2020 Year Of The Nurse

If you haven't heard already 2020 is the year of the Nurse!! This is your time to celebrate YOU and all you do! ANA has some great ideas on how you can Excel, Lead, and Innovate! Take a look at these suggestions for Celebrating and Elevating Nursing.
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Why your nursing networks matter

Why your nursing networks matter
March 2018 Vol. 13 No. 3
Networks help you advance your career, provide high-quality care, and support your colleagues.

Takeaways:

Professional networks are crucially connected to quality patient care.
Building a professional network can take two paths: a network in your immediate clinical environment or one created through an organization.
Professional networking has rules, such as adding value to others, building a professional image, and being prepared and positive.

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN, and Tanya M. Cohn, PhD, MEd, RN

nursing network matter
Maria is a direct-care nurse working on a medical/surgical unit in an acute-care hospital. She recently achieved certification and became a member of a national nursing organization for her specialty, both of which are needed to advance through the clinical ladder at work. However, Maria isn’t sure why her hospital values membership in the national organization or how it will help her career. She has a busy personal life and doesn’t have time to volunteer in her local chapter.

Maria’s lack of understanding about the value of professional networks isn’t unusual. Many nurses never make the investment of getting involved with professional associations or take the time to ensure that they have a strong network of colleagues within and outside their own organization. They wonder why they should spend what free time they have on an activity that seems so indirectly related to their work, and they fail to see how a network can enhance their professional growth or be a wise career investment.

The value of professional networks

Maria, like all direct-care nurses, is part of the profession of nursing. As a member of the profession, she has the opportunity to develop through continuing education, certification, and membership in nursing organizations. These activities will help Maria evolve from a novice to an expert nurse and open doors to professional networks. Professional networks also will provide her with mentorship, support, and teamwork opportunities. For example, if Maria’s interested in developing specific skills or advancing her education, she can use her network to identify a mentor for skill development or guidance on educational opportunities.

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Professional networks are crucially connected to quality patient care. Specifically, healthcare demands evidence-based practice, but nurses across the nation frequently are faced with variations in patient care and deep-rooted sacred cows of practice that are neither evidence-based nor current. Working in silos of individual clinical settings, nurses are left with less-than-optimal patient care and the need to develop evidence-based solutions from scratch. This is where professional networks can promote evidence-based practice through collaboration. For example, as a member of a national organization, Maria has access to networking with other medical/surgical nurses. Together they can compare and share best practices or research findings from their clinical practice, reducing the need to re-create the wheel individually. The result is consistent evidence-based, high-quality patient care.

For young nurses like Maria, a strong network can help when looking for new career opportunities. Many positions are never advertised, and workforce recruiters acknowledge that their best referrals come from professionals whose judgment they trust. Today’s healthcare environment is volatile, so building a strong network should be part of a professional insurance policy.
Steps to building a network

Building a professional network can take two paths: a network in your immediate clinical environment or one created through an organization. Both require common steps.

First, establish an understanding of your goals and who can help you achieve them. For Maria, this could include using her knowledge and experience as a certified medical/surgical nurse to establish a unit-based education program or to take part in a unit-based council to work collectively with other nurses through
evidence-based practice and nurse competencies. Maria also might be interested in tapping into the nursing organization she’s joined to seek out up-to-date practice alerts. Regardless of the professional network, after goals are set and the right people are identified, you can interact, share knowledge, and receive plans to help you achieve your goals.

If you don’t have a specific goal in mind, building a professional network might seem daunting or unclear. Start by putting yourself out there in the nursing profession. For Maria, who may not be able to commit to joining a committee within the nursing organization, she can plan to attend the organization’s annual conference. While there, she can take steps to maximize the networking experience. First, she should think about some conversational topics and introductory questions to use when interacting with other attendees. Depending on Maria’s professional goals, the topics and questions could revolve around clinical practice, leadership development, or advancing education. In addition, Maria should be professionally prepared for the conference, including wearing professional attire and taking business cards. She also should plan to attend all social events and interact with the conference vendors, who could be potential future employment opportunities or offer cutting-edge evidence-based products she can share with her clinical colleagues.
The golden rules of networking

Networking opportunities exist everywhere, including online with sites such as Facebook, LinkedIn, and Twitter. Many nursing organizations have Facebook and Twitter accounts that nurses can follow to support networking about clinical practice and professional development. LinkedIn, on the other hand, helps nurses identify mentors and colleagues with similar interests. Regardless of whether you’re networking at a conference, within an organization, or online, you’ll need to follow some rules. (See Expert advice.)nursing network matter expert advice
Networking for introverts

If you’re naturally introverted, networking may not come easily. You may even avoid networking events because they’re exhausting and force you outside your comfort zone. The hardest part can be walking through the door into a room. Fortunately, most people would rather talk than listen, so let others do the talking. You can never go wrong asking questions and establishing common ground. (See Get the conversation started.) Chances are that once you start asking questions, the conversation will flow easily. Most nurses like to be asked about their opinions and sought out for advice. You’ll be seen as a great networker because you take the time to listen.
Join the networked world

Over the course of her career, Maria will learn that building a network is one of the most powerful opportunities that membership in a professional association can provide. A good network outside her clinical setting will help her gain access to and act on new information quickly. She’ll also save time and energy by accessing other professionals who’ve overcome some of the same challenges she’s facing. Many young nurses have fast-tracked their careers by getting involved with association committees or running for office.

We live in a networked world, so developing your networking skill set is important to your career success. You never know what new opportunities you’ll encounter or who you’ll meet until you extend your hand, introduce yourself, and start asking questions.

Rose O. Sherman is a professor of nursing and director of the Nursing Leadership Institute at Christine E. Lynn College of Nursing, Florida Atlantic University in Boca Raton. You can read her blog at www.emergingrnleader.com. Tanya M. Cohn is a nurse scientist at West Kendall Baptist Hospital Nursing and Health Sciences Research in Miami, Florida.
Selected references

Cain S. Quiet: The Power of Introverts in a World That Can’t Stop Talking. New York: Broadway Paperbacks; 2012.

Henschel T. How to grow your professional network. 2018.

Jain AG, Renu G, D’Souza P, Shukri R. Personal and professional networking: A way forward in achieving quality nursing care. Int J Nurs Educ. 2011:3(1):1-3.

Mackay H. Dig Your Well Before You’re Thirsty: The Only Networking Book You’ll Ever Need. New York: Currency Press; 1997.

Maxwell JC. The 21 Irrefutable Laws of Leadership: Follow Them and People Will Follow You. Nashville, TN: Thomas Nelson; 2007.

Sherman RO. Building a professional network. Nurse Leader. 2017;15(2):80-1.

Celebrating Nurses with a little Blast from the Past!

10 Old-School Nursing Skills You Don’t See Anymore

by Scrubs Staff • March 23, 2016

Nursing, along with the rest of the medical field, is constantly evolving to ensure better patient outcomes. Nursing skills, in particular, have changed quite a bit over the last several decades. Some skills have even been discarded completely for the sake of safety or efficiency. Here are 10 interesting examples of old-school nursing skills that have either drastically changed or are no longer practiced:

1. Reusing syringes and urinary catheters

Believe it or not, new nurses, many of today’s disposable medical items, like urinary catheters and syringes, were made to be reused in the not-too-distant past. These items were sterilized between uses, a process that was eventually deemed too costly as disposable items became more common.

2. Charting patient care on paper

While it’s still possible to find rural and small-scale clinics that utilize paper charting, the majority of health-care facilities these days chart electronically. In addition to providing all members of the health-care team with easier access to patients’ charts, electronic charting is typically more efficient and more accurate.

3. Using urine dipsticks with sliding-scale insulin

Sliding-scale insulin has been in use longer than glucose meters. Before these meters were used to determine how much, if any, insulin to administer to a diabetic patient, nurses had to rely on urine dipsticks. Urine-dipstick results aren’t as accurate as those provided by glucose meters, so it’s no surprise that they aren’t used in this manner anymore.

4. Regulating IV fluids manually

Before infusion pumps were invented, it was necessary to manually regulate IV fluids. To do this, nurses had to count drops and calculate drip rates for each and every patient receiving IV fluids. Now, thanks to infusion pumps, administering IV fluids is easier, more accurate, and much faster.

5. Palpating for blood pressure

The vast majority of health-care facilities throughout the United States take patients’ blood-pressure measurements automatically, but this wasn’t always the case. Nurses used to rely on palpation to obtain blood-pressure measurements. To obtain a patient’s blood pressure in this manner, nurses would inflate and deflate a compression cuff while feeling for the disappearance and reemergence of the radial pulse.

6. Shaving patients prior to surgery

Up until fairly recently, hairy patients had their incision sites shaved prior to surgery. New evidence suggests that this leads to an increased risk of infection, and many hospitals have eliminated this practice. Now, instead of using a razor, nurses use clippers to cut away excessive hair as a part of their preoperative preparations.

7. Shaking mercury thermometers

Now that digital thermometers are used to obtain patients’ temperatures, the sight of a nurse shaking a mercury thermometer is extremely rare. In the past, however, nurses could be seen shaking mercury thermometers in hospitals on a daily basis. The reason that these old-school thermometers were shaken is that the mercury would often cling to the inner sides of the thermometer. Prior to taking a new temperature reading, bringing the majority of the mercury back down into the bulb by shaking the thermometer was the best way to ensure accuracy.

8. Cutting urinary catheters during removal

While cutting urinary catheters during removal is not recommended, some nurses and doctors still utilize this practice. It’s considered unsafe for two reasons primarily. Firstly, traction on the catheter could cause it to retract into the bladder if it’s cut. Secondly, the balloon might not deflate, which turns a simple catheter removal into something much more difficult and costly.

9. Irrigating NG tubes with Coca-Cola

Many old-school nurses swear by Coca-Cola for NG tube flushing. In theory, this is due to the coke’s acidity. Regardless of the reason behind this method’s supposed effectiveness, it’s not recommended as it can affect the plastic tubing. Before using coke, juice, or something similar to flush an NG tube, refer to your facility’s guidelines. More likely than not, using water when flushing an NG tube will be the preferred method.

10. Treating congestive heart failure (CHF) with rotating tourniquets

CHF patients used to be treated with rotating tourniquets. Essentially, these tourniquets were applied to the lower limbs to diminish venous return. These days, however, we have a wide variety of effective diuretics that can be used to help decrease the strain that excess fluid volume puts on the heart. Not only is this treatment more comfortable for patients than applying tourniquets, it’s much more effective.
Are there any old-school nurses working with you on your unit? If so, do they still practice a few of the skills mentioned in this article? Leave a comment below and let us know!

Smarter Alarm Management Fights Alarm Fatigue Jeanne J. Venella, DNP, MS, RN, CEN, CPEN

Note from Nurse Kim:

This is a huge issue right up there with compassion fatigue and violence in the workplace. Patient Safety is a priority strategy for healthcare providers. Our vigilance will reap great rewards for patients and staff when we make sure to not let this issue fall by the wayside.

Alarm Management Goes Into High Gear

"The failure to recognize and respond to actionable clinical alarms... in a timely manner" was the second highest-ranked patient safety risk identified in the ECRI Institute's Top 10 Health Technology Hazards for 2016.^[1] These threats include actionable alarms that are not detected, as well as alarms that are not handled appropriately by clinical staff owing to miscommunication and alarm fatigue.
The lack of hospital-wide clinical alarm management policies and procedures, and the dangers inherent to alarm mismanagement, achieved prominence in 2013 with the release of the Joint

Commission's National Patient Safety Goals on clinical alarm safety.^[2] This initiative mandates that hospitals must identify and prioritize alarms based on internal considerations by January 1, 2016. In phase 2, which also begins in January, "hospitals will be expected to develop and implement specific components of policies and procedures. Education of those in the organization about alarm system management will also be required."^[2]

Although hospitals and health systems have made progress in solutions development, missed alarms resulting from poor communication or alarm fatigue continue to pose clear and present threats to patient safety. The increase in the number of medical devices with alarm capabilities has only exacerbated the problem, as has the lack of standards on the proper configuration of alarm parameters.

Technology will play a critical role in getting alarms under control, but it is not enough. Without input from the workforce, technology solutions can fail owing to lack of adoption. Nurses and nursing leaders must get out ahead of this issue or solutions will not have representation from the correct stakeholders. Clinical and information technology (IT) leadership, including nurses, respiratory therapists (RTs), biomedical engineers, and IT staff, must come together to develop the policies and standards necessary to prioritize and reduce the number of alarms, as well as to establish protocols for altering current or default alarm parameters.

This article describes how two different hospitals achieved their alarm management goals using both technology and interdisciplinary expertise.

An Interdisciplinary Approach

In explaining why technology alone is not enough to solve the riddle of clinical alarm management, The Joint Commission said, "It is important for a hospital to understand its own situation and to develop a systematic, coordinated approach to clinical alarm system management. Standardization contributes to safe alarm system management, but it is recognized that solutions may have to be customized for specific clinical units, groups of patients, or individual patients."^[2]

In other words, each hospital has its own unique characteristics and needs. Identifying and documenting those attributes is critical to a successful alarm management program. Achieving measurable progress in clinical alarm management requires hospitals to identify direct clinical staff as internal champions.

Wesley Medical Center (Wichita, Kansas) surveyed every nurse in the facility to determine which alarms they considered "clinically relevant" and which they considered "nuisance alarms." On the basis of 200 responses, the hospital was able to evaluate which alarms were most important to them as providers of care and compare findings with the most frequent alarms that occurred in a baseline study.

Wesley Medical Center was able to reduce and prioritize more than 10,000 daily alarms, reduce alarm incidence in its coronary care unit by 78%, and capture and distribute data from more than 600 medical devices for enhanced clinical surveillance by leveraging a combination of interdisciplinary input and alarm management technology.^[3] The baseline evaluation enabled Wesley's clinical leadership to begin the process of mapping alarm trends, as well as classifying alarms by:

• Frequency, alarm type, and device;
• Variations by time and day as well as by rooms and units;
• Alarm parameters and thresholds; and
• Physiologic vs technical alarms.

"We used a multimember interdisciplinary team, including nurses, respiratory therapists, biomedical staff, and IT staff to formulate a list of alarms that we felt were important," said Deborah Free, RN, stroke program coordinator and quality manager at Wesley's Galichia campus. "At the same time, our [alarm management vendor] sent us a list of our most frequent alarms. We compared the two lists and prioritized the alarms we wanted to address."

The highly specific data generated by the baseline study and analysis helped Wesley's clinical staff develop a more effective alarm management system that will reduce the number of nuisance alarms requiring no action and will allow them to measure improvement over time to meet patient safety goals. An evaluation was conducted using a variety of factors, including:

• Setting a predetermined number of days (eg, 30 days or 90 days) for analysis;
• Analyzing alarm type by alarm category;
• Identifying which alarms are most frequent;
• Identifying changes in type and frequency of alarms by unit;
• Identifying variations in alarm type and frequency by device (eg, patient monitor, ventilator, infusion pump, etc.);
• Analyzing variations in alarm response behavior based on technical and physiologic categories, including time, day of week, room, and unit; and
• Analyzing common alarm limit violations to determine how potential changes in current limits may alter alarm frequencies.

By changing practice based on evidence, the staff of Wesley was able to reduce the number of alarms caused by nonactionable, brief physiologic changes. By collecting high-resolution physiologic data from medical devices—not just the individual alarm data—the interdisciplinary team was able to measure the potential impact on the number of alarms before making adjustments to alarm settings.

For example, Wesley now has the flexibility to determine which events will trigger alarms as well as where and how clinicians will be notified. Uniquely, Wesley's system provides staff with high-fidelity, real-time, intelligent data from myriad devices to improve patient monitoring and allow staff to intervene before a patient's condition turns critical—offering point-of-care clinical decision support and enhancing patient outcomes.

Nuisance Alarms

A major challenge in alarm management is sorting clinically relevant alarms from nuisance alarms (for example, an alarm caused by a sensor on a patient being momentarily detached or the Wi-Fi connection being momentarily lost). Hospitals need to develop a standard approach to alarms and have a strategy to reduce alarm frequency, alarm noise, and alarm fatigue. Moreover, providers must guard against the overuse of monitoring when it is not indicated, because this just adds to the number of nonactionable alarms.

The problem with attenuating alarm data is achieving the balance between communicating the essential, patient-safety specific information that will provide proper notification to clinical staff while minimizing the excess, spurious and nonurgent events that do not threaten patient safety. In the absence of contextual information, the option is usually to err on the side of excess because the risk of missing an alarm or notification carries with it the potential for high cost in terms of patient harm or death.^[4]

Wesley's clinical leadership was able to establish separate alarm thresholds as well as combination, trending, and frequency alarms to eliminate nonactionable alarms from being sent to the clinicians carrying phones outside of patients' rooms. For example, instead of an alarm based on a single vital sign, such as the ECG heart rate, a combination alarm might also look at the heart rate from the pulse oximeter or an invasive blood pressure wave to make sure the alarm is real and not just artifact. Overall, Wesley was able to reduce the number of these alarms daily in the coronary care unit from 1285 to 281—a 78% reduction.

The Table shows the reduction in the number of alarms sent to the nurses' phones. The "device alarms" column represents alarms generated by bedside devices and sent to nurses' phones. The "smart alarms" column shows the number of alarms that actually passed to the phones after implementing the smart alarm solution.

Table. Reduction in Number of Alarms With Smart Alarm Platform

Alarm Type	Device Alarms	Smart Alarms	Reduction
Respiratory rate - low/high	428	212	50%
SpO2 - low	508	61	88%
Heart rate – low/high	349	8	98%
Asystole	15	15	0a
V-tach	13	13	0a
V-fib	2	2	0a

SpO₂: pulse oxygen saturation
V-tach: ventricular tachycardia
V-fib: ventricular fibrillation
^aCritical pass-through alarms from the device

Medical Device Connectivity

In a 2013 survey, 9 of 10 hospitals indicated that they would increase their use of patient monitoring, particularly of capnography and pulse oximetry, if false alarms could be reduced.^[5] A tremendous amount of data is being generated by monitoring technology and needs to be viewed across the entire continuum of patient care.

The Hospital for Special Care (HSC), located in New Britain and Hartford, Connecticut, is nationally recognized for advanced care and rehabilitation in pulmonary care, acquired brain and spinal cord injury, medically complex adults and pediatrics, neuromuscular disorders, and cardiac disease. In addition to reducing or eliminating nonactionable alarms, HSC's goals for alarm management included collecting and distributing real-time data from more than 100 ventilators (each with its own set of alarms), as well as pulse oximeters, for enhanced, continuous patient surveillance, and analyzing objective, comprehensive clinical data after any patient incident to assess response processes and preventive measures.^[6]

The critical nature of ventilators as life-support devices and the number of alarms they produced were major drivers in HSC implementing a solution that would enable HSC's team of RTs to provide continuous surveillance monitoring of patients while reducing nonactionable alarms and enhancing patient safety. The solution allows HSC's team of RTs to provide continuous monitoring of vital patient information and intervene before a situation becomes critical, enhancing patient safety.
Networked laptop and desktop computers, as well as scrolling message bars, were deployed at key locations throughout the pediatric unit, providing RTs with access to data and alarms from all ventilated patients. In addition, ventilator alarms were routed through pagers to the specific RT assigned to each patient. The system also automates processes that were previously done manually, such as manual ventilator checks, which frees up the RT to focus on the patient rather than the ventilator.

HSC's platform achieved real-time surveillance of patients on ventilation support and reduced the number of ventilator alarms by an estimated 80%, helping achieve compliance with The Joint Commission National Patient Safety Goals on alarm management. Clinical alarm management also helped HSC with quality and reporting data. Before implementing the platform, HSC was dependent on individual recollections from the clinical responders after an alarm incident. Today, HSC has a clearer picture of every event. HSC can use the data provided by its platform to sort out the story behind any incident, increasing accuracy on occurrence reporting and resolution. Moreover, the data collected are used by the performance management audit committee, which monitors ventilator management performance and helps identify potential areas of need.

"Alarm management is already a fundamental part of what we do," said Connie Dills, MBA, RRT, RPFT, respiratory practice manager for HSC. "It's made a big difference in our staff's efficiency and effectiveness, and has reduced stress for our patients and their families."

Lessons Learned

Alarm management is constantly changing. It must evolve with the needs of the hospital's patients and clinical staff. The nursing leadership and staff at Wesley continue to make adjustments to the alarm management process and configuration. "Alarm parameters should be part of our nurses' practice, and setting actionable alarms will increase their ability to care for patients," said Free. "Alarm management—and the parameters—have to be based on an individualized approach to your patient. Attention to this process have given us ownership."

Wesley is also looking at how it can use alarm data for predictive analytics, collecting physiologic data from multiple devices to create a holistic picture of a patient's condition. For example, taken individually, a slight drop in heart rate, a gradual rise in end tidal CO₂, or a slight reduction in respiratory rate may not indicate anything critical in a patient's condition. However, data aggregated from those individual parameters could provide the caregiver with a more accurate, predictive picture of the patient's condition—in this case, an emerging risk for respiratory depression.

Addressing clinical alarm hazards in all their forms requires a comprehensive approach, free of the well-known departmental and data silos that hinder patient care and optimal clinical workflows. Technology certainly plays a critical role in alarm reduction and prioritization, but alarm management is a classic example of interdisciplinary leadership, involving clinical, IT, biomedical engineering, and other departments.

References

1. ECRI Institute. Top 10 Technology Hazard for 2016. November 2015. https://www.ecri.org/press/Pages/Dirty_Endoscopes_Top_ECRI_Institutes_2016_Technology_Hazards_List.aspx Accessed January 7, 2016.
2. The Joint Commission. The Joint Commission announces 2014 National Patient Safety Goal. http://www.jointcommission.org/assets/1/18/jcp0713_announce_new_nspg.pdf Accessed January 7, 2016.
3. Wesley Medical Center. Beyond Alarm Management. Bernoulli. October 2015. www.cardiopulmonarycorp.com/wp-content/uploads/2015/10/Bernoulli-Wesley-Case-Study-AM-01-vA-10-15.pdf Accessed January 7, 2016.
4. Zaleski JR. Alarm fatigue? What a nuisance! [Blog post]. October 4, 2014. www.medicinfotech.com/2014/10/mathematical-techniques-mitigating-alarm-fatigue Accessed January 7, 2016.
5. Wong M, Mabuyi A, Gonzalez B. First National Survey of Patient-Controlled Analgesia Practices. March-April 2013. A Promise to Amanda Foundation and the Physician-Patient Alliance for Health & Safety. http://www.premiersafetyinstitute.org/wp-content/uploads/PPAHS-national-survey-patient-controlled-analgesia.pdf Accessed January 7, 2016.
6. Hospital for Special Care. Achieving Clinical Clarity from Ventilator Overload. Bernoulli. October 2015. www.cardiopulmonarycorp.com/wp-content/uploads/2015/10/Bernoulli-HSC-Case-Study-LT-01-vA-10-15.pdf Accessed January 7, 2016.

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.

Compassion fatigue: Are you at risk?

Compassion fatigue: Are you at risk?

Publication Date: January 2016 Vol. 11 No. 1

Author: Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAANP

For many of us, nursing isn’t just what we do; it’s who we are. Most of us became nurses because we care about people and want to make a difference in their lives.
Over time, nurses develop a nursing intuition and a working knowledge of disease and trauma. Our intuition, knowledge, and caring don’t automatically shut off when we leave work. For example, have you ever seen a worrisome mole on a complete stranger? Have you felt concern about a friend’s weight or a neighbor’s smoking habits? Have you ever been in a public place when you heard someone coughing—and wondered at what point you might intervene? These experiences are common among nurses. Yet, inability to shut off our knowledge and caring may leave us feeling emotionally saturated and raise our risk for compassion fatigue.

Ideally, as nurses, we should feel satisfied with our work and derive satisfaction from providing excellent care. Compassion fatigue has been defined as loss of satisfaction that comes from doing one’s job well, or job-related distress that outweighs job satisfaction. Sometimes, merely being exposed to another’s traumatic experience leaves us feeling emotionally distraught. Called secondary traumatic stress, this is a part of compassion fatigue. As our sense of job satisfaction decreases, we may feel more burnout. A reaction to our work environment, burnout can stem from such conditions as short-staffing, long work hours, workplace incivility, and feeling dismissed or invalidated. (See Research on compassion fatigue.)

Who gets compassion fatigue?

Compassion fatigue can happen to any nurse—and it can be unpredictable. We know that nurses who work in oncology or see more patient deaths may be at greater risk. Also, when we form close, caring relationships with patients (especially if we lose our personal boundaries), we may be putting ourselves at higher risk.
Sometimes a particular patient or a patient’s family member may remind us of someone important in our lives. If that patient or family member has died, we may be triggered emotionally. Many nurses I interviewed in my research described being triggered unexpectedly and profoundly by a smell (caring for a child with second- and third-degree burns over 50% of his body), a sound (a mother screaming with grief when told her 3-year-old child had coded and died), or a sight (a dog on the hospital bed with his head across his master’s chest). Nurses who skip breaks, take extra shifts, or come in on their days off out of a sense of duty may be more at risk for compassion fatigue. One of the greatest risks for compassion fatigue comes when nurses forgo their own self-care.

What does compassion fatigue feel like?

In many cases, the first symptoms are emotional. Nurses talk about feeling bored with their work or feeling detached and distant from patients and colleagues. They may realize they’re irritable and short-tempered. They may feel they’ve failed to relieve a patient’s pain or to help a patient get well, losing their sense of pride in being a nurse.
Frequently, nurses with compassion fatigue talk about sleepless nights as they worry about what they forgot to do at work or replay disturbing events in their minds. They may be forgetful at work, in school, or at home. As compassion fatigue progresses, physical symptoms typically arise. Most nurses describe feeling physically and mentally exhausted, and many report headaches or backaches. Frequently, I hear nurses say they feel queasy just driving to work, and those feelings intensify as they walk in the door.
What happens to nurses who don’t deal with compassion fatigue symptoms? First, their work performance changes; for example, they may be at risk for medication errors. Without realizing why, they may start to call in sick more frequently. They may be short-tempered, sarcastic, or rude to colleagues and even to patients or families. They may appear tired and may become more easily startled.
Unfortunately, they may attempt to reduce their emotional saturation through alcohol or drug use. Ultimately, when emotional saturation becomes too intense, some nurses may view leaving the profession as the only means of escape.

Can you have compassion fatigue but still feel compassion?

Absolutely. In my studies, some nurses volunteered that they felt symptoms of compassion fatigue, yet stated, “But I also still feel compassion.” Clearly, a nurse can have symptoms of compassion fatigue while still feeling compassion. If anything, the more compassion a nurse feels, the greater the risk that she or he will experience emotional saturation or compassion fatigue.

Reducing compassion fatigue

What can you do to reduce or even prevent compassion fatigue? Start by being aware of how you feel physically and emotionally. If you realize, for example, that interactions with a specific colleague often feel uncomfortable or unpleasant, reflect on that a bit. Explore what’s beneath that feeling.
Perhaps you feel overlooked, ignored, invalidated, unfairly treated, or criticized—but instead of accepting those feelings and trying to make a change, you compound your feelings with guilt and shame. When you experience negative emotions, pay attention to how you feel physically. By bringing physical and emotional feelings to the surface, you can more efficiently address the underlying cause.

Establish healthy boundaries.

Establishing healthy boundaries is an important way to reduce the risk of compassion fatigue. Many of us face minor boundary issues frequently without really considering the consequences. Examples might include answering a question you feel uncomfortable with, sharing personal information you’d prefer to keep private, doing a favor for someone not because you want to but because you feel you have to, having someone hug or touch you in a way that makes you uncomfortable, and tolerating a rude or pushy person. By slowing your response and doing some self-reflection, you can address these issues with firm but courteous responses.

Make self-care and self-compassion priorities.

Perhaps the most important way to prevent or reduce compassion fatigue is to take care of yourself. As nurses, we work hard and really need our breaks. We need to eat, and to take time for ourselves without being interrupted by alarms, patients, or colleagues. We also need our time off, for our mental and physical well-being.
Before you were a nursing student and nurse, you probably had hobbies or activities you enjoyed. But later, between working long hours and trying to balance your personal and professional lives, those hobbies and activities were probably the first things you let go of. So try to bring them back into your life. Take the dog for a walk every day, listen to music, read a book for pleasure, go for a hike, call a friend—do something for yourself every day.
Self-compassion is important, but it may be hard to attain. Start noticing how you talk to yourself when frustrated, upset, or angry. Do you berate or criticize yourself? Try replacing that talk with kindness, just as you might talk to a loved one.

Practice self-reflection and mindfulness.

Parts of your job may make you feel frustrated because you feel powerless. As burnout and compassion fatigue build, your emotions may grow so strong that they become an overwhelming blur of anger, resentment, frustration, or helplessness.
Thoughtful and quiet self-reflection away from work may help you slowly separate events, interactions, and experiences. By examining each event or interaction, you can become more aware of your triggers (specific people, situations, or events) and address each one individually. Even if you can’t change your work environment, you can find power within by listening to your emotions with kindness and approaching colleagues and others from a wise and centered perspective.
Mindfulness is an important part of self-compassion. Although mindfulness has its roots in Buddhist meditation, it’s also a secular cognitive practice in the form of mindfulness-based stress reduction.
To practice mindfulness, take note of the present and pay attention with kindness and curiosity. You may notice physical or mental feelings of pain, fatigue, or pleasure. If you feel pain, ask yourself what your body or mind is trying to tell you—and address those concerns. By engaging in mindfulness, you can learn to identify which areas of your body react to your emotions. Mindfulness can reduce stress and anxiety and improve your physical and mental well-being. Through self-reflection and mindfulness, you allow yourself to consider events and triggers, learn from them, forgive yourself, and move forward.

Taking action

We can all reduce our risk of compassion fatigue and emotional saturation by reflecting on our triggers, practicing mindfulness, replacing self-criticism with kind self-talk, and engaging in daily self-care activities. Finally, if you’re suffering from sleeplessness, poor self-care, loss of interest, or other symptoms of distress, reach out for help from an employee assistance program or a mental health provider.

Kate Sheppard is a clinical associate professor and the psychiatric–mental health nurse practitioner specialty coordinator at the University of Arizona College of Nursing in Tucson.

Selected references
Hinderer KA, VonRueden KT, Friedmann E, et al. Burnout, compassion fatigue, compassion satisfaction, and secondary traumatic stress in trauma nurses. J Trauma Nurs. 2014;21(4):160-9.
Maiden J, Georges JM, Connelly CD. Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses. Dimens Crit Care Nurs. 2011;30(6):339-45.
Neville K, Cole DA. The relationships among health promotion behaviors, compassion fatigue, burnout, and compassion satisfaction in nurses practicing in a community medical center. J Nurs Adm. 2013;43(6):348-54.
Sheppard K. Compassion fatigue among registered nurses: connecting theory and research. Appl Nurs Res. 2015;28(1):57-9.

From ‘Dr. ColeMAN NURSE,’ an RNL blog, Push that reset button every day!

Why be content with going nowhere?

By Christopher Lance Coleman

The new year provides an opportunity for each of us to reflect on lessons learned in the past 12 months and to reset life goals. I sometimes ponder how long it takes to arrive at the point where we avoid making choices that lead us to the same uncomfortable place. They may involve neglecting to take care of ourselves, failing to set and follow through on goals, or responding poorly to situations where people have hurt us. Whatever the case, the result is the same—an endless walk on a “hamster wheel” that goes nowhere. For me, this past year has brought increased awareness of how quickly time is passing and how easy it is to not make the most of the time we have. I remember my beloved grandmother who firmly believed that taking time for granted is an irreversible mistake. By the time we realize our mistake, we find ourselves on the other side of an event that has disrupted our foundations. Clearly, we cannot stop time or reverse events that have already occurred. Tragic world events of 2015 remind us all that we cannot take life for granted. Time is a gift we should use for good, not for engaging in unproductive or destructive activities. Perhaps you are among those who pledged at the beginning of 2015 to use your talents and gifts to improve lives around you. Or you made a commitment to exercise more or eat better. If you’re like most, the result has been a mixed bag of successes and failures. The point is, we often find ourselves pivoting away from life-improving goals toward places of familiarity that do not move us forward. How do we stay engaged in working toward goals that move us forward? We push the reset button every day! Each day, we resolve to be our best, fully committing ourselves to excellence in all we do, whether it’s exercise, work, developing friendships, or nurturing family relationships. Like you, I have learned many lessons over the years. One is, if I don’t take care of myself, I can’t improve the lives of those around me. As you ponder what you want to accomplish in 2016, remember to invest in yourself so you can be that change agent who positively impacts the lives of others. RNL Christopher Lance Coleman, PhD, MS, MPH, FAAN, is Fagin Term Associate Professor of Nursing and Multicultural Diversity and associate professor of nursing in psychiatry at the University of Pennsylvania (UPenn) School of Nursing. He is senior fellow in the Center for Public Health Initiatives at UPenn and Institute on Aging Fellows in the Family and Community Health Division, Department of Psychiatry, School of Medicine at UPenn. He is also the author of Man Up! A Practical Guide for Men in Nursing, published by the Honor Society of Nursing, Sigma Theta Tau International. Published 1/12/2016, Vol. 42, No. 1