Changing Focus: How to Switch Specialties by Michele Wojciechowski

Changing Focus: How to Switch Specialties

by Michele Wojciechowski |

When she started in nursing, Peggy Lasoff, RN, BSN, was employed as the medical/surgical manager for the VA Medical Center in Brooklyn, New York on the 3-to-11 p.m. shift. In time, she decided that she needed a change.
“I realized working 3-11 p.m. was going to be difficult with [having my] children in school and changes were occurring within the hospitals,” Lasoff says.
Because she enjoyed working with the geriatric population, Lasoff earned a certification in gerontological nursing practice offered by the American Nurses Credentialing Center, and then she accepted a position as an assistant director of nursing at a nursing home. In this position, she was able to provide training to the staff and be home for her family when they needed her.
But this wouldn’t be her last career move. In fact, she’d be making one more.

Peggy Lasoff, RN, BSN

“While working in the facility, I heard many families and patients wishing they could be home. Their loved ones were looking for guidance to make this happen. I started researching home care and learned about hospice care,” she says. Lasoff found herself drawn to it. “I recognized that I had been caring for elderly patients in their last years of life. Why not move to caring for them in their homes?”
After earning certification for hospice/palliative care from the American Nurses Association, Lasoff began working in the field. Today, she is a hospice/palliative care clinical manager with the Visiting Nurse Association Health Group of New Jersey.

When It’s Time to Change

Now Mary C. Krug, MSN, APN, RN, works for UnitedHealthcare doing annual home visits for their Medicare Advantage members. She’s also on the Board of Directors for the New Jersey State Nurses Association. Throughout her career, she’s worked in a number of different nursing positions. But she always knew when it was time to change to the next one.
“I do not regret any of my job changes,” says Krug. “Each one gave me knowledge and experience, which serves me every day in caring for people. I would not do one thing differently. I only wish I had more working years in my future to try out a few more different positions!”
After she graduated and became an RN, Krug worked for a year in general medical/surgical nursing in a hospital. When she decided that she wanted to move to critical care, she took a six-week course at the hospital on reading cardiac monitors and intracranial monitors as well as managing ventilators and other information she needed to work in critical care.
Krug stayed in critical care for 10 years, then earned her Master’s degree in nursing in adult primary care and became an Advanced Practice Nurse (APN). While studying for her APN, Krug worked in an emergency room because while she knew how to treat critical patients, she wanted to handle other injuries or illnesses like sprains or upper respiratory infections.
When she finished her training, Krug worked for a primary care doctor. She would later work in college health, women’s health, and for a dermatologist before moving to her present position.

Mary C. Krug, MSN, APN, RN

For many of the transitions in her career, Krug obtained additional schooling. Sometimes, it would be through observing someone, as she did when working for the dermatologist. Other times, she earned additional certifications in critical care, emergency nursing, HIV, and adult primary care. She advises other nurses to continue to advance their educations, as doing so can open up other opportunities. “If I were younger, I would continue on to earn my PhD,” Krug says.
In the beginning of her career, Mary Ellen Levine, MSN/Ed, RN, was a staff nurse with a medical and surgical unit that specialized in respiratory and neurological care. When she was asked to educate a family about hospice care for their loved one who had experienced a severe brain injury with no chance of recovery, it triggered something in her.
“It touched a chord in me. I would want to have all the information and know all the options if this were my family,” says Levine. She knew that it was time to make a change, and for her, that change was to become a hospice nurse.
To transfer to hospice nursing, Levine needed to undergo an organizational orientation at her current place of employment, the Karen Ann Quinlan Hospice, and have two weeks of focused education specifically about hospice care. She also shadowed more seasoned nurses in the field.
“I encourage all nurses to seek out options throughout their careers,” says Levine. “You have to like what you do.”

Advice for Others

Know that making a move may be stressful. “Change is not easy. Moving from one job to another requires a certain amount of patience with yourself. It is a major life change and being comfortable with your decision takes time,” explains Levine. “Learning about different organizations is as important as learning about a nursing position.”

Mary Ellen Levine, MSN/Ed, RN

Lasoff says that “Looking back, the transitions I made in my nursing career were easy, although a bit of anxiety came with each move.”
Levine adds that it takes time to go from a novice in a particular specialty to an experienced nurse, no matter how young or old you are. Asking colleagues for help may not come naturally, but it will help you to learn more about the new environment. She advises nurses to talk with their families before they make a change; having hers support her was key to her success. Speak with colleagues to determine what you might like to try. Also, check into your state’s nursing association. Levine says that hers was a great source of support. In fact, she’s now president of the New Jersey State Nurses Association, Region 1.
“Changing nursing positions is not about feeling that you are not good enough at what you are doing,” says Levine. “You can be the best nurse in the practice, but if at the end of the day, you feel your strengths are not being used to the best of your ability, there is most likely a position out there where you might feel more fulfilled.”

Michele Wojciechowski

Michele Wojciechowski is an award-winning writer and author of the humor book Next Time I Move, They’ll Carry Me Out in a Box.

Taking the Next Steps...Planned Succession

The career handoff: Intentional sharing of knowledge and wisdom ​Chapter from The Career Handoff, an STTI book.

By Kathy Malloch and Tim Porter-O'Grady

This chapter from The Career Handoff: A Healthcare Leader's Guide to Knowledge & Wisdom Transfer Across Generations examines the critical components of successful communication, transition, handing off, and succession planning in the healthcare profession.   “Tell me and I forget, teach me and I may remember, involve me and I learn.” –Benjamin Franklin Every year, Tim and I schedule time for a retreat to plan what we are going to focus on in the next year. We select a special place where we can both think and play and do something special. At our latest retreat at the Ojai Valley Inn & Spa in California, we found ourselves wondering how many more revisions of our work we could do—and how much longer our ideas and strategies would be relevant for healthcare organizations. And then came the even tougher question: What would happen to our textbooks? Would Quantum Leadership just sail into the sunset? We humbly wanted the information that would be meaningful to future generations not to be lost; we did not want future generations to rediscover what we had already identified and shared. These questions got us to think about how to hand off our successful ideas to younger colleagues and selectively discard that which is no longer relevant. From that conversation, we began to strategize and learn about how to hand off knowledge and wisdom to younger generations, and this book is a result of those ideas.   We realized from our consulting practices that highly successful professionals are often reluctant to consider retirement, and many people avoid the thought of moving away from active engagement with colleagues in sharing knowledge and wisdom. It is even more challenging to figure out how to hand off or give one’s intellectual property to another colleague. As an unprecedented number of baby boomers move closer to retirement, there is much to share with succeeding generations. There is also some content or intellectual property that might not be applicable in future generations. We believe a formalized process for sharing and designating intellectual property and products would be helpful to not only our baby boomer colleagues but also to other generations of colleagues.   The Need for Generational Sharing Our professional consulting focus has been on the importance of leadership and in helping others to learn as much as possible about leadership—to embrace new ideas to become the most successful leaders possible. Our belief has always been that everyone is a leader, regardless of whether they have a formal leadership title. Whenever two individuals are together, one person begins the dialogue or movement in the simplest way, and leadership is evident. Each one of us has some special knowledge and expertise that future generations should or might want. Creating a culture as well as validating the science that assists others in handing off and nourishing our colleagues with our wisdom is important to both of us. Cultivating a culture of giving to others with minimal expectations of receiving something in return will allow future generations to grow and move on with what is vital to them. Our focus has shifted from figuring out what to give and how to instruct them to “love our stuff” to identifying interested colleagues and turning our work over to them to sort out and retain what is deemed valuable. It is also time for us to get out of the way of future leaders and shift from driving the boat to creating a safe space for others learning how to manage the boat’s journey!   Soon after our retreat, I was invited to keynote a leadership summit group; my focus was on this topic of generational sharing. Participants at this meeting included successful professionals from three generations, including chief executive officers, nurse executives, consultants, real estate executives, and physicians. As part of the keynote, I presented the plan Tim and I developed to hand off two of our books (see the feature that follows) and the discussion began to flow. Participants were highly interested in learning more and becoming involved in advancing the science of both giving and receiving intellectual property and the wisdom of ages.   Handing Off Our Publications After many years of writing books and revising those books, Tim and I wondered what would happen to our book content when we were really finished writing. So, after some thought, we decided to be proactive and formally pass on the writings. Over the course of our careers we had had many excellent students and colleagues; we selected two who we thought embraced our philosophy about innovation and leadership and had a track record for getting things done. We asked Dr. Dan Weberg and Dr. Sandra Davidson if they would be interested in taking on the work of combining our evidence-based practice (EBP) books with our Innovation Leadership book to make one “Innovation–Evidence Dynamic” book. They were extremely excited and ready to set up and pursue a plan to make this happen. Our next step was to contact the publisher and present our idea. The publisher developed a contract, and Tim and I reviewed and approved it. Then it went to Dan and Sandra as the new lead authors. For this new book, Dan and Sandra would be the lead authors while Tim and I followed them. In the next edition, only Dan and Sandra will be listed as authors, and Tim and I will be contributors as the new authors deem necessary. Dan and Sandra skillfully took the chapter content from both books, rearranged it, added new chapters, and deleted those they thought were less relevant in today’s healthcare world. Interestingly, this process seemed complicated when we began; however, with the highly professional new authors, the book has taken on a life of its own and is due to be published in the fall of 2015. We are excited to see the new book and know that Dan and Sandra will have exceeded our expectations. Reflecting on these ideas, we created a book proposal with the interested retreat participants. We now had a team of wisdom experts to join us on this journey and, most importantly, the authors represented three generations of interested professionals. We realized quickly that the importance of sharing generational wisdom was significant and that there was much interest from younger generations in learning more about our work and how to keep the useful knowledge alive and contemporary. Rather than seeing ourselves as the fading generation, it is time to see ourselves as a generation who now has much to share with the younger generations! We believe we created a talented team of wisdom managers to assist in this work. Further dialogue with the contributing authors provided clarification and enhancement of our ideas and solidified the importance of documenting and sharing generational wisdom, successes, and strategies that we would not repeat. We believe formalizing this process and providing guidelines for colleagues will be an important contribution to professional nursing practice. Each one of our authors has included specific discussion on what the handoff is, some practical tips for sharing knowledge, and exemplars to demonstrate personal experiences (and, of course, some irreverent humor; we all need to laugh and enjoy the nuances of our journey!). This book reflects our commitment to professional coaching, mentoring, and assuring that our young nurses are not chewed up by the system but are supported proactively. Mentoring is a vital professional behavior and an ethical obligation to our profession; we need to nourish our young rather than engage in the proverbial “eating our young.” In the next section, we share our personal and scholarly connections to the art and science of mentoring. Life Journey: Membership in the Profession Transitions and transformations are a fundamental part of the journey of life. Naturally, as we age and grow, we gather information, skill, insight, and wisdom that accumulate and aggregate in a way that becomes a part of our characters and personalities. As professionals, one of the most important considerations is the responsibility that membership in the nursing profession brings. Who we are and what we are become a part of our professional identity such that our person and profession become one and the same thing (Malloch & Porter-O’Grady, 2010). As we journey through our careers and our lives and are recognized as professional nurses, we essentially become the “person of the nurse.” As professionals, we integrate our work, our relationships, and our individual persona in a way that creates the frame for who we are and provides the substance of the image we present to the world. Consider a notice you might see in a newspaper about the appointment of a position to an administrative or public role—the writer acknowledges the relationship between the person and profession by identifying the particular individual as a “physician.” However, when a nurse is appointed in a similar fashion to an administrative or public role, he or she will more frequently be identified as a “former nurse.” For the physician the identity is singular; for the nurse the same identity is dual (a nurse is a job different from the administrative or public role and, therefore, cannot be identified in singular terms). Sage Insight Shared Across the Generations  We have had many opportunities to work with a number of organizations in helping to increase awareness of the many “sage” resources within those organizations. Often, the usual obligations of work overtake the value of reflection on past experiences, special skills, organizational tenure, insights, and wisdom gained from many years of providing healthcare services. In their haste to embrace contemporary challenges and opportunities for innovation, leaders often forget to access the tremendous acumens and talents of the more mature and long-tenured contributors in their midst. At the same time, those with gifts and wisdom to share need also to be available to their colleagues and new members of the professional staff in ways that are open, responsive, and engaging. A positive and renewing attitude that generates a sense of accomplishment and confidence provides a firm foundation out of which connections between a mentor and mentee can stimulate more positive relationships, meaningful interactions, and learning that can occur only between generations. Handing off knowledge to successive generations implies commitment and communication with those among us who have fresh ideas and different perspectives that need to be included in the dialogue among generations. As consultants with long tenure, we have been able to bring insights from outside the organization that may have already been available inside the organization, but leaders were often tied up with the challenges of the day in ways that didn’t make the same important insights easily visible to them. Taking advantage of these sage resources, leaders can fully access for the organization and for themselves the utility of the wisdom, insight, and history of those in the organization who have much to share. Often, a part of this scenario is the need to formally access and provide continuity to use of clinical and management leaders who have much of value to share. Sometimes decisions lacking sage information could lead to organizational challenge or failure. As consultants, we often communicate with more mature staff regarding long-term implications of a particular current crisis or challenge in a system. Often, what we have found is that the current critical issue has a direct or implied relationship to a continuum of decisions and actions predicated on a set of assumptions that could have been better informed had the key stakeholders been a part of the decision. Through the consultant’s lens, when leadership uses a succession or leadership handoff system that provides the right information, tools, and insights, many challenges and possible errors in leadership insight and strategy can be easily avoided. The trajectory of our experiences gives us information with regard to how complex systems work and represents the substance of our development. Along with our learning, our experience provides the platform for translating what we know and what we do in a way that has an impact on our own lives and on other people’s lives and experiences. At the same time, the experience and skills of colleagues and others that are significant in our lives have as much an impact on our development and growth, and those people do their part in influencing the course of our lives and the people we become. In our personal life journeys, there is a sort of developmental dance among our learning, our experiences, insights gained from others, and the relationships we share with people with whom we intersect (Patton, Zalon, & Ludwick, 2015). Each of these influences and the sum of them link within our persona to create a unique and individual life lens and insight related to our world and how we have lived in it.  “I am not a teacher, but an awakener.” –Robert Frost One of the joys of this life journey is the increased knowledge, insight, and skill we develop as we aggregate experiences and learning relationships. If we have had an open attitude in all these arenas, we have been available to the opportunities to deepen our insights and understandings and broaden our awareness in a way that helps us develop expertise that advances our talent as professionals. One of the urges this dynamic generates is the desire to share and to extend these insights and talents in a way that benefits others who are also eager for learning and personal development. This desire to share knowledge and skill is an outgrowth of our own openness and availability to learning and personal development. Those individuals who understand this dynamic also recognize that embedded in it is the give-and-take reflected in the interaction of all who share a commitment to growing, learning, and deepening their knowledge and understanding.

Poetry by Nurse Monique A. Shaw

Molestation, a sad plight

It's not enough to keep me up at night.

Projects, shelters, even evictions

Is that enough to make me lose my conviction?

The witness of a horrible stabbing,

Domestic abuse and a kidnapping.

She’s your mom! Yes, I know!

But the paperwork said she let me go!

All this before the age of ten

At what age will this tragedy end?

Brighter days must soon be near

Off to San Diego where the skies are clear.

Is it here that this will all end

Is my triumph about to begin?

No, not now I’ll have to wait

Let’s pile some more upon my plate.

ADDICTION! Why mom? Why did you choose

Drugs will surely make you lose.

Our home, our friends, our money, our things

You smoked them, you snorted and shot them up.

Walking the Downtown streets late at night

Nowhere to go, we spot a light.

Is that a sign? A vacancy?

Yale Hotel on F Street, our new home to be.

It is here where friends become family

And, of course, more tragedy.

NO! STOP IT! IT ISN'T SO! MY MOM DOES NOT HAVE HIV!

STOP TALKING! I'M NOT LISTENING! STOP LYING TO ME!

Off we move and leave our friends

The family that stays with me through thick and thin.

Now, In-Home Nurses and medication

I’m only in Junior High School, I need a vacation.

The drugs, they’re just too strong

She can’t let go and continues to succumb.

Now three little letters turn into four

AIDS came tapping at my mother’s door.

DEATH! Two times in a one year span

First dad now mom, it’s too much man!

Junior High, High School and College is the future for me

Constantly holding a 3.0 to a 3.33.

Life has many twists and turns and crooked paths

As we often learn.

Love provides an interruption

But abandoning college was never my solution.

Marriage at age twenty and a new place to call home

Military life in Illinois is where I'll roam.

Also Virginia and Mississippi

The love is now gone, there’s nothing here for me.

Back to San Diego from where I came.

Time to pack up and start again.

Now a single mother, I must go back to school

Go back to the path which I always knew was cool.

A Medical Assistant I’ll quickly become

To make decent money to try and move on.

Child, work and school that’s my daily routine

Working hard to fulfill my lifelong dream.

Along comes the news I’ve patiently waited for

Two long years or maybe more.

Monique, you’ve made it, your name has come up

Are you ready for Nursing School? Of course, there’s a but.

But I’m pregnant with another child, over ten years later.

Its OK, we’ll see you next year but not any greater.

The year came and went quick as a flash

Nursing School is here, time to attend class.

The toughest two years I really must say

But I remember my past and what I endured many days.

I persevered and progressed and completed the program

And walked across the stage with my kids looking on.

And knew that although life sometimes seemed bleak

That this was the TRIUMPH I always did seek.

So you may ask, “Do you think this scholarship can help you live your dream?”

Yes in many ways, one can only imagine

Higher education is the goal and is my passion.

From RN to BSN this is now my desire

This scholarship will help me live my dreams and aspire.

Monique A. Shaw, R.N.

 Monique is a registered nurse in the Southern California area. She is currently working on her BSN while balancing the busy life of work and mom.

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