Monday, June 30, 2014

Nurse-Midwives and Physicians: The Team Approach Is a Win-Win

By E’Louise Ondash, RN


There was a time when C-sections were reserved for mostly emergency situations, but today, 1 in 3 pregnant women undergo a C-section to deliver their babies--a 60 percent rise since 1996. This, according to a report from the Congress of Obstetricians and Gynecologists.  

The World Health Organization (WHO) recommends that the C-section rate for any nation not exceed 15 percent.

A cesarean section, or C-section, is often the delivery-method-of-choice for the busy woman who works outside the home, a trend that has escalated as more women enter the workforce. But experts say the health of mother and child can be in jeopardy with the unnecessary surgery.

A new San Francisco Bay Area program aims to encourage women to let nature take its course and to reduce the C-section rate in the area by half. It pairs nurse-midwives with physicians, who will always be available for backup in case of an emergency, according to a recent story in the San Jose Mercury News.

"The philosophy is to trust the body's ability to do that process, and we are the overseer," explained Lin Lee, RN, CNM, in an interview with the newspaper. Lee will direct the program, called Bay Area Maternity, with two physicians.

The program is funded by the Lucina Maternity Foundation, so named for the Roman goddess of childbirth who was believed to keep women in labor safe.  Seed money for the foundation totaling $1 million was donated by two big names in Silicon Valley--Anne Wojcicki, CEO of biotech start-up 23andMe, and Angela Buenning Filo, wife of Yahoo co-founder David Filo. Lee was midwife for both women.

The foundation also will fund a second center at Santa Clara County’s Valley Medical Center. The county is located at the southern end of the San Francisco Bay Area and includes Silicon Valley. 

Creating nurse-midwife and physician teams is not new. The idea has been around for some time, and there are practices all over the country; some have up to 10 or 12 midwives and as many doctors working together.

But there are still places where professional rivalries between physicians and these advanced practice nurses exist, as well as divisions in philosophy. These differences can generate tensions and "turf wars," which end up putting patients on the losing side.

It doesn’t have to be that way, according to the American College of Nurse-Midwives, which favors teaming nurse-midwives and doctors.

"Having midwives working in collaboration with physicians, where everyone is using their appropriate skills and the appropriate time, is better for the mother and baby--and is more cost-effective," said Tina Johnson, CNM, MS, director of professional practice and health policy at ACNM, in an interview.

Pairing nurses and physicians in other areas of practice like gerontology and pediatrics can not only be cost effective but result in a higher level of care. The complexity of today’s health care demands a team approach if we are to continue to deliver quality care.

Do you work in an area that pairs nurses and physicians or implements the team care philosophy? Do you think the team approach improves the quality of care?

Tell us about it.

Sunday, June 1, 2014

Can Patients Share Too Much on Social Media?

By E’Louise Ondash, RN

I think social media is wildly out of control.

Don’t get me wrong. I’m all about free speech and the ability of anyone to say whatever they want whenever they want, short of yelling “Fire!” in a crowded theater.

But just because you CAN disseminate an opinion throughout cyberspace doesn’t mean that you SHOULD.  Editorializing via social media can be interesting and informative, but sometimes it can be just TMI (too much information)--especially when it comes to healthcare.

A recent commentary by Bill Saporito in TIME magazine highlights this new reality.

Saporito wrote about sharing the experience of being a long-time cancer patient via blogging and Twitter. He told readers about Lisa Bonchek Adams, a Connecticut mother of three who has breast cancer. In the past seven years, she has posted “more than 165,000 tweets and frequent blog posts” sharing her journey dealing with breast cancer. Her blogs are well written and include details about her care. She even provides links to videos explaining procedures like how patients drain fluid from their lungs at home.

Adams’ latest postings indicate that she has Stage IV cancer (it has metastasized to her bones) and is undergoing chemotherapy. The posts often are quite detailed and contain information that I’d be uncomfortable revealing to thousands of people I don’t know. While reading some of them, it occurred to me how ironic it is that medical professionals must always be on guard about patient privacy, while some of these very patients are sharing intimate details about their illnesses with the whole world.
 
Apparently there are those who are eager to hear about Adams’ life. She has garnered more than 14,000 followers on Twitter, and one of her most recent blogs prompted more than 120 comments. Here, in her words, are the reasons that she writes so extensively about living with cancer:
 “I think understanding the day to day lives of those of us living with (cancer) is a great way to truly become more aware. It’s one of the reasons I spend so much time writing here. I try to bring you the science, the experience, the thoughts of a mother trying to cope with raising a family and managing an (sic) terminal diagnosis… My posts often give my insights into how to raise children who are resilient and can cope with inevitable hardship. The blog also will be a record of my love and devotion to my children.”

Adams’ arguments for putting her life on a stage are credible and defensible (although I still couldn’t do it). Additionally, blogging and tweeting are two-way streets. Adams has received many messages of support and love, which has to be a boost and a comfort for her and her family. However, while thinking about all of this, I suddenly realized that there is another side to patients sharing so much information; some are also blogging and commenting on social media sites about their caregivers.

This could be a good thing if the patient-caregiver relationship is a good one – and most of the time it is. But what if that relationship turns negative?

Knowing that patients could, at any time, blog or tweet about their caregivers is disturbing.  Being afraid of a “negative review” is no motivation for giving good care, but knowing that patients can tell the world if they are unhappy or dissatisfied puts nurses and other medical professionals on the defensive. It’s a strange place to be.  

Have you ever worried that your patients have commented or will comment via blogging, Facebook or Twitter about you or the care they are receiving?

Tell us about it.

Tuesday, May 6, 2014

When School Nurses Are Absent, It's the Kids Who Lose

By E’Louise Ondash, RN

Most of us are well aware that it is National Nurses Week, but did you know that May 7 is National School Nurse Day? 

It seems fitting to recognize these hard-working colleagues who are continually challenged to do more with less. After all, the days when school nurses were limited to applying Band-Aids and ice packs are pretty much gone.

Today’s school nurses are expected to insert urinary catheters; attend to ventilators; suction tracheotomies; and monitor type-1 diabetics, according to a report by researchers at California State University-Sacramento's School of Nursing.

The report found that an increasing number of California students – currently estimated to be 1.4 million -- have chronic and serious health conditions. The majority of them attend public schools which, the report notes “lack efficiency and effectiveness” when it comes to student health care. 

The nurse investigators reached this conclusion by analyzing data from the 2011–2012 school year and interviewing members of the California School Nurses Association, who reported that their duties and responsibilities are increasing while resources and funding are decreasing.  
 
Reading about this report reminded me of the time I shadowed a nurse at a middle school for a day.

I was astounded at the breadth of her job as she darted around the campus, never stopping for lunch or the bathroom in seven hours. She cared for kids who ranged from mildly disabled to severely disabled, doing many of the tasks mentioned above.

In between attending the children, she explained that her co-worker recently had been laid off. No one seemed to understand that you can’t double a nurse’s workload and expect him or her to give the same quality of care.

“For the administrators, it’s all about numbers on paper,” I remember her saying, “I just do the best I can.”

Underfunding health care for California students means that 57 percent of public school districts in the state have no certified nurses on staff, according to the report. This means that students often receive care from unlicensed school staff who aren’t properly trained or monitored.

Should parents and guardians expect schools to provide monitoring and care for all children?  If you have school-aged children, do you feel there is adequate health care in their schools?

Tell us about it.  (And then tell a school nurse that you appreciate what he/she does on a daily basis.)

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?