reported the following disheartening NEJM study results:

“People in nursing homes are much more likely to die of Covid-19 if the staff caring for them remains largely unvaccinated, a study published Wednesday in the New England Journal of Medicine found.”

Other forms of decline accelerated by the lockdown.

But the isolation from family members and other external contacts imposed by the many months of lockdown had other less easy to measure costs. This month’s Reflections essay, “Again in a Heartbeat,” by Jeanne Kessler, MSN, RN-BC, details her own dawning awareness that something had begun to change in her mother as time went by during the lockdown at her assisted living facility.

Suddenly her mother couldn’t talk on the phone any longer. This wasn’t like her at all. Her attention span had shortened drastically. There were other worrisome indications. While someone who didn’t know her mother and her history might have just accepted the change for the worse in her cognition, since she already had some dementia, Kessler had studied delirium, and knew that it can easily be confused with dementia.

Distinguishing delirium from dementia.

The change in her mother’s mental status while in isolation had been just too rapid, and Kessler decided to bring her home. 

Lab and physical exam results ruled out a medical cause for her delirium, which I therefore attributed to the effects of her COVID-imposed lack of stimulation, altered routine, and isolation.

Gradually, with regular interaction, she was able to bring her mother back to her baseline level of cognition. I’m just giving the bare bones of the story here, and it’s worth reading for the clear narration and many convincing details that draw us into the essay.

Again in a heartbeat.

Near the end of this short essay, Kessler sums up the situation with eloquence.

My mom, who is still living with us for the time being, is a good mother who sacrificed a lot to give me a good start in life. How could I do any less for her in these later years of her life? I’m sad for the many elderly who died alone, afraid, and unable to say goodbye to loved ones. I’m grateful that I had the resources to do what I did for my mom. I would do it again in a heartbeat.

The article will be free to read for the rest of December.

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Photo © Shuttertock.

Association is stronger when marijuana use is frequent.

As the decriminalization of marijuana becomes more widespread, its use is on the rise among young adults. Yet, the effects on overall health have not been well studied, including how marijuana use affects cardiovascular health.

Now a large-scale study in the Canadian Medical Association Journal has found an association between recent marijuana use and increased risk of myocardial infarction (MI) in young people, ages 18 to 44 years. The association was strongest among those who used marijuana at least four times a month, primarily by smoking it. Users who vaped or ingested marijuana through baked goods or other edibles also had a higher incidence of MI compared with nonusers, but only those who smoked frequently showed elevated risk that was statistically significant.

The study was based on 2017 and 2018 behavioral risk survey data from the Centers for Disease Control and Prevention. It sought to evaluate known evidence of cardiovascular effects of marijuana in the context of MI risk for individual users. Marijuana’s chemical components can increase myocardial oxygen demand while simultaneously reducing blood flow to the myocardium. This cannabis-induced oxygen supply and demand mismatch, in the setting of myocardial dysfunction, may be the mechanism for acute MI, the researchers suggested.

Study does not demonstrate causality, but large sample size suggests a link.

Of 33,173 people in the study cohort, 4,610 (17.5%) reported using marijuana in the past 30 days. Of these, 1.3% reported a history of MI, compared with 0.8% of nonusers. Smoking was favored by more than three-quarters (76.3%) of the marijuana users, and most (70.5%) reported frequent use, defined as more than four times in the past 30 days. Another 11.3% reported vaping, and the remainder consumed marijuana-laced edibles.

Although the study does not demonstrate causality, its large sample size suggests a link. Nurses caring for young adult patients with chest pain and a known history of marijuana use should consider the possibility of MI. Nurses should also ask any patient with chest pain about marijuana use, including those consuming edibles since data show this group accounts for a significant number of ED visits for cardiovascular symptoms.

—Joan Zolot, PA

 Ladha KS, et al. CMAJ 2021;193(35):E1377-E1384.

You can find a version of this article and other news stories in our December issue, including articles on improving discharge procedures, informed consent and decision-making in high-risk surgery, and a world health roundup. All are currently free to read.

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“Even when good workplace policies and support exist, without enough staff to meet essential patient needs, nurse fatigue cannot be properly addressed.”

Photo by Matthew Waring on Unsplash

When I was working as an ED nurse, if a colleague was out sick we’d invariably be asked to work a double shift—so, 16 hours instead of our usual eight-hour shift. It wasn’t bad as a one-time occurrence. But I can’t imagine how nurses have managed working five or more days of 12-hour shifts in a row, or even more, during the surges of Covid-19 patients needing hospitalization in various parts of this country. It’s no wonder there are so many stories and reports of nurses leaving the acute care setting.

While the obvious answer is that there needs to be more staff to share the work, not only to improve staff well-being but also to make care safer—and this is not a COVID-induced phenomena; we’ve known this for years thanks to research by Linda Aiken and others—getting that to happen has largely been unsuccessful.

Hospitals staff conservatively as a policy, causing many to be short-staffed on an almost ongoing basis. This makes for a stressful work environment that in turn causes nurses to leave, thus further exacerbating the problem. And along came the pandemic.

What we know about nurse fatigue, and what we can do.

In the December issue of AJN, nurses from the Fatigue Subgroup of the Health Behavior Expert Panel of the American Academy of Nursing provide a review of the evidence on nurse fatigue and several strategies—for nurses as well as for institutions—that can help mitigate it.

While the authors point out that addressing fatigue is a shared responsibility of both the individual nurse and the organization, they also note that, “[e]ven when good workplace policies and support exist, without enough staff to meet essential patient needs, nurse fatigue cannot be properly addressed.”

Why are nurses short-staffed?

I’ve spoken with some CNOs who say they’d hire staff in a minute if they could get them, but many nurses are not interested in staff jobs and instead are opting for the high wages being offered by travel nurse agencies. I’ve spoken with others who said the pandemic’s closure of elective procedures that bring in revenue decimated hospital budgets and they can’t afford to hire staff. A fact sheet from the American Hospital Association as early as late 2020 noted that three dozen hospitals had gone bankrupt since the start of the pandemic and the industry already estimated yearly losses at over $323 billion.

That said, hospital financing—and especially how budgets are allocated for nursing staff—needs to be revisited. Hospitals exist because people need nursing care and when the nurses leave, hospitals will close. We’ve recently seen a number of hospitals forced to shut down services and beds because of staff shortages.

In the interim, nurses need help to manage fatigue and hospitals need to do all they can to help until they can increase staffing. This article offers several suggestions. You can read it for free. Also listen to the podcast conversation with three of the authors.

The post What Can We Do About Addressing Nurse Exhaustion? appeared first on Off the Charts.

Nursing during a pandemic is no laughing matter…but it was for me.

Photo by Mathias Konrath on Unsplash

Assessing mental health patients over the phone at the VA was always challenging. I worked with the primary care providers, assessing new patients and getting them the right mental health resources.

Little did I know it was going to be taken to another level during the pandemic. It was Covid mental health mayhem: Covid cold calls, suicidal calls, PTSD patients plummeting with increased isolation and hospitalizations. There was increased depression, anxiety, and insomnia (and that was just the RN staff members, LOL!).

I couldn’t control this pandemic, my frustration over anti-vaxxers, the fatigue, fears, or sadness. But what I realized I could control was my daily interactions with the patients. I had to do review the PHQ-9 questionnaire for major depression symptoms and the GAD for anxiety. Once I’d finished the mental health assessments, I’d concentrate on the behavioral activation their results suggested.

Cultivating patient connection through laughter.

Having taken part in research on the therapeutic benefits of humor, one strategy I often used with these patients was to ask them, “What made you laugh today?”

At first, many couldn’t think of anything. So I decided to ask about more specific subjects to stimulate their thinking. I used an easy acronym to remember: STATUS.

• S – Start
• T – Talking
• A – Animals
• T – Television
• U – Yourself
• S – Stories or Sayings

It worked. Sad conversations would often naturally evolve into lighter personal interactions touching on positive things. My patients did not disappoint:

“My wiener dog Buddy keeps me protected and sits on my lap most of the time. I tell him I have chores to do and to get up. He pretends he is deaf as me.” We giggled. Another female patient told me, “When I feel like I can’t go on for the day, I say ‘keep swimming like Dory.’” I loved her creativity in motivating herself using Disney characters even as an adult. Another patient told me he watched old shows like the dentist scene from the Carol Burnett Show. “It’s 10 minutes of nonstop laughter,” he said.

While the laughter could be an outlet for the patient, it was also a way to motivate myself through 18 calls a day. We found connection and strength. By the end of many calls, my patients would tell me that they felt better, and say, “I needed to laugh. I needed this talk.” Laughing became a coping skill and a source of motivation for other behavioral mental health goals.

The science of therapeutic humor.

Laughter boosts immunity, lowers stress hormones, decreases pain, relaxes muscles, prevents heart disease, and increases respiratory activity. Humor increases positive thoughts, decreases anxiety, and relieves stress. In addition, it increases level of alertness, helps coping skills, and decreases depression. With veterans, I find that humor diffuses conflict, increases confidence, and healthily promotes bonding and increased medical compliance. It is an easy intervention for a hard patient population.

Years ago I started my research in humor therapy with a national nonprofit organization, the Association for Applied and Therapeutic Humor (AATH). AATH unites researchers from institutions like Johns Hopkins, Harvard, and the American Institute of Stress with expert practitioners in many fields—including nurses.

Who knew humor and laughter can be researched? I loved it as a science. I learned through studies and practice that the physical, mental, and social benefits of laughter are priceless. I attended Humor Academy and had to complete a work project and a national project. I worked on a presentation called Humor Heals Heroes, teaching nurses, doctors, and patients the history of the use of humor in the military and how it can increase rapport with veterans and elevate their moods. For my national project, “Keep the Boots in Hoots,” I sent humor boxes to active duty service members to increase their morale, including books, comic books, gag gifts, funny hats, and funny games. They were so appreciative at being given something to lighten their deployments.

A way to lighten the nurse’s work, too.

So remember your laughing STATUS with all your patient interactions. I promise that the laughter and lightness you bring to patients will have a lasting effect on both of you. How have you made your patients laugh or be lighter during COVID? I’d like to hear your humor experiences.

By Judy Oliverio, RN, BSN, CRRN, CCM. She is a case manager in a VA homeless program, a USAF veteran, and an AATH member.

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As we near Thanksgiving, I increasingly find myself looking for positive things—partly to help diminish my sadness about the still-mounting COVID-19 deaths and the nearly universal strain that everyone, perhaps especially those in health care, seems to be feeling.

As I wrote in last November’s editorial:

“Though I’m by no means a Pollyanna, I do believe incessant dwelling on the negatives doesn’t help any of us; we also need to examine the positives. I recall how exhausting it was to work a long, hard shift alongside someone who complained about everything. The negativity colored my own perceptions and stayed with me well after the shift ended. Conversely, working with colleagues who offered support and voiced a “we will get through this” attitude inspired confidence and optimism. My first nurse manager in the ED was superb at this, especially during some very harrowing shifts.”

What are you grateful for?

I went on to offer a list of things that I was grateful for, including public health officials, the nurses who have been there for patients under sometimes impossible conditions, scientists who worked on vaccines that have now saved millions of lives, grocery clerks and restaurant workers and many others who kept things running, and yes, the team at AJN.

But, as I also wrote in last year’s editorial, “I challenge you to come up with your own lists. . . The heartaches will inevitably come, so it’s important that we celebrate the successes and keep faith that yes, we will prevail.”

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“Nurses don’t care about being heroes. They want to be respected, protected, and enabled to do their jobs.”—editor-in-chief Shawn Kennedy in her December editorial, “Finding Joy in the Dark”

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

CE: Nurses Are More Exhausted Than Ever: What Should We Do About It?

This article discusses causes and challenges of nurse fatigue, evidence-based strategies and solutions for individual nurses and organizations, and changes needed to transform nursing culture and workplaces into more supportive environments for nurses.

Clinical Feature: Care Coordination: A Concept Analysis

The authors clarify care coordination as a concept and practice role and examine the value that nursing brings to its implementation.

Special Feature: A New Framework for Practice–Academic Partnerships During the Pandemic—and into the Future

This article outlines a model to provide nursing students with in-person clinical experiences during a public health crisis such as COVID-19, as well as the implications of using this model once the pandemic ends.

Ethical Issues: Nurses Spreading Misinformation

The author explores how the COVID crisis has inspired some nurses to engage in misinformation on social media and other venues; describes the ethical responsibilities of nurses to seriously examine what they think they know and understand; and offers strategies for nurse leaders, managers, and educators to address misinformation.

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

• A Viewpoint on why nurses should care about the Supreme Court.
• A Nursing Beyond Borders column on the global nursing community.
• A Nursing Research, Step by Step column on cohort study design.

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

A note on the cover.

This month’s cover photo shows the Northwell Health Nurse Choir performing in the September finale of the NBC television show America’s Got Talent.

The post December Issue: Nurse Fatigue Solutions, Addressing Misinformation, More appeared first on Off the Charts.

Since the COVID-19 pandemic began, public health measures to control the spread of the virus have provoked fierce debate. In recent months, at least 15 state legislatures have passed or are considering bills to limit the legal authority of public health agencies, according to the Network for Public Health Law, which has partnered with the National Association of County and City Health Officials to document the situation. In addition, lawmakers in at least 46 states have introduced bills to rein in the power of governors to take action in public health and other emergencies.

The anger fueling these actions stems from the perceived overreach by health officials, resulting in a backlash of legislative attempts to limit their authority. These include measures to prevent the closure of businesses or allow lawmakers to rescind mask mandates.

In addition, some state courts have limited the emergency and regulatory powers that governors used to respond to the pandemic. Demands for “individual freedom” spurred some of these state actions, though their consequences are likely to be more far reaching.

New laws could undermine infection control.

“Many of these new laws are dangerous because they were passed without fully considering the expertise of public health leaders and health care providers, who were consumed with responding to the pandemic,” said Jill Krueger, director of the Network for Public Health Law’s Northern Region. “Had legislators heard directly from more infectious disease experts, including nurses, they might have been less likely to pass laws that change long-standing definitions of terms like isolation and quarantine.”

Among problematic laws cited by the network in its report, Proposed Limits on Public Health Authority: Dangerous for Public Health, are one in North Dakota that would ban all mask requirements even for such contagious diseases as tuberculosis, another in Kansas that eliminates gubernatorial authority to close businesses for public health reasons, and one in Montana that limits quarantine powers of local health boards. “Prohibition of quarantine orders undermines the basis of infection control and would make it impossible to stop outbreaks of deadly diseases that are spread by individuals who are not yet symptomatic,” the report states.

“Nurses know that when it comes to public health emergencies, acting quickly can save lives,” said Kreuger. “In states that shift authority from public health leaders and governors to state legislatures, it is nearly inevitable that responses to emergencies will be slower and less nimble, because decision-making is more dispersed.”

Nurses as advocates for appropriate legislation.

Kreuger recommended that nurses educate themselves about proposals in their states to weaken or strengthen public health authority and use their position as trusted professionals in the community to advocate for appropriate legislation.

“Whether they have cared for COVID patients, organized vaccination clinics, or served in one of the other ways by which nurses keep our communities healthier and safer, nurses should be at the table when public health authority is being discussed,” she said. “I would encourage nurses interested in speaking out on this issue to seek out training in the legal issues as well as in advocacy skills. It takes practice to learn how to make your case to a legislator or legislative staffer, and how to build a longer-term relationship with them.”

—Roxanne Nelson

You can find a version of this and other news stories in our November issue, including articles on COVID-19 illness in children, changes to titration standards that negatively impact nursing, and a COVID-19 vaccine roundup. All are currently free to read.

The post States Seek to Limit Health Officials’ Powers to Act appeared first on Off the Charts.

Family caregivers should be partners in caring when family members are hospitalized.

“An estimated 41.8 million Americans were caregivers of an older adult relative or friend in 2020.” (From “The Four Ms of an Age-Friendly Health System” in AJN‘s November issue.)

That’s an impressive number, especially when one considers that any of the caregivers themselves may be older adults with chronic illness.

Are we preparing caregivers?

We ask a lot of these individuals, especially given the many complex tasks they are asked to perform, often with little or no training. And that’s nursing’s role—ensuring our patients are discharged to family members prepared to provide the care needed.

As a nurse, I felt prepared to be a caregiver for a family member who was discharged after complex cancer surgery. I was astonished at the brief discharge instructions for managing the Foley catheter, drains, and eight different medications; then I was handed a manila folder of papers about each medication. It took me a few hours to sort out schedules for medications and flushing drains.

But what about caregivers with no health care training, or who may not have manual dexterity or see clearly, or perhaps lack literacy at the level needed? Unfortunately, many hospitals are under resourced—in teaching materials as well as in staff with the time to teach patients and caregivers.

New AJN series in collaboration with AARP.

November is National Caregiver Month, and as we have done for the past few years, we are debuting another series in our collaboration with AARP’s Public Policy Institute to provide nurses with information to help them better support family caregivers.

This new series of articles and videos developed by AARP and the Rush Center for Excellence in Aging and funded by the John A. Hartford Foundation focuses on helping caregivers ensure that, when hospitalized, their family members receive the care that addresses what matters to them. It focuses on the framework of “The 4Ms of an Age-Friendly Health System” (What Matters, Medication, Mentation, and Mobility). (You can find a podcast with the authors of this month’s article in our Behind the Article podcast collection.)

In their guest editorial, authors Heather Young, Susan Reinhard, and Terry Fulmer write:

“[N]urses have the opportunity to make a difference for family caregivers by engaging them, listening to their concerns and priorities, providing instruction and support, and linking them to the resources they need.”

Over the years, AJN has amassed a broad collection of articles to help nurses provide evidence-based information to teach caregivers various procedures. Each article has a “Tips for Caregivers” section (including links to instructional videos) that nurses can copy and give to caregivers.

You can access all the articles in the collection for free. We hope they help you better help caregivers.

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Today, on Veteran’s Day, AJN would like to honor all of those who have served in the U.S. military, including the 19 million who served during at least one war. This of course includes all those nurses who have served in the armed forces.

Veterans’ health care.

Nurses in every care setting, from hospital to primary care clinic, may encounter veterans, and it’s important to be aware of particular health concerns that may affect them. Please visit our collection of articles on the military and veterans’ health care, which will be free for the next week.

Topics in the collection include, among others:

• caring for families with deployment stress
• screening for posttraumatic stress disorder
• enhancing veteran-centered care
• traumatic brain injury.

While some of the articles are older, they are still pertinent today. We honor and thank all those who have served.

(Photo credit: Photo by sydney Rae on Unsplash.)

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