Tuesday, March 10, 2015

Adequate Nurse Staffing Means Reduced Readmissions

By E’Louise Ondash, RN

I spent a few hours in a local emergency room recently, and with only curtains dividing the cubicles, it was difficult to ignore the doctor–patient conversation happening only a few feet away.

An elderly, debilitated woman had come to the ER via ambulance and her caretaker was explaining to the doctor that the woman had been discharged from the hospital only five days before. The woman wasn’t capable of caring for herself and it had been a couple of days after discharge before her caretaker arrived at the home. Since her discharge, the patient’s condition had deteriorated significantly. The caretaker told the doctor that the patient’s breathing had become more difficult, and there also was some confusion about her multiple medications.

I couldn’t help wondering how this woman got out the hospital door without the assurance that there would be someone to care for her, and without an explicit discharge plan. I also wondered how often this scene is repeated in hospital ERs throughout the country.

Medicare doesn’t like it either.

The Centers for Medicare & Medicaid Services (CMS) spends $15 billion annually on what it calls “preventable readmissions” and is looking at ways to save money while improving patient care. One of the ways is to penalize hospitals for excess readmissions within 30 days after discharge by withholding 1 percent of payments. As of October 2012, CMS says it has saved $280 million with this policy.

Nurses know that sending patients on their way correctly requires a lot of time, attention to detail and planning – things that are nearly impossible if staffing is inadequate. A recent study confirms this.

Researchers at the University of Pennsylvania’s School of Nursing, Institute of Health Economics, and the Wharton School of Business compared more than 1,400 hospitals with high and low staffing levels. They found that higher staffing levels were associated with a better chance of avoiding the penalties associated with excessive readmission rates. The study was published in the October 2014 issue of Health Affairs.

This isn’t a surprise to nurses. We are keenly aware that discharge planning has become more complicated, especially since patients today are older and have more problems – both medical and social. There are many things to consider when trying to coordinate family, caretakers, social workers, visiting nurses, skilled nursing facilities, pharmacies, therapists and more. The bottom line is that it takes adequate staff to do the job right and avoid readmissions.

Does your hospital have adequate nurse staffing to ensure each patient receives proper discharge planning? What measures have you or your co-workers implemented to reduce readmissions? Tell us about it.

Thursday, March 5, 2015

Overwhelmed With Too Much Information? Ask the Public for Help

By E’Louise Ondash, RN

Some in the scientific community have finally said it: There is too much information out there to handle – even for us.

I’ve felt overwhelmed more than once when doing internet searches, but I figured it was just me. Therefore, I didn’t expect this pronouncement to come from seasoned researchers. But scientists at Scripps Research Institute in San Diego, charged with finding cures for rare diseases, finally admitted that they’ve reached the point at which the information has overwhelmed them and that they worry about what they are missing.

According to one of the experts, there are about a million articles on biomedicine alone that are published each year, and no individual can possibly read them all. So the researchers are turning to the public for help. They are asking “citizen scientists” to share their findings with them on certain topics. Having all those extra pairs of eyes, the experts reason, will help in supplementing the scientists’ body of knowledge and sorting the good from the useless.

This got me to thinking: Why couldn’t nurses do the same thing?

Nurses aim to provide the best care for their patients via evidence-based practices. They arrive at their conclusions by researching the literature, talking to other nurses, attending conferences and considering patient preferences. What if they included the public in this process?

This might not work in all areas of care, but certainly could help in some. For instance, those who care for the disabled and those with Alzheimer’s disease have much they might contribute to this body of knowledge. Those who are adept at wilderness medicine or work in situations where improvising is a necessary skill must have a wealth of information to offer the medical community. Surely there are parents who have discovered what works when their kids are ill. And certainly there are those who live and work with immigrant and/or ethnic populations who know the secrets to motivating their clients.

These are just of few of the possible areas in which citizen scientists can add to the body of knowledge that nurses need and want. The bottom line is that members of the public have tested ideas and found them to work, but most of these citizen innovators have not shared them directly with medical professionals.

There are already online sites where interest groups share information with each other, but what about a place where non-medical people can share these ideas directly with the nursing community?

While taking and using advice from people other than medical professionals might seem unthinkable to some, chances are that many younger nurses think it’s the natural order of things. We are living in a new age. This new generation of nurses is used to sharing and to turning to the internet to solve problems, so an online place for citizen scientists to share their knowledge with nurses may not seem crazy at all.

Can you think of instances in which you might have benefitted from the findings or experiences of non-nurses? Tell us about it.

Tuesday, January 13, 2015

The 10 Most Important Issues For Today’s Nurses

By E’Louise Ondash, RN

A few decades ago, there weren’t that many job or career options for nurses.
There was generally plenty of work – finding a job was not difficult – but the choices were limited to positions in hospitals, schools, physician offices, visiting nurses and private duty – or you could apply to the airlines. At one time, it was mandatory that flight attendants (then called stewardesses) also were registered nurses.

Except for the break room, cafeteria or occasional conference, there were few forums where nurses could come together to discuss topics of common interest. With no internet, blogs, websites or social networking, many nurses worked mostly in a vacuum.

Today there are innumerable career options for nurses and multiple forums for discussing topics of interest – everything from the casual blog to scientific journals. Because there are so many nursing specialties and career options, many of these forums are directed at the specialties, but are there concerns that are universal?

At least 10, according to the book “The Power of Ten – 2011-2013: Nurse Leaders Address the Profession’s 10 Most Pressing Issues” (published by the Honor Society of Nursing, Sigma Theta Tau International; paperback; $24.95).

The authors, 30 nurses from a host of countries, identify the following issues as having importance for all nurses, regardless of specialty or interest:
• Evidence-based practice: Harmful or helpful?
• What impact does technology have on nursing?
• Should a bachelor’s degree be the minimum level of education?
• DNP vs. PhD
• Attaining a seat at the policy table
• Coping with growing ethical demands
• Improving workplace culture
• How do nurse leaders affect the profession?
• Closing the workforce age gap
• How to make the profession as diverse as the population

Critics have written that the authors have approached these hot-button topics “with uncommonly provocative prose, often poking at sacred cows or playing the devil's advocate to get readers to challenge conventional, status quo thinking.”
For instance, one author poses questions about the possible compromise of power that nurses may be experiencing as the result of specialization. Another asks whether the importance of credentials has diminished the significance of actual accomplishments and contributions.

Looking at the list, what issues are most important to you?

Would you add any issues to the list or do you think it is complete?

Tell us about it.

'Still Alice’ - Seeing Alzheimer’s From the Inside

By E’Louise Ondash, RN

Here’s a New Year’s resolution: see the film “Still Alice,” starring Julianne Moore as a college professor who faces a diagnosis of early-onset Alzheimer’s disease.

Just writing the phrase “early-onset Alzheimer’s disease“ brings up deep emotions that make me want to stop right here, and the idea of watching a story about a vibrant woman slowly losing her ability to function is not one that I want to entertain. But as a nurse and a person who knows of so many with the disease, I believe I must see it. We need a reminder that Alzheimer’s is not just a disease of the very old, but that it cuts normal life short for so many in their prime years.

The movie trailer also hints that this story illustrates the deep impact Alzheimer’s has on family and loved ones.

From what I’ve read, Moore extensively researched what it’s like to live with Alzheimer’s. The actress attended support groups and spoke with medical experts, researchers and social workers. She underwent testing for the disease, and even spent a lot of time with a woman who developed Alzheimer’s at the age of 46.

“Still Alice” is especially poignant because Moore plays a linguistics professor for whom words are everything, and yet she finds the ability to use them slipping away. “When we were adapting the book, we highlighted language as a kind of index of how far the disease has progressed,” explained co-directors Wash Westmoreland and Richard Glatzer in an interview with the American Film Institute.

The film is based upon a novel of the same name written by neuroscientist Lisa Genova. Critics say that while other productions about Alzheimer’s disease tell the story from the point of view of family and friends, this film develops the story from the victim’s point of view. The camera permits us to see and feel how the disease affects Alice and how her world changes.

“Losing language is an incredibly heartbreaking and frustrating process,” the directors said. “We heard of many different ways that Alzheimer’s patients handle this – ranging from wanting to know everything about the progress of the disease to not even wanting to use the word ‘Alzheimer’s’ themselves.”

While using language as a yardstick is a clear-cut way of measuring and illustrating the devastation of dementia, we must remember that the course of Alzheimer’s is not always so clean and simple. But keeping it simple should help leave a lasting impression on the minds of moviegoers and raise awareness--and that’s a good thing.

The role of Alice’s husband is played by Alec Baldwin; her three grown children are played by Kristen Stewart, Kate Bosworth and Hunter Parrish. “Still Alice” is set for release Jan. 16.

The movie is predicted to be a nominee for Oscars in several categories, but even if it wins no awards, it will hopefully remind us of the need for more Alzheimer’s research and promote greater understanding of those who suffer from the disease.

Monday, November 10, 2014

Our Health Care (Non) System is Chaotic; Can Nurses Help?

By E’Louise Ondash, RN

I’ve been thinking about it a long time, and I just don’t see how our health care nonsystem can survive such as it is for the long run. Many have told us this already, but it’s taken me a while to catch up. The costs are absurdly exorbitant and seem to be increasing, and obtaining the right care—never mind for the right price—can be a task that even health care professionals find difficult and confusing.

I’ve had several recent experiences, or frustrating mishaps, with health care and health insurance—and I’m a nurse who has written fairly extensively about consumer medical matters. If this has been challenging for me, how difficult must it be for those who know little about medicine or how to navigate through the nonsystem?

I use the prefix “non” because there is no system.

Rules vary widely among health plans, and to the consumer, it feels like a free-for-all. Even within the same health plan, the rules are inconsistent, and can be viewed as unfair. Some would even call them unethical.

So many people are finding it so difficult that it’s increased the need for the role of nurse-navigators. These navigators are needed to assist patients in getting the care they need and deciphering the complicated rules and regulations, and of course, it’s an extra expense.

Here’s one problem that seems to be a growing trend: patients are being billed for the services of out-of-network physicians who are working for in-network hospitals. Patients who come to these hospitals for care, as dictated by their insurance plans, are discovering only when the bill comes that the doctors who saw them do not accept their insurance.

This has happened twice this past year to me and my family members, and I’ve read about others having a similar experience. For instance, the New York Times recently ran a story about a man in his mid-30s who needed cervical spine surgery and was billed $117,000 by an assistant surgeon. The patient had no knowledge of this assistant surgeon, had no contact with him, and the surgery was performed in a hospital that is covered by surgical residents, who could have assisted for free.

The patient’s insurance company actually paid the assistant surgeon the full fee, much to the chagrin of the patient. (The surgeon is being investigated for “exorbitant” charges.)

As nurses, I’m not sure what we can do to stop the escalation of health care costs beyond what any consumer would do. I do think nurses should answer honestly any questions that patients have about acquiring care or what their options are if patients have choices.

There is no debate that some of the burden of high costs rests with consumers whose lifestyles promote poor health habits that can become chronic conditions. Nurses should do everything they can to help these patients whose unhealthy lifestyles cost us all. Still, there are many who, like the patient who needed cervical surgery, have no control over their health care expenditures.

Nurses also can report any unethical or illegal actions by individuals, institutions or health insurance companies, and write local and federal legislators about escalating costs and the problems they see within the nonsystem.

Have you experienced or seen instances of over-charging or unethical charges for health care? What did you do? Tell us about it.

Thursday, September 4, 2014

Why Mature Workers Choose Nursing the Second Time Around

By E’Louise Ondash, RN

She talks about how the nursing care she received after a severe trauma was inspirational and never forgotten. He explains that working in home care allows him to know patients much better. She says that her people and organizational skills readily transfer to a nursing career, and he says that his years in a monastery were excellent preparation for helping addicts recover.

These are some of the thoughts of men and women who have chosen to be nurses after other long and successful careers. I read about them – a crime reporter, a judge, a chief of personnel for the New York Fire Department, and a Buddhist monk – in a recent issue of the AARP Bulletin. One of the featured nurses is 50; the other three are in their mid-60s.

They represent, according to the article, the increasing numbers of men and women who are choosing nursing as a second career at a point in their lives when most people are thinking about retirement. Their reasons are both altruistic and financial. Nurses today are compensated much better for their skills than in previous decades, and fast-track programs for those who already have bachelor’s and master’s degrees make the profession attractive to mature and talented people.

Entering a rigorous new career path in one’s fifth or sixth decade is a marked departure from the formerly traditional path to nursing. In decades gone by, most nursing students were young women – teenagers, really – fresh out of high school.

Many veteran nurses tell of how they knew from an even a younger age that they wanted to follow in Florence Nightingale's footsteps. Their motivations were certainly admirable, but at 18 or 19, these young women came to the profession with little life experience.

Second-career nurses have one very big advantage: they bring to their second careers a wealth of experience, knowledge and understanding. They already may have mastered the skills that an 18-year-old won't acquire for years to come. They may have witnessed multiple deaths; endured great loss; chronicled the pain, misery and mistakes of others; learned to work under less-than-ideal situations and with difficult co-workers; mastered balancing family and work; decided the fate of others; made a bad decision or two; learned how to say just the right thing; and even how to be patients themselves.

I have nothing but admiration for those who make the leap into a nursing career when they could easily and deservedly enjoy a life of leisure.

What advice would you give a newly graduated second-career nurse?

At you own graduation, if had known then what you know now, would you have approached your nursing career differently?

Tell us about it.

Monday, August 11, 2014

Paperwork Can Be a Powerful Anti-smoking Tool

By E’Louise Ondash, RN

There are many days when nurses feel like the paperwork never ends, but there is one nurse who makes it her mission to delve into thousands of pages of documents in order to help nurses promote public and individual health.

Ruth Malone, RN, PhD, FAAN, professor and chair in the Department of Social and Behavioral Sciences at the University of California, San Francisco, conducts extensive searches through documents kept by the leading U.S. tobacco companies. She does this to uncover just how they go about promoting smoking and thwarting the efforts of health care professionals to help people quit.

Malone writes that the tobacco industry “actively tries to undo nurses’ efforts at the individual level.”

For instance, the companies know that nurses may encourage patients to quit on New Year’s Day or on their birthdays. “We discovered that tobacco companies sent consumers discount coupons and other promotional offers at these specific times, hoping to weaken people’s resolve to become tobacco-free,” Malone writes.

Malone also points out that, before tobacco companies existed, people became ill from using tobacco, but not to the extent that they have in the last century. Once tobacco companies were created, they aggressively advertised and promoted their products, which were engineered “to increase addictiveness and deep inhalation.”

Somehow, she says, tobacco companies spent the last 100 years trying to convince us that smoking wasn’t harmful, and that it was still acceptable to sell a product that kills half of those who use it.

“Cigarettes would never be allowed on the market if introduced today,” Malone writes. What can nurses do to counteract the tactics of tobacco companies?

Here are some suggestions from Malone:

* Remind patients that they may not want to continue giving money to companies that have lied and deceived users about the deadliness of their products.
* Instruct patients how to recognize industry efforts to discourage them from quitting.
* Remind patients that tobacco companies have purposely engineered their products to contain increasing amounts of addicting substances.
* Tell kids and adolescents that tobacco companies need “replacement smokers” for all those who die each year using tobacco products. The companies do this by promoting tobacco use as cool and edgy.
In the spirit of full disclosure, there is no neutrality on my part when it comes to this subject.

There have been three deaths in my immediate family directly due to tobacco use, and I’ve watched other family members and friends struggle with tobacco addiction. In every case, the smoker started in his/her preteen years because they thought smoking was a “cool” and “mature” thing to do. They all expressed the desire to quit but acknowledged that it was a terribly difficult thing to do.

I’ve also been twice-deposed by a team of lawyers representing a large tobacco company and had my computer and emails “mined” for discussions with my family members about the health hazards of tobacco. Sadly, I’m only one of millions who have lost loved ones or watched them suffer terribly.

I admire Malone and her colleagues for spending hundreds or perhaps even thousands of hours delving into the communications of tobacco companies so that we have a full picture of their tactics to undermine the efforts of nurses and other health care providers.

“Nurses need to learn more about the tobacco industry so that we can all further educate the public,” Malone writes.

Have you had experience in assisting patients, family or friends to quit smoking? What has been the biggest roadblock to success?

Tell us about it.