Monday, March 31, 2014

Why Did You Become a Nurse?

By E’Louise Ondash, RN

Why did you become a nurse?

I’m a little embarrassed to reveal how I landed in the profession. While some people know from the time they can walk that they want to be a nurse, my decision was quick and, well, a bit frivolous.

I was a senior in high school and didn’t have a clue as to what I wanted to do the following year. It was distressing; all of my classmates seemed to have their courses charted. Coming from a large family, I was reluctant to ask my parents to finance a college education when I was directionless.

Then my best friend announced she was going to attend nursing school. This was a complete surprise to me, as she had never mentioned it. The thought of a career in medicine had never appeared on my radar, but I began to think about it. Within a week, I had decided to give it a go – mostly because I couldn’t think of anything else to do.

Actually, I had given nursing a very quick glance just a few weeks before.
Another friend, in her last year of nursing school, came home for the weekend and I listened to her describe her life as a student. There were some hilarious stories, some serious ones and some downright scary ones. After she launched into a description of her first urinary catheterization, I couldn’t run away fast enough.

“Never!” I thought. “I will never be a nurse.”

I can’t say how I got from there to announcing that I would be taking the entrance exam for nursing school. My parents were more than surprised, but they supported me. “Besides,” they said, “it’s something that you can always fall back on.”

And so I have – many times.

By the way, my best friend left nursing school after our first year, but we remained close until her death a few years ago.

I thought about my path to and through nursing recently while reading “The Call of Nursing: Stories from the Front Lines of Health Care” by William B. Patrick. It contains the stories of 23 nurses told in the first person. Each nurse explains how he/she arrived at the profession’s door, and tells readers about his/her career, favorite  patients, most memorable moments and what each has learned through the years.

One of the stories that stood out to me was by Rebecca Sweet, a hospice nurse in Albuquerque.

She writes that she knew from the time she was 6 years old that she wanted to be a nurse, but didn’t realize this goal until she was almost 60. She started a two-year RN program in her 20s, but dropped out. Sweet earned a master’s degree in English, a second bachelor’s in geography, and taught at a university. Then life came apart; her marriage failed, she drank too much and she fell into depression.

Sweet believes that, at this point, God called her to return to nursing. 

She had a plan and stuck to it. Sweet first earned her CNA certificate, worked as a hospice aide, which she loved, then graduated from an LPN program. She worked in a jail, a retirement home and several other places before passing the NCLEX for her RN the day before her 60th birthday.

“That was probably the happiest day of my life,” she writes. Today, she coordinates care for hospice patients.

“When you are with people as they are dying,” Sweet writes, “you develop an honest connection with them that I think is pretty rare in our society… Our society focuses more on wealth, on talent, and on ownership of material possessions than on relationships. But hospice offers opportunity for deeper meaning.”

She adds, “That’s what nursing is all about.”

Why did you become a nurse? Do you think this was the right reason or have you changed your mind?

Tell us about it.

Friday, March 7, 2014

Treating Obese Patients Without Prejudice

By E’Louise Ondash, RN

Are some nurses biased against their obese patients?

I have to admit this is an issue that I personally struggle with at times.

Intellectually I know that there are multiple reasons for being overweight and that every patient is an individual. But I also know the health risks and problems that come with weighing too much, as well as the costs, which are often shared by others who are not obese. I am not proud that I lose patience with people who do not seem to want to lose weight or refuse to do so. I never express this impatience, but it’s there, nonetheless.

Apparently I’m not alone. Studies have shown that many health care providers are biased when it comes to obese patients, but few will admit it. 

A 2003 study in the journal Obesity Research found that more than half of the 620 U.S. doctors surveyed saw obese patients as “awkward, unattractive, ugly and noncompliant,” according to the story. In another study, it was found that nearly 2,300 physicians scored similarly to the general population when associating overweight people with negative words, and there was a strong preference for thin people.

Now consider that nearly 1 in 3 U.S. adults are considered obese, and we can see that any kind of obesity bias can lead to widespread issues with patient care.  Many overweight patients have shared their stories of medical treatment that ranged from less-than-respectful to downright degrading.

I know from talking to nurses in the primary care field and in diabetes education that obese patients are one of their greatest sources of frustration. In many cases, nurses are stumped as to how to care for overweight patients and motivate them to lose pounds and lead a healthier lifestyle.  

The reality is that obesity costs individuals a great deal when it comes to their personal health, as well as their pocketbooks.  It also drains a lot of money from the health care system. So in an era when it’s all about cutting the cost and improving the quality of health care, what can nurses and other health care providers do?

The Obesity Society, which strives to understand the causes, consequences, prevention and treatment of obesity, suggests these strategies:

• Approach patients with sensitivity; consider that they have already had negative experiences with other health care providers, and that they likely have tried to lose weight several times.
• Understand and share that obesity is a complex problem and not a problem solely associated with lack of willpower.
• Look beyond obesity for other causes of patients’ immediate complaints.
• Acknowledge that losing weight is difficult.
• Offer concrete advice.
• Recognize that even small weight losses can have positive health benefits.

There is debate among health care experts as to whether obesity is a disease or not, but there is no debate about this: We won’t accomplish a thing if, even as we assure that all citizens have health care insurance, we cannot assure that they are living healthier lives.    

Thursday, February 20, 2014

Lack of Compliance Costs Money and Lives

By E’Louise Ondash, RN

Uh oh.

Shame on us.

According to new research from Columbia University School of Nursing, we are not doing our job and following the rules when it comes to infection control.

It’s not that nurses don’t know what to do. We all recognize the problem of health care-associated infections and why they occur, but we aren’t following through with proven preventions, like posted checklists. Despite all we know, the study found that 10 percent of hospitals lack these checklists to prevent bloodstream infections, and 25 percent lack checklists to help avoid pneumonia in ventilator patients.

And this may be the worst part: Even when checklists exist, only about half of hospital workers follow them.

This costs lives.  Sources vary on the numbers, but between 5 percent and 10 percent of all hospital patients in this country develop infections annually.

The Centers for Disease Control and Prevention estimates that 1.7 million people contract infections in U.S. hospitals each year (some argue that the number is higher), and that these infections kill an estimated 90,000 to 100,000 patients annually. In the past 20 years, the incidence of healthcare-associated infections  has increased by 36 percent, according to the Institute of Medicine.

Our failings also cost money. Lots of it. Estimates vary widely; they run from $28 billion to $45 billion annually, according to the National Institutes of Health. Even if the lowest estimate is the correct one, it’s a lot of money that could be spent on other health care needs.

According to a press release from the university, the school of nursing’s “comprehensive review” (1,653 ICUs at 975 hospitals) focused on three of the most common preventable infections: central line-associated bloodstream infections (CLABSIs); ventilator-associated pneumonia (VAP); and catheter-associated urinary tract infections (CAUTIs).

The authors suggest two solutions for infection prevention that most hospitals are not yet employing: electronic monitoring systems (only one-third of hospitals have them), and full-time certified clinicians to supervise compliance.

But bedside nurses must play their part, too. We have to wash our hands before procedures and in between patients, and we can’t put off those dressing changes when materials get wet or dirty. Something as simple as keeping patients’ heads elevated can help prevent pneumonia in those who are on ventilators.

If there are reasons that these measures are difficult to do or can’t be done, we need to speak up.

“This study shows we still have a long way to go in compliance with well-established, life-saving and cost-saving measures that we know will lower infection rates,” said lead researcher Patricia Stone, PhD, MPH, RN, FAAN, Centennial Professor of Health Policy at the school of nursing,
The findings of the study were published in the American Journal of Infection Control.

Does your workplace have established protocol or checklists for infection prevention?

If so, do you think there is a high level of compliance?

Tell us about it.

Tuesday, January 14, 2014

Diabetes is Forever: A Life-changing Diagnosis

By E'Louise Ondash, RN

Diabetes type 1 is a monster of a disease.

I imagine that it must be like having a baby that will never grow up and be independent. Once you’ve given birth, you are forever responsible and this obligation will never go away. You’ll never be able to take a vacation from this “eternal” baby, and if you make a mistake, forget about your baby or don’t care for him properly, there is hell to pay.

The overwhelming reality is that diabetes type 1 is forever; there is no turning back.

I’ve known several adults with type 1 diabetes, as well as parents and grandparents of children with type 1. From my experience, they generally they don’t express how the disease has overwhelmingly altered their lives. They are brave. And since they don’t complain, I’ve never had the courage to ask, “How do you do it?” I often wonder how they live daily with diabetes, knowing its long-term consequences. 

As nurses, we work with and care for sick people all the time, so we tend to become somewhat complacent about disease and its effects – physical, mental and social. We sometimes forget that for these individuals, illnesses are a big deal. They can suddenly go from feeling “normal” to  learning that they are “chronically ill” as patients are when they receive a diagnosis of type 1 diabetes. The news impacts them in every facet of their lives―including their physical and emotional health, their daily routines, and even their financial health.

Sometimes nurses need to be reminded just how devastating such news can be, as I was when I read the recently published “Shot: Staying Alive with Diabetes” by Amy F. Ryan. The author, an attorney in Virginia, was diagnosed with type 1 diabetes in 1996 at the age of 29.

Her book follows her unfolding awareness and realization of what having this disease means and how it changes the course of her life and those close to her.

Ryan’s journey gets off to a rocky start because she receives inadequate information and help, but she eventually understands the scope and enormity of what has happened. Her story is an excellent one to pass along to anyone who has been newly diagnosed.

Ryan’s story reminds us that those who meet the daily challenges of diabetes type 1 are courageous, tenacious and deserve a whole lot of credit.

What has been your experience with people/patients who are newly diagnosed with type 1 diabetes?

Friday, December 6, 2013

A Chat with Canadians About Universal Health Care

By E’Louise Ondash, RN

I had the good fortune to visit Beautiful British Columbia recently. They call it that without apology because it is beautiful and has everything -- the ocean, beaches, old-growth forest, mountains, glaciers, rain forests and wine country. In light of the controversy in this country about the Affordable Care Act (ACA or Obamacare), I used the opportunity to talk to random Canadian citizens about their health care, health insurance and mandatory coverage.

Full disclosure: As a nurse, I find it difficult to disagree with the goal of providing health care coverage for every citizen. It seems almost redundant to explain why: no coverage, no care. There are many ways to provide coverage for everyone in this county and that’s where many disagreements arise. No system of coverage will be perfect, but the ACA is, at least, getting us off the starting block. (Okay, the website problems have made it a bit of a rocky start, but we are on the way.)

Canadians have already been down this road. Federal law there requires that every citizen have health care insurance, and each province has the freedom to design its own rules and types of coverage. It came as somewhat of a surprise to learn that Canadians are not insured under one, giant monolithic system, even within the provinces. Canadians acquire health insurance through many avenues.

For instance, one man in his early 50s said that he is covered under his wife’s policy. She is a nurse and the terms of coverage are negotiated between the hospital and the nurses’ union. He was more than satisfied with their health plan, but acknowledged that if you need an elective procedure like a knee replacement, you will wait. A board of physicians decides your place in the queue.

Another man I spoke with was a low-income musician in his late 50s. His premiums were subsidized by taxpayers, and like others who cannot afford to pay premiums, he is enrolled in “the provincial plan.” This is a low-cost, no-frills policy, but he was glad to have it. He is not responsible for any medical charges that he incurs, and he also said that he doesn’t abuse the system. “I only go to the doctor when I have to,” he told me.

A third Canadian with whom I spoke was a single woman in her early 60s who paid for the provincial (cheapest) plan. When it comes time to pay her premiums, she said, “I don’t even think about it. It’s something we have to do and I’m glad to have the coverage.”

One last example: A low-income, single mother of two who lives in a rural area told me that she and her children are enrolled in the subsidized provincial plan. “If it weren’t for that, I don’t know what I’d do,” she said. Nevertheless, she was upset because the nearest hospital is probably going to close because of fiscal problems, and if that happens, she will have to drive at least 30 minutes for care.

All of these Canadians must buy separate policies for drug coverage and services like physical therapy, or pay for them out-of-pocket.

Shortly before we left for British Columbia, I had the bad fortune to spend six hours in outpatient surgery. The bills for this one-quarter-of-a-day in the hospital totaled about $25,000. The hospital billed the insurance company, knowing it would never see full reimbursement. In the end, my insurance paid about $9,000 and thankfully I am not responsible for the difference. With no insurance, I would’ve been responsible for the entire $25,000, and we all know what’s wrong with that logic.

I hope that someday our medical bills reflect reality, but I don’t expect it to happen soon. In the meantime, assuring that everyone has health insurance is a good thing because, in all likelihood you will get sick or injured at some point and incur large bills.

Canadian health care is not perfect, but at least no one worries about declaring bankruptcy because of medical bills.

Do you think nurses should take a stand for or against the ACA, or remain neutral?

Have you had any medical bills that threatened your financial stability?

Tell us what you think.

Wednesday, October 30, 2013

Lack of Resources Makes for Distractions and Non-Compliance

By E’Louise Ondash, RN

Non-compliant patients are the bane of the health care provider’s existence.

My nurse colleagues complain about them all the time.

“Why don’t they just do what they are supposed to do?” they chant. “It would make things so much easier and they would be so much healthier.”

I agree; in a perfect world, all patients would do exactly as they are told and it would be a whole lot easier on us.

I thought about the non-compliance problem after reading a feature written by Ivan Semeniuk, a science reporter for The Globe and Mail in Toronto. He interviewed Eldar Shafir, a professor of psychology and public affairs at Princeton University. Shafir’s most recent work looks at why the poor seem to make bad decisions which usually have negative impacts on their lives.

What Shafir found was that “those who are living on meager incomes are often frantically juggling resources – money, time and health – in a high-stakes game where the consequences of making an error can be severe.”

Such juggling of time and money requires a lot of energy and can be exhausting. It leaves few mental resources for dealing with tough decisions.

“Scarcity focuses our attention to the exclusion of all else,” Shafir explained. “Scarcity…tends to block out competing demands.”

Nurses need to think about this when working with low-income patients, and even with those who may be financially stable but have a scarcity of time and rest because of the demands of job and family. In my experience, though, higher-income patients are generally better educated about their health and the health care system; feel more empowered; and tend to be more compliant than low-income patients. When the chips are down, they at least, unlike the poor, have more resources (people and money) to call into play.

The poor and those who are losing ground in the middle class face many obstacles when it comes to obtaining health care: fewer and more confusing options for insurance coverage; unreliable transportation to appointments; the high cost of medication and good food; lack of support networks; the challenge of caretaking; and potential job loss or underemployment. Financial struggles are a huge distraction, so these hurdles usually appear higher on their priority list than compliance.

But without compliance, health problems only intensify.

If you work with lower-income and/or struggling middle-class populations, have you encountered problems of non-compliance?

If so, have you been able to help solve any of their “distracting” problems?

Tell us about it.

Friday, September 13, 2013

New Directions in Health Care Bring New Jobs for Nurses

By E’Louise Ondash, RN

The more I read and learn about medicine of the future and new ways of delivering health care, the more I feel that the number of jobs for nurses is going to go only one way – up. And although there will be some new jobs in acute care, the largest growth in employment opportunities is likely to be in a wide variety of outpatient arenas, in long-term and chronic care settings, in patients’ homes, and in phone consultations or telemedicine.

Some of these “new” jobs have already appeared.

For instance, every week around the country, large retail stores like Target and drug store chains like Walgreens establish walk-in clinics (also known as convenient care clinics or CCCs) that are staffed by nurse practitioners who diagnose and prescribe. They see adults and children and treat minor ailments like ear infections, pinkeye and urinary tract infections; give immunizations; and perform camp and sports physicals. Some nurses in CCCs have even assumed the responsibility of monitoring and advising patients with chronic diseases.

According to a 2008 survey by Deloitte Center for Health Solutions, this form of primary care is most popular with “millennials” – those who have come of age around 2000 – but an average of 20 percent of all age groups say they would or have received care at a CCC.

The increasing complexity of obtaining health care also has given rise to the patient advocate or “navigator,” both ideal jobs for nurses. The nature of our profession dictates that we be patient advocates, and our education and work experience is our on-the-job training for becoming a navigator. Nurses also are flexible and resourceful – necessary qualities for dealing with third-party payers and increasingly specialized health care providers and institutions.
As more people live longer and with more chronic illnesses, the concept of coordinated or team care becomes important, and nurses make ideal team members. Team care is necessary because it’s impossible for one health care provider to meet the multitude of needs of the long-term chronically ill. Nurses are invaluable components of these health care teams because they understand patients holistically, and serve as patient advocates and communication links between patients and teams.

The public health arena is another area where nurses will find an increasing number of job openings especially in health education.
According to a statement by the American Nurses Association, health care in this country is currently shifting its emphasis from an “illness care system” to one focused on health promotion and disease prevention. This change of direction is occurring because of the “convergence of multiple economic, political, and social factors,” including the Patient Protection and Affordable Care Act (ACA) and other federal legislation focused on preventive health.

The brave new world of medical technology, mobile devices, and a plethora of health care apps afford opportunities for nurses that didn’t exist just a few years ago. New electronic monitoring devices and apps allow providers to personalize care, increase compliance and lower costs by decreasing hospitalizations and emergency room visits. Patients report to nurses and also look to them for guidance. And medical practices that offer email or other online communication with their physicians often have a nurse available for virtual triage or consults.

All of these new jobs require that nurses do their part – obtain higher levels of education that focus on clinical care, as well as participate in continuing education. It’s up to the powers-that-be to recognize the huge and important role that nurses play in pursuing the country’s health care goals – to increase quality of care, promote prevention, and decrease costs – and to provide them with the tools and autonomy they need. 

Do you work at one of the new-generation jobs?

What new nursing specialties do you see on the horizon?

Tell us about it.