Secondary prevention of stroke

Continuing Education

Secondary prevention of stroke

Publication Date: December 2015 Vol. 10 No. 12

Author: Carole L. White, PhD, RN

Every 40 seconds, a stroke occurs in the United States. This translates to approximately 795,000 strokes annually; of these, about 25% are recurrent strokes. Although stroke has declined from the fourth to the fifth leading cause of death in this country, it remains a major cause of adult disability and significantly changes the lives of stroke survivors and their families. The need for better stroke-prevention strategies is crucial. Without them, stroke prevalence and costs are expected to rise substantially over the next two decades.

Defining stroke

While the broader definition of stroke includes both ischemic and hemorrhagic stroke, this article focuses on ischemic stroke and transient ischemic attack (TIA).

• Ischemic stroke is a central nervous system (CNS) infarction accompanied by signs and symptoms of stroke persisting more than 24 hours.
• TIA conventionally is defined as signs or symptoms of a brief neurologic dysfunction that lasts less than 24 hours. However, more widespread use of brain imaging (especially magnetic resonance imaging) has shown that up to one-third of patients with symptoms lasting less than 24 hours have had a CNS infarction. This has led to a new definition of TIA as a transient neurologic dysfunction resulting from focal brain, spinal cord, or retinal ischemia without infarction, regardless of duration.

Primary vs. secondary stroke prevention

Primary stroke prevention refers to prevention strategies in persons with no previous history of stroke or TIA. Secondary prevention refers to treatment strategies in persons who’ve already had a stroke or TIA, with the goal of preventing a recurrence.
Stroke risk factors can be modifiable or nonmodifiable. Nonmodifiable risk factors include age, race, sex, ethnicity, and a family history of stroke or TIA. Modifiable factors include hypertension, hyperlipidemia, diabetes, and lifestyle factors. This article focuses on modifiable risk factors.
Risk factors for both initial and recurrent stroke are similar. However, people who’ve had a stroke or TIA are at increased risk for a recurrence. Annual risk for future ischemic stroke after an initial event is approximately 3% to 4%—a significant decrease over the past two decades. The decline stems from widespread use of evidence-based secondary prevention practices, including antiplatelet therapy, effective blood pressure and hyperlipidemia management, and atrial fibrillation (AF) treatment.

Secondary stroke prevention

The most recent prevention guidelines for stroke and TIA place greater emphasis on lifestyle, based on the growing evidence that supports the role of lifestyle modification in vascular risk reduction. As a nurse, you can play a key role in helping stroke and TIA patients achieve evidence-based lifestyle changes. For treatment of each risk factor, see Stroke risk factors and treatment recommendations.

Hypertension

Hypertension is the most significant risk factor. Approximately 70% of people with a recent stroke have a history of hypertension. Evidence shows that lowering blood pressure (BP) is effective in secondary stroke prevention. A recent meta-analysis of 10 randomized trials confirmed the benefits of lowering BP in preventing recurrent stroke. Overall, antihypertensive drug therapy was associated with a 22% reduction in stroke recurrence.
Experts recommend initiating therapy in adults with a history of stroke or TIA who have a systolic BP of 140 mm Hg or higher or a diastolic BP (DBP) of 90 mm Hg or higher. No evidence suggests a specific antihypertensive medication or class of medications is best for secondary stroke prevention. Instead, the goal is to reduce BP.
Besides pharmacologic treatment, several lifestyle modifications are linked to BP reduction and should be considered as part of a comprehensive BP management plan. They include sodium restriction; weight loss, if needed; a Mediterranean-type diet rich in fruits, vegetables, and low-fat dairy products; limited alcohol consumption; and regular aerobic physical activity.

Hyperlipidemia

Epidemiologic data suggest a modest link between high low-density lipoprotein cholesterol (LDL-C) levels and increased risk of ischemic stroke among stroke and TIA survivors. A clinical trial that examined LDL-C lowering for secondary stroke prevention found a 2.2% absolute stroke reduction over the 5 years of follow-up in the group receiving atorvastatin (a cholesterol-lowering drug) compared to placebo. (Statin treatment carries an increased risk of hemorrhagic stroke, so statin drugs may need to be avoided in certain stroke survivors with a history of intracerebral hemorrhage.)
Recommendations for hyperlipidemia treatment among patients with a history of stroke or TIA are consistent with the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. High-dose statin therapy (to reduce LDL-C by 50% or more) is recommended for patients who have had atherosclerotic-related strokes, are age 75 or younger, and have an LDL-C level of 190 mg/dL or higher.

Diabetes mellitus

Both prediabetes and diabetes mellitus (DM) are common in persons who’ve had a stroke, with an estimated prevalence of 25% to 45% among stroke and TIA survivors. DM carries a higher risk for recurrent stroke. The Cardiovascular Health Study (CSH), funded by the National Institutes of Health, is a large epidemiologic observational study of cardiovascular risk factors in adults ages 65 and older living in four U.S. communities. In a substudy of participants who’d had a stroke and were followed for recurrence, those with DM were almost 1.6 times more likely to have a recurrence than those without DM.
Given the high DM prevalence among stroke survivors, everyone who has had a stroke or TIA should be screened for DM. Because no studies of secondary stroke prevention have examined interventions for prediabetes or DM in preventing stroke recurrence, general recommendations are based on achieving good DM management, with lifestyle interventions and pharmacotherapy as the mainstays.
Studies on the optimal level of glucose control among stroke patients haven’t reported a benefit from intensive glucose lowering. Clinicians should follow recommendations from the American Diabetes Association (ADA) for glycemic control and cardiovascular risk-factor management. Also, no evidence suggests one antidiabetic agent is better than another for secondary stroke prevention; this remains an area of intensive research. ADA recommends a patient-centered approach that considers the desired glycated hemoglobin reduction, side-effect profiles, and cost.

Overweight and obesity

Defined as a body mass index (BMI) of 30 kg/m2 or higher, obesity is linked to an increased risk of first stroke. Central obesity (large waist circumference) is more strongly associated with first stroke than general obesity.
Diagnosed in approximately one-third of persons with a recent history of stroke or TIA, obesity is linked to increasing prevalence of vascular risk factors. Its association with recurrent stroke is more controversial; in fact, recent studies indicate obese patients with stroke had a somewhat lower risk for a recurrent vascular event than lean patients. This unexpected relationship is puzzling because weight loss is linked to improvements in major vascular risk factors, including dyslipidemia, DM, hypertension, and inflammation. Underestimation of the adverse effect of obesity may stem from bias in epidemiologic studies. Although weight loss benefits cardiovascular risk factors, its usefulness in secondary stroke prevention is unclear.
Despite the uncertain relationship between obesity and recurrent stroke, the most recent guidelines recommend BMI and obesity screening for all patients who’ve had TIA or strokes.

Physical inactivity

Physical activity improves stroke risk factors and may reduce stroke risk. No clinical trials have examined the effectiveness of exercise in secondary stroke prevention, but the presumed benefit is based on indirect evidence related to improved risk factors, such as BP, lipid metabolism, insulin resistance, and weight management. Two trials currently underway may provide information about the effectiveness of exercise in secondary prevention.
Although the American Heart Association (AHA) recommends adults participate in three to four 40-minute sessions per week of aerobic physical activity, fewer than half of noninstitutionalized American adults achieve this goal. For stroke survivors, these recommendations may be even harder to achieve because of motor weakness, altered perception and balance, and impaired cognition. For stroke and TIA survivors who are capable of exercising, the above AHA recommendations apply. Patients with post-stroke disability should be supervised by a rehabilitation specialist at least during initiation of an exercise program.

Diet and nutrition

Several components of diet and nutrition can lead to increased BP and consequently an increased stroke risk. They include increased sodium intake, excess weight, and excess alcohol consumption. DASH-type diets (Dietary Approaches to Stop Hypertension), high in consumption of fruits and vegetables and low-fat dairy products, and reduced intake of sodium and saturated fats can help reduce BP and thus may lower stroke risk.
More recently, several studies have examined the Mediterranean diet and its link to reduced stroke risk. This diet emphasizes fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, olive oil, and nuts while limiting sweets and red meat. A recent study found it had a significant effect on primary stroke prevention compared to a low-fat diet. Recommendations include the Mediterranean diet and counseling for stroke and TIA patients to reduce sodium intake to less than approximately 2.4 g/day, with an additional reduction to less than 1.5 g/day associated with an even greater BP reduction.

Cigarette smoking

Extensive data confirm a link between cigarette smoking and first ischemic stroke, although evidence in secondary stroke prevention is less well-established. In the CHS, elderly smokers were twice as likely as nonsmokers to have a recurrent stroke. No clinical trials have investigated smoking cessation for secondary stroke or TIA prevention. Given the overwhelming evidence on the harmful effects of smoking, such trials are unlikely to be done. All patients with stroke or TIA who are current smokers should be strongly advised to quit smoking and avoid passive tobacco smoke. Counseling, nicotine products, and oral smoking-cessation medications are recommended to support smoking cessation.

Alcohol consumption

Few studies have directly evaluated the link between alcohol consumption and recurrent stroke. With ischemic stroke, the association with alcohol appears to be J-shaped, meaning that light to moderate consumption is protective whereas heavier alcohol use carries an elevated risk. The protective effect may relate to the effects of alcohol on high-density lipoprotein cholesterol (HDL-C), whereas the elevated risk with heavier alcohol use may come from its effect on BP and glucose, as well as atrial fibrillation.
Because alcohol consumption can lead to dependence and alcoholism is a significant public health problem, an important goal for secondary stroke prevention is to eliminate or reduce alcohol consumption in heavy drinkers. Light to moderate consumption (up to two drinks daily for men and up to one drink daily for women) may be reasonable, although nondrinkers shouldn’t be counseled to start drinking.

Antiplatelet and anticoagulant agents for secondary stroke prevention

The mainstay of secondary stroke prevention is either antiplatelet or anticoagulant therapy, depending on the stroke mechanism. For people who’ve had strokes or TIAs of a noncardioembolic origin, the Food and Drug Administration has approved four antiplatelet drugs for prevention of vascular events—aspirin, combination aspirin/dipyridamole, clopidogrel, and ticlopidine. Each agent carries an approximately 22% relative risk reduction for recurrent stroke, myocardial infarction, or death.
The drugs have important differences with direct implications for selecting a specific agent. Aspirin alone or in combination with dipyridamole is recommended as initial therapy for preventing a recurrence. Clopidogrel is recommended as a reasonable replacement for aspirin or aspirin/di­py­rid­a­mole, as well as for patients with aspirin allergies. The aspirin/
clopidogrel combination isn’t recommended for routine long-term secondary prevention because of an increased hemorrhage risk. Ticlopidine rarely is used in clinical practice because of its side effect-profile and availability of newer agents.

Atrial fibrillation

AF is an important risk factor for stroke and may cause 10% to 12% of all strokes each year. Several validated risk assessment tools classify stroke risk among patients with AF, taking into account such factors as comorbid heart failure, hypertension, DM, and age. Research shows an increasing stroke risk with higher scores on the classification system (more comorbidities along with AF). The evidence is strong and consistent for using warfarin in preventing stroke among AF patients, for both primary and secondary prevention. The optimal warfarin dose for stroke prevention among these patients is one that produces an international normalized ratio (INR) of 2.0 to 3.0. Maintaining a therapeutic level is a challenge, though. A high percentage of AF patients have subtherapeutic levels and therefore inadequate stroke protection.
Newer agents, such as apixaban, dabigatran, and rivaroxaban, also can be used for secondary stroke prevention in patients with nonvalvular AF. For patients unable to take oral anticoagulants, aspirin alone is recommended. Clinicians should base selection of an agent on the patient’s risk factors and preference, drug interactions, and other clinical characteristics.

Life’s Simple 7®

Despite our knowledge of stroke risk factors and strong evidence on treatment strategies to control risk, we’ve been largely unsuccessful in supporting good risk-factor control after stroke. Research continues to show suboptimal control of vascular risk factors in patients who’ve had strokes. The American Heart and Stroke Association’s 2020 goal is to improve Americans’ cardiovascular health by 20%. Toward this goal, these organizations have defined seven modifiable health metrics (BP, cholesterol, glucose, exercise, smoking, diet, and BMI) that increase the chance of living free of cardiovascular disease and stroke; these are called Life’s Simple 7. Although designed for primary prevention, Life’s Simple 7 metrics also apply to secondary stroke prevention.
In a recent study examining Life’s Simple 7 among stroke survivors, investigators reported that fewer than one in every 100 stroke survivors met all AHA criteria for ideal cardiovascular health. (See Defining poor, intermediate, and ideal cardiovascular health.)

Implications for nurses

Clinicians need to develop effective interventions that engage stroke survivors and their families in achieving excellent risk factor control and subsequently reducing stroke burden. For nurses, a key challenge in secondary stroke prevention is providing education and supporting adherence to secondary-prevention medications and lifestyle changes. Nursing has played a significant role in quality improvement programs, such as the American Heart and Stroke Association’s “Get With the Guidelines–Stroke” program to improve initiation of secondary prevention measures in acute-care settings.
As nurses, we have a responsibility to ensure secondary stroke-prevention practices across the continuum of care. Research shows that medication adherence diminishes over time, with more than one-third of patients stopping medications in the 2 years after stroke. Not only must we provide information about secondary-prevention drugs patients will take after discharge (including antiplatelets or anticoagulants, antihypertensives, and statins); but we also must assess for potential barriers to adherence. Poststroke disabilities, such as swallowing difficulties, motor weakness, and cognitive impairment, may interfere with medication management. Involving family members (especially the primary family caregiver) in discussions about medications is crucial. Also, be sure to assess the patient’s financial and insurance-related issues. If inadequate finances are a potential barrier to medication adherence, consult with a social worker to assist the patient.
Begin education early in the patient’s hospital stay and reinforce your teaching on a regular basis. Be sure to provide written materials, as stroke survivors and their families report difficulty recalling information given during the hospital stay. Post-discharge follow-up programs (by telephone or in person) to identify concerns about medications and to ensure all prescriptions have been filled can boost adherence.

Health promotion

Although health promotion is an important domain of nursing care, some nurses devote little patient-encounter time to it. The significance of lifestyle in secondary prevention and the low rate of control among stroke survivors highlights the need for action in this area.
We need to use approaches that support patients in risk-factor self-management in their own environment. Lifestyle changes, such as increasing physical activity, need to be tailored to each individual, with consideration of stroke-related deficits. Interventions with stroke survivors to increase awareness of risk and manage risk factors over the long term, such as education, written materials, behavior modification, and stroke nurse specialist follow-up, have shown modest effects. Empowering patients to succeed in goal-setting around healthy lifestyle choices has proven to be an effective strategy.

Post-Stroke Checklist

The Post-Stroke Checklist was developed in 2013 by an international team of stroke experts to help ensure stroke survivors’ long-term needs are identified and managed appropriately. The tool addresses 11 areas, including secondary stroke prevention, mood, communication, relationships, and incontinence. These often-overlooked needs have a tremendous impact on quality of life and long-term outcomes after stroke. The easy-to-use checklist can be incorporated into regular follow-up care after stroke; visit http://goo.gl/0RZKT4 to see the checklist.

Health information technologies

Health information technologies may hold promise for supporting self-management practices around risk- factor control—both in real time and over the long term. A Netherlands study reported modest support for improved risk-factor control through a website personalized to individual risk, identified during a baseline visit with a nurse practitioner. Patients were instructed to use the website frequently and to log in at least every other week to submit new risk-factor measurements, BP, or smoking status, as well as to read and send messages. The sample included both patients at risk for a first stroke and those at risk for a recurrent stroke. After 12 months of participation, patients in the Internet-based, nurse-led vascular prevention group showed a 14% reduction in Framingham heart risk score compared to patients in the usual care group.
Evidence is building for the effectiveness of mobile health (mHealth) tools in supporting lifestyle changes. Numerous health apps can be recommended to stroke survivors to identify their risk factors and provide a risk score, including the American Heart Association’s My Life Check, which provides a score related to Life’s Simple 7. A recent study examined use of an mHealth app at the bedside; nursing students used a secondary prevention app to provide patients with information about risk factors at the bedside. Evidence-based practice has been cited as a core competency for nurses; now it’s possible to have this evidence at the bedside so nurses can more easily translate it into practice, thereby improving secondary stroke prevention and promoting better patient outcomes.
The global trend of increasing stroke incidence underscores the importance of working with patients who’ve had strokes or TIA to reduce their recurrence risk. Nurses play an essential role in screening for risk factors, increasing awareness of risk, and supporting stroke or TIA survivors in reducing risk, particularly when it comes to adhering to medications and lifestyle changes. The complexity of behavior change required suggests multifaceted and tailored strategies most likely are needed to support and sustain change.

Carole L. White is an associate professor in the School of Nursing at the University of Texas Health Sciences Center at San Antonio.

Selected references
American Heart Association. My Life Check – Life’s Simple 7. heart.org/HEARTORG/
Conditions/My-Life-Check—Lifes-Simple-7_UCM_471453_Article.jsp
Brenner DA, Zweifler RM, Gomez CR, et al. Awareness, treatment, and control of vascular risk factors among stroke survivors. J Stroke Cerebrovasc Dis. 2010;19(4):311-20.
Bushnell CD, Olson DM, Zhao X, et al. Secondary preventive medication persistence and adherence 1 year after stroke. Neurology. 2011;77(12):1182-90.
Crossman T, Rider T. Novel oral anticoagulants. InnovAiT. 2013;6(8):535-7.
FitzGerald LZ, Rorie A, Salem BE. Improving secondary prevention screening in clinical encounters using mHealth among prelicensure master’s entry clinical nursing students. Worldviews Evid Based Nurs. 2015;12(2):79-87.
Kaplan RC, Tirschwell DL, Longstreth WT, et al. Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly. Neurology. 2005;65:835-42.
Kernan WN, Ovbiagele B, Black HR, et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/
American Stroke Association. Stroke. 2014;45(7):2160-236.
Lloyd-Jones DM, Hong Y, Labarth D, et al; American Heart Association Strategic Planning Task Forces and Statistics Committee. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. 2010;121(4):586-613.
Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.
Philp I, Brainin M, Walker MF, et al. Development of a poststroke checklist to standardize follow-up care for stroke survivors. J Stroke Cerebrovasc Dis. 2013;22(7):e173-e180.
Vernooij JW, Kaasjager HA, van der Graaf Y, et al; SMARTStudy Group. Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial. BMJ. 2012;344: e3750.
Wei J, Hollin I, Kachnowski S. A review of the use of mobile phone text messaging in clinical and healthy behaviour interventions. J Telemed Telecare. 2011;17(1):41-8.

Preceptor education: Focusing on quality and safety education for nurses

Preceptor education: Focusing on quality and safety education for nurses

Publication Date: Jan 2016 Vol. 11 No. 1

Author: Fidelindo Lim, DNP, CCRN; Kimberly A. Weiss, MSN, FNP-BC; and Ingrid Herrera-Capoziello, MSN, RN, ANP NURSING

The transition from novice to expert nurse has been an important topic in nursing circles for more than 30 years, since Patricia Benner adapted the Dreyfus model of skills acquisition to the nursing profession. The model still serves as an excellent conceptual framework for the professional development of new nurses. Combined with core competencies from the Quality & Safety Education for Nurses (QSEN) initiative as the foundation for preceptor education, the model provides a road map for assessing and evaluating skills acquisition of new nurses or new preceptors. QSEN competencies include patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.
The impetus to anchor preceptor education to a solid framework rests on evidence that prelicensure nursing education, although sufficient for fostering formation of professional identity and ethical comportment, doesn’t provide hands-on clinical experience. By focusing on well-defined competencies such as those outlined in QSEN, preceptors can better guide novice nurses on what skills to focus on and develop.

Preceptor council: Transforming education

Organizations with Magnet^® designation have vibrant, robust unit practice councils that address such core safety issues as falls, pressure ulcers, and hospital-acquired infections. At the Hospital for Special Surgery in New York, NY, a robust preceptor council composed of champions from all units and specialties grew out of a staff-identified need. Co-chaired by two clinical nurse specialists and overseen by the senior director of Nursing Excellence, the council meets once a month to discuss challenges and opportunities for quality improvement. It has become the forum for advocating transformational preceptor education, leading to
a redesigned and interactive preceptor education model based on QSEN competencies.

Competency and life-experience osmosis

In the United States, the average age of the practicing nurse is near 50. Contrast this with 31—the average age of nurses graduating with their initial nursing degree (considerably higher than the 1985 average age of 24). Additionally, 52.8% of new RNs received a previous bachelor’s degree and 7.2% hold a master’s degree or higher. The implications of these evolving demographic trends vary and require careful consideration when planning preceptor education. For example, older students with higher qualifications may be more experienced and have more confidence in addressing patient-care issues than traditional nursing students. When planning preceptor education, the overall lived experiences of new RNs must be taken into account.
Considering that preceptors generally are chosen from a pool of more experienced senior nurses, the potential for transferring hard-earned clinical skills and professional comportment is significant. Failing to use this prolific source of human capital to the full potential as knowledge, skills, and attitude transfer agents would result in a great loss. Because a growing majority of new RNs are entering nursing with professional backgrounds, they bring valuable and diverse life experiences that can be harnessed to shape their competencies in clinical judgment and technical proficiency.

Best practices for preceptor education

Situated learning, reflection on action, and outcomes measurement are a few examples of evidence-based practices in high-quality preceptor education.

Situated learning

Situated learning uses contextualized scenarios based on actual events and demands of the nursing unit. Interactive exercises in small group discussions using realistic and unfolding precepting case scenarios engage would-be preceptors in situated learning, helping them analyze and solve practice issues that might arise during preceptorship.
In this type of preceptor education, five carefully designed scenarios dealing with such issues as generational differences, experiential or learning gaps, missed opportunity, safety breaches, and work­around and work ethic issues are appraised and critiqued. Learners are asked to identify safety concerns, handle crucial conversations, suggest a quality-improvement or a research project to address the issues identified, and reflect on the merits of precepting best practices. Learners then present their work to their peers and the facilitator uses reflective questioning to address nuances of the scenario.

Reflection on action

Reflection on action is a deliberate ongoing process of learning from experience that will shape clinical judgment for future situations. Because precepting is a high-stakes interface among staff members and patients, it can cause significant stress. Effective preceptor education should allow exploration of novel precepting challenges, either in carefully designed scenarios or anecdotal reports from participants. The goal of reflection on action is to highlight what preceptors gain from their experience that contributed to their ongoing professional development and to build capacity for clinical judgment in future situations.

Outcomes measurement

The preceptor council’s deliberation at the Hospital for Special Surgery conducted a pre- and post-training survey to assess how full-day preceptor training was received and to appraise participants’ attitudes toward precepting. Another survey was sent to trained preceptors after they precepted a new staff member. Compared to pre-training survey data, post-training data indicated an improved level of comfort and confidence in precepting and an overwhelmingly positive attitude toward the preceptor role. (See Three strategies for effective precepting.)

Preparing future preceptors

Seen through the lens of the QSEN competencies, preceptor education prepares future preceptors not only as socializers of novice nurses into the profession, but also as guardians of patient safety and quality care. A conceptual or theoretical framework is an essential foundation for a well-designed preceptor education. In organizations with Magnet designation, creating a preceptor unit practice council fosters an impetus to provide evidence on measurable outcomes.

Fidelindo Lim is an assistant clinical professor at New York University College of Nursing in New York, N.Y. Kimberly A. Weiss is a clinical nurse specialist in the postanesthesia care unit and Ingrid Herrara-Capoziello is a clinical education specialist and coordinator in the Office of Professional Development at the Hospital for Special Surgery in New York, NY.

Selected references
American Nurses Association. Fast Facts. The Nursing Workforce 2014: Growth, Salaries, Education, Demographics & Trends. http://goo.gl/uwHPH5
Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-7.
Benner P, Sutphen M, Leonard V, Day L. Educating Nurses: A Call for Radical Transformation. San Francisco, CA: Jossey-Bass; 2010.
Budden JS, Zhong EH, Moulton P, Cimiotti JP. Highlights of the National Workforce Survey of Registered Nurses. J Nurs Regulation. 2013:4(2):5-15.
Dreyfus SE, Dreyfus HL. A Five-Stage Model of the Mental Activities Involved in Directed Skill Acquisition. ORC, 80-2, Operations Research Center, University of California, Berkeley. 1980.
Ramsburg L, Childress R. An initial investigation of the applicability of the Dreyfus skill acquisition model to the professional development of nurse educators. Nurs Educ Perspect. 2012;33(5):312-6.
Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204-11.
U.S. Department of Health and Human Services. Health Resources and Services Administration. Bureau of Health Professions. National Center for Health Workforce Analysis; April 2013. The U.S. Nursing Workforce: Trends in Supply and Education. http://goo.gl/ZjvLJs
U.S. Department of Health and Human Services. Health Resources and Services Administration. The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. 2010. http://goo.gl/1iyvPO

Healthy Nurse and Your Weight Goals

 Unpacking the pounds that weigh you down

Publication Date: June 2012 Vol. 7 No. 6

Author: Gary Scholar, MEd

How long have you dreamed of losing weight and keeping it off—of what it would feel like to be healthier and have more energy for your nursing job and your personal life?
University of Maryland nursing researchers found 55% of nurses surveyed were overweight or obese. For many nurses, weight loss remains an elusive dream that never becomes a reality. Weight loss and weight management can drive you up the wall and down the other side. It’s easy to slip into negativity and end up sabotaging yourself. To stop struggling with your weight, you need to know the three critical factors for unpacking the pounds that weigh you down, and create a list of priorities to help you manage your weight.

Getting unstuck

The first critical factor that keeps you stuck at the same number on the scale is the emotional and physically demanding nature of your job. For many nurses, the second factor is the huge disconnect between overperforming in your job and underperforming when it comes to your own self-care. This disconnect stems from what I call the Nurse Type E Personality—you do Everything for Everybody, ignoring your own needs.
The third major factor contributing to overweight is fear: Fear of disappointing others if you don’t take care of their needs first. Fear of having to give up your favorite comfort foods on a diet. Fear of committing your time and energy to weight loss. Fear of failing to lose weight. Fear of losing weight but gaining it back.
Fear is an emotional trap that holds you back from a healthier weight. A nurse wrote to me about how her fear, challenging work environment, and Type E personality contributed to her weight gain. She explained, “Since I was a child, I’ve never been somebody who could easily put myself before other people. I can read other people well and adjust my behavior to please them and get their needs met….As a nurse, I have a difficult time setting boundaries. ‘Sure, I can pick up the 12-hour shift after working my own shift. Take care of an extra patient? No problem!’ It doesn’t stop there. It carries over to my second shift of responsibilities when I get home, taking care of my family’s needs. The result is I constantly feel overwhelmed and burnt out, and I eat unhealthy comfort food to ease my stress…I’ve always sabotaged myself when I try to lose weight because of my fear of failure, caused by my yo-yo dieting over the years and my fear that if I give up comfort foods, I won’t be able to cope with my stress.”
Sound familiar?

Patients as role models

To rise above the factors that stymie successful weight management, think of the ill patients you’ve known who’ve successfully transformed their lives. Have you ever witnessed how illness seems to give some patients a new lease on life, how it gives them a strong sense of priorities and clarifies what’s really important? Suddenly they feel more alive and engaged, as if they’ve been given a second chance. Illness forces them to take a hard look at their past, present, and future. It gives them a chance to reconnect with themselves and be the person they were meant to be by rising above their fears, procrastination, and skewed priorities.
These patients transform their lives by being fully committed to integrating what I call their N.E.W. priorities. You can apply the hard lessons they’ve learned to help rise above your own weight-management struggles. To manage your weight, reconnect with yourself and be the person you were meant to be.

The N.E.W. approach

To kick-start your weight-management campaign, you need to fully commit to your N.E.W. priorities and set specific goals in line with them. The N.E.W. approach centers on what I call the weight-management triage list:
N stands for Nurturing self-care
E stands for Exercise, nutrition, and sleep
W stands for Work empowerment.
Managing your weight successfully means integrating these priorities into your life. It doesn’t mean you should make weight an obsession.

N: Nurturing self-care

When patients commit to transforming themselves to be healthier, they put nurturing self-care at the top of their priorities. Nurturing self-care helps you rise above your Type E personality and conquer your fear by helping you see that you deserve to succeed in managing your weight so you’ll be healthier.

E: Exercise, nutrition, and sleep

Daily exercise, healthy nutrition, and proper sleep are essential for ill patients hoping to regain their health. Similarly, to manage your weight, you need to integrate these three elements into your lifestyle. (See Power grocery shopping below.)

Power grocery shopping On your next shopping trip, use these tips to help fill your cart with healthy food choices. Buy produce during the week, because most deliveries are made Monday through Friday. Look for produce that’s in season. Select lean cuts of meat. Choose beef from grass-fed, not grain-fed, cows. Select cold-water fish, such as wild salmon, halibut, and tuna, because they sustain energy levels and satisfy hunger. Avoid prepackaged and canned foods (other than soup and beans). Choose whole-grain pasta and brown or wild rice. They fill you up so you’re less likely to overeat. Select low-sugar cereals with 6 g sugar or less per serving. Adapted with permission from Fit Nurse: Your Total Plan for Getting Fit and Living Well by Gary Scholar (Sigma Theta Tau International, 2010).

Here are two examples of nurses who lost weight by integrating self-care, exercise, nutrition, and proper sleep into their lives. When her granddaughter was born, Kim, age 45, started thinking about her weight and the things she might miss out on if she didn’t lose weight. She didn’t want to be a grandmother who couldn’t play with her grandchild, so after years of yo-yo dieting, she set out to create a healthier lifestyle by nurturing herself and integrating daily exercise, healthier nutrition, and plentiful sleep. She implemented her “Couch to 5K Plan” by jogging 3 miles several times a week and lifting weights. She lost 150 lb.
Josephine, a trauma nurse, also lost 150 lb—and has kept it off for 2 years. She started eating healthier and taking Zumba (dance fitness) lessons. Eventually she became a Zumba instructor. She went from viewing healthy living as a punishment to seeing it as a form of enjoyment.

W: Work empowerment

When patients return to work after an illness, one of their priorities is to be assertive in getting their needs met and creating a supportive work environment. Otherwise, stress and an unhealthy environment could negatively affect their health and well-being. The same is true for you as a nurse trying to integrate healthier weight management into your daily life. To become more empowered and promote your own and your colleagues’ weight-management efforts, advocate for effective support initiatives in your workplace. (See Workplace strategies that promote weight management below.)

Workplace strategies that promote weight management Nurse administrators and managers might want to consider implementing the following strategies to help staff nurses manage their weight. “Let’s do lunch” initiatives Quality-time meal breaks can promote healthy eating. Too many nurses skip meals because they are busy or feel guilty taking time out to eat. But when you skip a meal, your blood glucose level drops and your metabolism shuts down (what I call “nurse glycemia”). As a result, you go into your next meal famished and eat more than you should. Quick, healthy food choices Nurses need quick, healthy food choices. Providing onsite healthy snack carts at nurses’ stations can help you sustain your energy level by maintaining adequate blood glucose levels throughout your shift. Wellfood cafeteria Transforming unhealthy hospital cafeterias to wellfood cafeterias makes healthier foods available to shift nurses. Wellfood cafeterias also can serve as healthier-nutrition outreach models for patients and the family members and friends who visit them. Healthy food zones To create a healthy food zone, encourage workers, patients, and visitors to only bring healthy foods to the hospital. Fitness activities Onsite yoga, tai chi, and Zumba classes can help nurses raise their endorphin levels, metabolism, and energy levels, which in turn aids weight-loss efforts. Chair massages Stress can cause unhealthy comfort-food eating. A chair massage program, where nurses can get a 10-minute chair massage several days a week, can reduce stress. Education on adapting to long shift hours Topics might include how to integrate meals into the shift, the best foods to eat during long shifts, the most effective types of exercise for shift workers, and how to create proper sleep patterns. Emotional support programs When a patient dies, many nurses “suck up” their emotions. This can exacerbate stress, which can cause nurses to pack on the pounds. Instituting an emotional support program can help reverse this trend. In one hospital’s pilot program, when a cancer patient died, the charge nurse conducted an emotional needs assessment of that patient’s nurse. The nurse was permitted to take 20 minutes off to meet with an “emotional support” nurse—a nurse who volunteered to provide emotional support to colleagues on that unit.

An overweight nurse complained to me about her unhealthy eating habits, but wouldn’t take responsibility for them. I asked her, “Who does the grocery shopping in your family?” She replied, “I do.” “Who does the cooking?” She replied, “I do.” “And who puts the unhealthy food in your mouth?” She said, “I do.” Then I asked, “So whose responsibility is it that you eat an unhealthy diet?” Without hesitation she replied, “It’s my husband’s fault because he drives me crazy!” While this story makes you laugh, it also drives home the point that we all need to take responsibility for our actions—including those that jeopardize weight management.
You become what you believe. Choose to believe you can make a shift toward healthier weight management by modeling the N.E.W. priorities of patients who’ve transformed their lives.

Gary Scholar is a health and wellness consultant, wellness coach, speaker, and author of Fit Nurse: Your Total Plan for Getting Fit and Living Well.

RN and a Healthy Lifestyle

 Living a healthy lifestyle

Publication Date: March 2014 Vol. 9 No. 3

Author: Beth Battaglino, RN, BSN

As nurses, we know how to check blood pressure, administer medications, and counsel patients about healthy living. But let’s face it—some of us don’t practice what we preach. At the end of a long shift taking care of others, we sometimes fail to take the best care of ourselves.

It doesn’t have to be that way. Take it from me—a busy practicing nurse, chief executive officer of a women’s website, a wife, and the mom of a 1-year-old boy: You can fit healthy habits into your life. You just have to want to. And once you do, you’ll see how much better you feel, physically and emotionally. As a bonus, exercise and healthy eating habits improve your cardiovascular health—a major concern as we age. (Heart disease is the #1 killer of women.) If improving your own health and well-being isn’t reason enough, keep in mind that getting healthier can help you take even better care of patients.

The power of exercise: Working out your body and your stress

I learned at a young age I’m not one of those women who can eat whatever they want and stay thin. I also discovered I can’t simply cut calories to lose weight; I need to exercise, too. For weight and overall fitness, I can’t stress enough the importance of physical activity. As a country, we exercise more today than we did 10 years ago—yet obesity rates are higher than ever. Why? Researchers suggest diet and other lifestyle changes are also components to maintaining a healthy weight.
Most people need to exercise (and eat well) to keep weight off and stay fit. The American Heart Association recommends at least 150 minutes of moderate exercise or 75 minutes of vigorous exercise each week, or a combination. This comes to at least 30 minutes, 5 days a week—a good goal.
What form of exercise is right? Like me, you might want to mix up your workouts to keep your mind and body challenged. I run one day, do kickboxing the next, and go to boot camp the next. (Kickboxing and boot camp are great ways to relieve work stress, by the way.) I also do strength training a few times a week.

To stay motivated, I exercise with friends. It’s much harder to make excuses for skipping an exercise session when you know others are counting on you. Once you show up, friends will push you to give it your all. I run with a group of 40+ moms every Saturday morning. Last year, I trained with the group and completed a half-marathon and three triathlons. Running is a great therapy session, too. One of us might say, “Hey, I’ve been having this problem at work”—and get great feedback from friends while running.
During the week, I fit my workouts in early—at 5:30 in the morning, while my husband stays home with the baby. He gets his turn to work out at night. It’s all about juggling and balancing your schedule to fit exercise into your life.

Nurse Nutrition 101

I plan my meals ahead of time. Healthy eating is crucial to controlling weight and promoting cardiovascular health. Research has deemed the Mediterranean diet a winner for a healthy heart. With this diet, you consume a lot of vegetables, fruits, beans, whole grains, and olive oil, plus a weekly intake of fish as the primary protein—but very little red meat or other sources of saturated fat.
To follow both the Mediterranean diet and U.S. nutritional guidelines, try to eat fish high in omega-3 fatty acids, such as tuna, salmon, or mackerel, at least two or three times a week. As an added bonus to its heart-healthy benefits, fish may improve brain function and fight depression. (And in nursing, we all know the power of a clear head and a positive mood.)
Here are more nutrition tips:

• Always eat breakfast. To be on your feet all day taking care of patients, you need the proper fuel. I never miss breakfast. My regular breakfast is instant, high-fiber maple oatmeal with walnuts. If I go out for breakfast, I order an egg-white omelet with cheese and ham.
• Keep healthy snacks with you at all times. Unless you plan ahead, a busy shift can leave you reaching for the worst convenience foods. Mix a pouch of tuna with low-fat Greek yogurt topped with avocados (hold the mayo). Sprinkle this over your lunch salad or make a sandwich packed with super foods. Also, I never leave home without an apple, yogurt, an energy bar, and a package of almonds.
• Don’t set yourself up for a binge. Fight the urge for a peanut-butter cup. If my sweet tooth beckons, I give in—but just a little. If I really feel as if I need something sweet, a few Twizzlers or Swedish fish usually do the trick. (Editor’s note: If you work shifts, read “Nutrition for night-shift nurses” for more ideas on how to eat healthy.)

No need for extremes

You don’t have to go on an extreme fad diet or exercise 3 hours a day to become a model of health for your patients. Healthy living isn’t hard. Go online and bookmark webpages that offer tools on how to eat right and maintain a healthy lifestyle. If you incorporate small, enjoyable steps into your life, before long you’ll see a real difference in how well you work and play.
Click here for a list of selected references.

Beth Battaglino is the chief executive officer of Healthywomen.org, a nonprofit organization providing objective, in-depth, medically approved information on a broad range of women’s health issues. In addition to her BSN, she holds degrees in political science, business, and public administration from Marymount University (Virginia) and the University of Oklahoma. Ms. Battaglino currently serves as an educational consultant to the National Fisheries Institute, a nonprofit organization that offers a health-focused website with fish tips and recipes.

Mindful Nursing

Mind/Body/Spirit

 The mindful nurse

Publication Date: September 2015 Vol. 10 No. 9

Author: Lois C. Howland, DrPH, MSN, RN, and Susan Bauer-Wu, PhD, RN, FAAN

Mindfulness is an increasingly common topic in both popular and professional literature. In clinical populations, evidence suggests mindfulness-based interventions (MBIs) can reduce symptoms linked to various conditions, including cardiovascular disease, cancer, and depression. Among healthcare professionals, mindfulness training can reduce psychological and physiologic stress, emotional distress, and burnout while improving empathy, job satisfaction, and sense of well-being. This article gives an overview of mindfulness and MBIs and discusses how mindfulness practices can benefit nurses both personally and professionally.
What exactly is mindfulness? It’s the capacity to intentionally bring awareness to present-moment experience with an attitude of openness and curiosity. It’s being awake to the fullness of your life right now, by engaging the five senses and noticing the changing landscapes of your mind without holding on to or pushing away what you’re experiencing.

Being mindful doesn’t mean stopping your mind from thinking or trying to be relaxed and peaceful. Nonetheless, many people who practice mindfulness regularly report feeling more calm and clearheaded. You can develop the ability to be more mindful in everyday life through mindfulness meditation and other mindfulness practices.

Living on automatic pilot

Throughout our lives, we develop beliefs, judgments, and habitual thinking patterns that may result in living in an automatic or habit-driven way. Many of us are on “automatic pilot,” with our bodies operating in a routine pattern while our minds are somewhere else—usually anticipating future events or ruminating over something that has happened. This “mindless” way of living can limit how we experience life, the choices we make, and the quality of our relationships. It also can exacerbate feelings of stress.
Mindfulness practices can help us recognize mental habits that limit our understanding of something or restrict our options for action. Consider, for example, how negative self-talk can grip your attention and circle in your mind like a hamster in a wheel. By being able to notice when your mind is engaged in these common but unhelpful thinking patterns, you can bring attention to the feeling of the breath as it’s moving in and out of your body or noticing the physical sensations of your body as it is right now. This intentional shifting of the mind to present-moment experience can help interrupt stressful thinking and may enhance your sense of calm and centeredness.

How does mindfulness work?

The mind is busy. It constantly processes memories and plans, rehashes past events, and takes in and pro­cesses information from the senses and internal body. At the same time, it orchestrates the activities that allow us to function in daily life. The mind also must respond to the challenge of our ever-expanding and complex technological environment, which bombards us with a relentless stream of information from electronic devices and social media—increasing our mental distraction and stress.

Neuroscience research shows mindfulness training can enhance the brain regions responsible for attention and executive function (problem-solving and intentional action) while modulating the amygdala, the brain area that identifies threats and triggers such emotional responses as fear and anger. Mindfulness practices can enhance your ability to pay attention and notice what’s actually happening, particularly in stressful situations. This ability to notice attentively and see situations more clearly can help you respond thoughtfully rather than react. This has particular relevance for nurses in terms of self-care and optimal care of patients.

Learning to be more mindful

In 1979, Jon Kabat-Zinn at the University of Massachusetts Medical School developed the seminal mindfulness training program known as mindfulness-based stress reduction (MBSR), in an attempt to reduce suffering in patients with chronic pain. This highly structured, 8-week group program includes training in exercises to increase the capacity to be more mindful. Core mindfulness practices in the MBSR program include the body scan (learning to mentally tune in to body sensations), gentle yoga (moving the body with attention and kindness), and breath awareness (focusing on the sensations and experience of breathing). Research examining the effects of MBSR training found significant improvements in the health and well-being of participants with various medical conditions.
Hundreds of hospitals, universities, and community settings across the country and around the world offer MBSR training. Also, MBSR and other related MBIs have been developed to target specific nonclinical populations, such as business leaders, professional sports teams, schoolteachers, and students. Instructional books, websites, compact discs, and personal device applications are available to help people learn more about mindfulness practices.

Mindfulness and nursing

How can mindfulness help nurses? Greater awareness and less distraction in the clinical setting can improve your assessment skills (for instance, allowing you to identify subtle changes in a patient’s condition) and your performance of complex technical procedures that may reduce the risk of clinical errors. Mindfulness can enhance your communication with patients and other healthcare team members by bringing a greater awareness to how and what others are communicating. Listening and speaking with greater attention can lead to more effective communication and better clinical outcomes, particularly in crisis situations.
Moreover, research shows mindfulness training can help nurses cope more effectively with stress and reduce the risk of professional burnout. One randomized, controlled trial of nurses found those who participated in an 8-week mindfulness training program had significantly fewer self-reported burnout symptoms, along with increases in relaxation, mindfulness, attention and improved family relations, compared to nurses in a control group. (See Developing a more mindful nursing practice.)

Wiser and more compassionate care

Mindfulness is a way of living with greater attention and intention and less reactivity and judgment. You can learn and develop mindfulness through regular mindfulness practices. Consider integrating mindfulness into your self-care plan to reduce stress and minimize burnout.
Being more mindful and bringing receptivity to whatever is happening can deepen your understanding of clinical situations, relationships with colleagues, and ultimately yourself. With this understanding comes the possibility of providing wiser and more compassionate care for your patients and yourself.

Lois C. Howland is an associate professor at the University of San Diego and a senior teacher at the Center for Mindfulness at the University of California, San Diego. Susan Bauer-Wu is the director of the Compassionate Care Initiative and the Tussi & John Kluge Endowed Professor in Contemplative End-of-Life Care at the University of Virginia School of Nursing in Charlottesville.

Nurse staffing and patient experience outcomes: A close connection

Focus on...Quality and Patient Safety

Nurse staffing and patient experience outcomes: A close connection

Publication Date: January 2016 Vol. 11 No. 1

Author: Nell Buhlman, MBA

As healthcare providers set and refine their strategies for staying competitive in a value-based delivery and payment system, a sharper understanding of the interplay between inputs and outputs becomes a strategic imperative. Nurse staffing is a key input for acute-care hospitals—key both for its impact on care and its budget prominence. This puts it squarely at the center of hospitals’ efforts to deliver on their value promise.
The relationship between staff­ing and patient outcomes across quality, safety, and experience domains is appreciated intuitively, if not always precisely understood. The imperative to strike the perfect balance drives considerable interest and research in fine-tuning this understanding. Yet vast scholarship on the topic hasn’t produced a precise staffing formula that will lead predictably to desirable outcomes.

That’s because high-quality nursing care hinges on much more than the number of nurses on the job for a particular patient load. It also depends on multiple under­-lying structural and process factors, such as nurses’ skills and education, availability of sufficient supplies and equipment, staff training, facilities, and reliable use of demonstrated best nursing practices—as well as such factors as interprofessional relationships, nurse engagement, and job satisfaction.
To fully understand the impact of staffing levels on patients’ clinical and experience outcomes, we must consider the relationships within and among these variables—something we can do only through data integration and cross-domain analytics.

Value of NDNQI data

In 2014, Press Ganey acquired the National Database of Nursing Quality Indicators® (NDNQI®)—the industry gold standard for assessing nursing excellence—from the American Nurses Association. NDNQI national benchmarking data are invaluable for monitoring key nursing-sensitive structure, process, and outcome measures. Similarly, Press Ganey’s vast patient experience database offers critical insight into patients’ perceptions about the effectiveness of hospital operations, clarity of the care team’s communication, and caregivers’ ability to meet patients’ needs.
As with nurse staffing, a growing body of evidence shows associations between patient-experience outcomes and clinical outcomes. Combining NDNQI and patient-
experience data provides unprecedented access to the relationships among key pieces of information. Together, these measures can help nurse leaders identify how performance changes in certain structural and process indicators affect patient safety, experience, and clinical outcomes.
Given the enormous impact of nursing on the patient experience—and because nurse staffing often is a lightning rod in the debate on how to deliver high-value care—using the combined dataset to better understand how the two relate is a research priority. Our early analyses show that performance on both Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) domains correlates significantly with nursing hours per patient day and RN hours per patient day, with the latter showing stronger associations in every domain. (See Correlations between nurse staffing and HCAHPS scores.) The link between more bedside nurses and a better patient experience isn’t surprising. That the correlations stretch across all experience domains—not just those that examine quality and frequency of nurse-patient interactions—is eye-opening.

Staffing that meets patient needs and reduces suffering

While domain-level correlations confirm long-held beliefs about the relationship between staffing and patient experience, we seek to understand which aspects of the patient experience are most sensitive to staffing. Where do staffing levels make a difference in caregivers’ success in meeting patient needs? Where can staffing serve as a lever to improve performance?
Item- and question-level analyses help answer these questions. In the two tables HCAHPS scores and nursing hours per patient day and Press Ganey mean score, we see that for HCAHPS top-box scores and Press Ganey mean scores, every item showed sensitivity to staffing levels. Where the difference in patient experience scores is greatest (meaning when hospitals in the top decile of staffing ratios dramatically out­-perform hospitals in the bottom decile), staffing can be viewed as a more powerful performance-improvement lever.

Reducing patient suffering

Of particular interest are differences in performance on key patient-experience questions related to patient suffering, which may indicate how effectively an organization provides patient-centered, personalized care. Press Ganey staff believe that relieving suffering should be central to efforts aimed at providing patient-centered care.
Patient suffering falls into two categories:

• Inherent suffering results from the patient’s diagnosis, treatment, or both. It can’t be avoided entirely, but it can be mitigated. Some types of inherent suffering are well understood and addressed with some consistency—for instance, using pain control and explaining and managing symptoms. Inherent suffering includes psychosocial suffering, which caregivers are less comfortable with and therefore less practiced at addressing. Such suffering includes fear, anxiety, confusion, loss of dignity and autonomy, and uncertainty about self-care after discharge.
• Avoidable suffering arises from systemic defects, which may include long waits to receive treatment, poor communication, poor coordination among providers, errors, and failure to follow best practices. An important first step in determining how to avoid that kind of suffering is to understand that dysfunction creates additional suffering for people already burdened by inherent suffering.

Inherent suffering can be reduced by understanding and meeting inherent patient needs. Performance on certain patient-experience survey questions can tell caregivers much about how well they’re meeting patients’ needs. Examining the relationship between staffing ratios and performance on these questions is illuminating. The table Reducing suffering: Top-decile vs. bottom-decile hospitals illustrates the dramatic differences in performance between top-decile and bottom-decile hospitals on questions relating to patient anxiety, autonomy, and the need to be informed about and involved in their care. These differences speak volumes about the importance of adequately resourced nursing units to give caregivers sufficient time to meet these patient needs.

It’s never just one thing

These findings don’t suggest that increasing nurse-patient ratios will automatically lead to performance improvements. Certainly, adequate nurse staffing is key to a range of outcomes, but changing staffing volume alone won’t produce optimal outcomes. Multiple aspects of structure and process also shape outcomes, and these findings must be leveraged with that in mind.
Such factors as demographics of the nursing force, education and certification, engagement, and organizational staffing models are associated with patient-experience outcomes, as are cultural and structural practices and processes. In this regard, answers to the questions below also factor into outcomes:

• Is the nursing staff following best practices associated with better patient experiences?
• Are they executing on those best practices consistently and in the prescribed manner every single time?
• Do nurses have the right resources and training to promote consistency?

For example, a best practice such as purposeful hourly rounding on patient experience can have a dramatic impact. A 2013 Press Ganey study shows that patients who report they were visited by staff hourly during their hospital stay were much more likely to give top box scores on all HCAHPS questions—a clear sign their needs were being met more consistently. See the table Effect of hourly rounding on HCAHPS scores for details.

The concept of value over volume extends beyond changes to delivery and payment models. For hospitals, “getting it right” with their nursing organizations is particularly important because nursing care provides much of the value hospitals create. Adequate human resources are critical, but they’re not enough on their own. Nurse leaders must consider the full range of inputs—in addition to adequate human resources—that drive outcomes, including staff quality or caliber, the environment in which they operate, and shared commitment to providing a high-value experience for patients.

Nell Buhlman is senior vice president of Clinical and Quality Solutions at Press Ganey Associates in South Bend, Indiana. Note: Charts are copyrighted by Press Ganey and used with permission.

Selected references
Armstrong K, Laschinger H, Wong C. Workplace empowerment and Magnet hospital characteristics as predictors of patient safety climate. J Nurs Care Qual. 2009;24(1):55-62.
Dempsey C, Reilly B, Buhlman N. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm. 2014; 44(3):142-51.
Halm MA. Hourly rounds: what does the evidence indicate? Am J Crit Care. 2009;18(6): 581-84.

What do you do with a PhD in nursing?

I now view the question as an opportunity to educate.

By Tiffany Montgomery

​Almost weekly, I am asked about my choice to pursue a Doctor of Philosophy in nursing. The frequency of this makes me wonder if the general public only sees nurses as bedside handmaidens who take orders from physicians. The more frustrating thing is when these probing questions come from other PhD students. I was shocked the first time I was asked by a non-nursing PhD student, “What do you do with a PhD in nursing?” I’ve now grown used to hearing this question from my doctoral colleagues outside the school of nursing. Still, it’s quite bothersome, because the question usually isn’t framed as an inquiry about what area of research I’m interested in or what type of employment I plan to seek upon graduation. It’s more, “Why in the world would a nurse want a PhD?” Before I became accustomed to the question, I wasn’t sure how to answer it. Oftentimes, it was difficult to decipher whether or not the person asking was trying to be sarcastic (especially if the question came from another PhD student). At one point, I became irritated by the question and started giving a pretty snappy reply: “The same thing you do with a PhD in anything else!” After completing a year of doctoral studies, however, I now realize that the general public is unaware of all the wonderful avenues available to nurses. So, now I view the question as an opportunity to educate. What do you do with a PhD in nursing? Whatever you want! There are PhD-prepared nurses who teach, conduct research, evaluate programs, write books, lead health care organizations and work for the government. With a doctoral degree, the sky is the limit. One thing I doubt most nurse PhDs want to do is work full time in direct patient care. At the doctoral level, nursing is less about hands-on patient care and more about the abstract thinking that helps move the profession forward. More than anything else, a nurse with a PhD has the training needed to conduct research and add to the body of available nursing research knowledge. While not all PhD-prepared nurses choose to work as researchers, all have been exposed to great amounts of research and have had to demonstrate their ability to conduct high-quality research on their own. Three jobs I’ve noticed that most PhD-prepared nurses consider are listed below. The job descriptions provided are based on my observations of nurses employed in these positions, and they may vary from facility to facility: Nursing faculty member—A nurse educator who works in an AS, BSN, MSN or PhD program as a classroom instructor. Nurse faculty members are also responsible for creating, implementing and evaluating program curricula and mentoring nursing students. Oftentimes, in addition to their teaching responsibilities, they are expected to conduct research. They typically disseminate this research in scholarly journals and at research conferences. Director of nursing research—a nurse researcher who serves as administrator of the nursing research department of a health care facility or coordinator of the facility’s nursing research program. The director may supervise other nursing research employees, or he or she may be responsible for overseeing all nursing research projects conducted within the facility. The director of nursing research is typically the go-to person within the facility for questions regarding the design and implementation of a desired research study. He or she may or may not be responsible for dissemination of research findings. Director of clinical services—a clinical administrator who oversees daily operations of patient care departments in a health care facility. He or she is the liaison between upper management and department managers. Although the director is not involved in direct patient care, he or she is aware of the work flows in each department that promote optimal patient care. The director may generate or receive reports addressing the efficiency of departmental work flows, and this information is then given to each department manager in an effort to increase efficiency and patient satisfaction. Other jobs available to PhD-prepared nurses include research or high-ranking administrative positions in pharmaceutical companies, research institutes, health advocacy organizations, health care information technology corporations and nursing or other health-related publishing companies. A nurse who has attained a PhD can practically work anywhere that research, education, or program evaluation takes place. The important thing to remember is that graduation from a reputable PhD program ensures that a nurse has received proper research training. If you have any additions to the types of jobs held by nurses with PhDs, please post below. I’d like to learn of new opportunities for nurses with the terminal degree. RNL