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.

Celebrating Nurses with a Little Bit of Poetry

IF MY STETHOSCOPE COULD TALK

by Kimberley Ensor, MSN, RN

If my stethoscope could talk what would it say about me today?

Would it say that I rushed through my assessment so I could scope out a place at the nurses’ station?

Would it say that I was thorough or going through the motions?

Did I just kill time until break? Lunch? End of my shift?

What would my stethoscope say?

If my stethoscope could talk how would my listening skills be evaluated?

Did I actually hear my patient?  When medications were refused or when the patient expressed they had enough, would I actually listen?

As my stethoscope moved across their body, did I notice a change that needed to be addressed in the plan of care or did I just do business as usual?

Was I listening to my patient and their family members’ concerns or did I just perform lip service as from a script.

What would my stethoscope say?

If my stethoscope could talk would it say that I had my eyes open as I took care of my patient?

Did I completely understand the physician’s orders?  When my patient addressed me did I provide eye contact or was I too busy looking at monitors and equipment?

Did I notice something and speak up as an advocate for my patient or did I leave it for the next shift to handle?

What would my stethoscope say?

If my stethoscope could talk would it say I half-heartedly gave education and explanations about medications?

Would what I speak actually come from a desire to be a help to my patient or just to look good as an authority figure?

Did I form my words to be culturally sensitive or did I disregard my patient’s views, beliefs and preferences?

When I spoke to colleagues or interacted with the multi-disciplinary staff was I a source of encouragement.

Did I include my unit assistants in the plan of care for the patient?  Did I recognize my charge nurse as a valuable resource?  Did I appreciate my unit clerk for their invaluable help?

What would my stethoscope say?

If my stethoscope could talk, would it say that I am an example of patient centered care?

Did my care come from my passion to be a nurse or am I just hanging around for a paycheck?

Did my body language speak I care about you or was I stand offish and couldn’t be bothered?

Was I first to the room when an IV or bed alarm sounded or did I say ‘that’s not my patient and turn a deaf ear and go about my day?

Did I make myself available to my colleagues, to my patient or was I nowhere to be found during busy periods?

Did I take a moment to step outside and let the sun touch my skin, reminding me of why I wanted to be a nurse in the first place?

What would my stethoscope say?

My stethoscope would say,

I bring my joy and positive spirit with me each time I step on the unit.

It would say I strive to listen with open ears and see with both eyes.

It would say I try to be an asset to my unit and an instrument of excellent care.

It would say I utilize evidence based practices when answering patient questions and use simple languages.

It would say I work daily to be an advocate, a hand to hold, and an empathetic ear.

My stethoscope would say I am a nurse and I put my heart into everything I do.

I wear my stethoscope with pride.

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.

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