In hopes of gaining a breadth of experience, many nursing students immediately look for a job in a hospital setting upon graduation. But Judy Liesveld, associate professor at the University of New Mexico’s College of Nursing, encourages students to look past the typical offerings.
Working on a “Nurse Education, Practice, Quality and Retention-Bachelor of Science in Nursing Practicum” grant from the U.S. Department of Health and Human Services, Liesveld runs a program in which selected nursing students from the University of New Mexico and San Juan College in Farmington, New Mexico, work twice a year (once in fall and once in early spring) in the Chinle Indian Health Service Unit on very rural Navajo Nation Reservation located in Arizona, three hours outside of Albuquerque.
In their two-week stay on the reservation, the students are immersed in an unfamiliar culture and with medically underserved people who need healthcare that runs the gamut from minor to serious. Students who want to return are able to complete a senior capstone in the following term.
“When they are in this setting, they are in a very rural setting where it’s a totally different culture with a vulnerable population,” she says. “This totally helps to expand their world view. This is a robust, rich experience for them.”
And the experience the nursing students get in a short time rivals intense clinical experience in a larger healthcare setting, she says. Liesveld should know—her first job out of nursing school was working in Chinle Health Services.
The Chinle clinicals, as they are called, bring students through things like the emergency department, obstetrics, urgent care, and pediatrics. There are primary care clinics that the students participate in as well as home visits where many residents live without running water or heat in extremely remote areas where dirt roads are common. Even in living conditions that aren’t what they are used to, students see the human bonds that make the community what it is, Liesveld says. They see an incredibly close family structure and a culture that is powerful and strong.
The nursing students give presentations on health topics to different populations increasing both their presentation capabilities and their understanding of the different needs throughout a community.
“They presented at a senior center on smokeless tobacco and at a middle school on self esteem,” she says. Through the presentations, the nursing students interacted with people and felt like they were making a difference.
“The hope is students will love the experience and will work in rural settings,” says Liesveld. But if they never work in a rural setting again, she says the experience they gain on the reservation is one they will never forget and one that will offer them skills they will use throughout their careers.
“They learn they have to be resourceful and they learn how to think on their feet,” says Liesveld. Students quickly develop authentic rapport with the residents and they use nursing skills they might not have a chance to use in other places. “It changes their world,” she says.
If they stay in the region, they are likely to work with a Native American population, so the exposure to their culture will give them a cultural competency that can only be gained by such an immersive experience.
And the ripple effect of what they have learned can lead to advocacy as well. Students begin to think about health policy on a national level and what that means for the country as a whole and these rural pockets of communities that exist across the nation.
When there is that kind of meshing of skills, understanding, and cultural exposure, nursing students, wherever they land after graduation, will have a broad view that will benefit them and their patients.
Overdose deaths related to prescription opioids have quadrupled since 1999, according to the Centers for Disease Control and Prevention (CDC), which has made it a topic of dinner conversation as well as a top priority in health care. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients. But it’s also important for nurses to be well aware of steps they can take to help protect themselves from possible legal action stemming from opioids.
Scope of the Problem
The depth and breadth of prescription opioid abuse is far reaching. In 2014, almost 2 million people in the United States abused or were dependent on prescription opioids. At least half of all opioid overdose deaths involve a prescription opioid. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.
The most common drugs associated with prescription opioid overdose deaths are methadone, oxycodone, and hydrocodone. According to the CDC, prescription opioid overdose rates between 1999 and 2014 were highest among people aged 25 to 54.
Role of the Nurse
A 2016 study published in the Journal of the American Medical Association (JAMA) by Baker and colleagues notes that there is significant variability in the amount of opioids prescribed, and the most commonly dispensed opioid was hydrocodone (78%), followed by oxycodone (15.4%). Interestingly, a 2015 study in the American Journal of Preventive Medicine reported a decrease in the rate of prescribing opioids (-5.7%), perhaps indicating that more health care providers are becoming aware of the addiction issue.
Nurses are well positioned to detect patients with substance misuse. One simple screening tool is the National Institute on Drug Abuse (NIDA) Quick Screen. If a substance use disorder is suspected, the nurse should remain nonjudgmental while referring patients for further evaluation and treatment, so they receive the care they need.
One model for follow-up of possible substance abuse is Screening, Brief Intervention, and Referral to Treatment (SBIRT) from the Substance Abuse and Mental Health Services Administration. SBIRT is a method for ensuring that people with substance use disorders and those at risk for developing these disorders receive the help they need.
Assess the Patient Carefully
Pain medication should be matched to the individual patient’s needs. This begins with a detailed history, including a list of currently prescribed and past medications. Ask about a history of substance use or substance use disorders in the patient and the patient’s family. If opioids are being considered, assess the patient’s psychiatric status.
A physical exam should also be completed, keeping in mind signs and symptoms of possible substance abuse such as advanced periodontitis, traumatic lesions, and poor oral hygiene. If patients are already being managed for chronic pain, the nurse should consult with the appropriate provider.
Apply Evidence-Based Pain Management
To provide optimal patient care, as well as to protect themselves from legal action, nurses should practice evidence-based pain management. That includes considering non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, as first-line pain medication.
NSAIDs have been shown to be at least as effective (if not more so) than opioids for managing pain, particularly in combination with acetaminophen. Before patients begin taking NSAIDs, verify that they are not taking other anticoagulants, including aspirin, and check for hepatic or renal impairment.
Nurses should complete continuing education courses in pain management, and document they did so, which can provide evidence of their knowledge in event of legal action.
Nurses have an opportunity to educate patients about the role of pain medication in their care. This education should include pain medication options and the reasons why non-opioids are preferred.
Verbal and written instructions after the procedure need to contain name of drug, dosage, adverse effects, how long the drug should be taken, and how to store it. Results from a 2016 survey published in JAMA Internal Medicine found that more than half (61%) of those no long taking opioid medication keep it for future use, so patients need to be told to dispose of unused drugs and how to do so. Patients can search for places that collect controlled substance drugs through the Drug Enforcement Administration at www.deadiversion.usdoj.gov.
The same survey found that about 20% shared the opioid with another person, so education material should mention not to do this. Nurses should also discuss the perils of driving or undertaking complex tasks while taking an opioid. Document in the patient’s health record that this information was provided and the patient acknowledged receipt and understanding. An office visit can also provide the opportunity for nurses to address opioid abuse on a larger scale.
Refer Patients as Indicated
Nurses need to closely monitor patient use of controlled drugs to avoid overdependence or potential addiction, and refer chronic pain patients to a pain management center or specialist. Be sure to document the referral in the patient’s health record. Nurses also should consider referral for patients who seek opioids beyond when they are likely to be needed.
Pain Medications Cautions
Below are some considerations for the use of pain medication in patients:
- Use non-steroidal anti-inflammatory drugs (NSAIDs) as the first option. Consider a selective NSAID to avoid increased risk of bleeding. Know that using acetaminophen in combination with NSAID may have a synergistic effect in pain relief. (Do not exceed 3,000 mg/day in adults.)
- Provide patient education.
- Document patient communications, education, and referrals in the health record.
Protecting Patients and Nurses
Nurses who assess and monitor patients for treatment of pain are encouraged to be mindful of and have respect for their inherent abuse potential. Doing so helps protect patients from harm and nurses from potential liability.
Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.
This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 650,000 nurses since 1976. INS endorses the individual professional liability insurance policy administered through NSO and underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500.
A new study on paid family and medical leave by the Pew Research Center shows American workers want access to paid time off for family or medical events. But even if they have access, many workers don’t a;ways feel secure to take the leave.
On the whole, Americans appreciate paid time off after a child is born or is adopted, if they have a medical issue that requires time off, or if they need time to care for an ill family member. But many study respondents disagreed on who should absorb the cost and just how reliable the system was.
Despite many calls to elevate the United States’ paid leave policy to that of other countries, respondents were divided over if the government should mandate access to paid leave. Only 51 percent thought that the government should mandate time off in those circumstances while the remaining 48 percent thought employers should be able to decide whether or not to offer employees that benefit.
In general, most people believe that paid family and medical leave is beneficial, with 82 percent believing the benefit should be available to new moms and 69 percent believing new dads should have the option. And if the government mandates the policy, 73 percent said they believed it should be available to both mothers and fathers (only 26 percent thought it should be for new moms only).
The United States stacks up woefully behind many other countries in offering paid parental leave to workers who have just had a child or adopted a child. According to another Pew study, the United States ranks last out of 41 countries in paid leave policy.
But industries are taking notice. Many respondents, while acknowledging that paid family leave was more beneficial to families and individuals than to businesses, said they thought offering the benefit would attract more quality works and also help retain them.
No matter where you work, according to a Henry J. Kaiser Family Foundation study, larger firms tend to offer more access to paid family and medical leave. But the Pew study asserts that many workers don’t take the time even if they are able to for reasons ranging from fear of losing their job to overwhelming job demands.
Those in lower income brackets were much less likely to receive or take paid family leave. Nearly one-third of those with household incomes of $30,000 or less said they were unable to take leave within the past two years although they wanted to, while only 14 percent of those with households of income above that level reported the same.
The study reveals that American workers, while they might support this leave, aren’t always able to, don’t always have access to it, or feel there might be career repercussions if they take the leave.
What do you think about paid family or medical leave for American workers?
Hospitals have dedicated tremendous resources to create an integrated clinical environment that results in better patient care and outcomes, reduces readmissions, and increases hospital utilization, in hopes of reducing the overall cost of health care.
Unfortunately, health IT projects either fall short of business and clinical goals or are completely abandoned at an astonishing rate. Studies vary, but failure-rate estimates range from 35% to 75%.
Overrun budgets and functionality problems are often cited as the primary culprits of doomed implementations. However, the failure to include direct-care clinical staff—including nurses—in the evaluation, implementation, and training of new technology should not be overlooked.
It’s easy to consider a new hardware or software solution and imagine its transformative potential. Health care trade shows brim with thousands of devices, enterprise systems, and software applications marketed as painless solutions for any clinical challenge facing a hospital or care unit. But a poorly implemented system that did not evaluate the impact to the clinical workflow can just as easily exacerbate inefficiencies and reduce the overall quality of patient care.
Equipment that doesn’t work properly or causes needless redundancies in daily tasks is enormously frustrating. The lack of sufficient training and vendor support increases the chances of mistakes or encourages direct-care staff to either work around a new solution or outright revolt at go-live.
A Shared Vision
Many of the doomsday scenarios associated with technology adoption and implementation can be mitigated with adequate planning, training, and collaboration. By listening to, engaging with, and educating front-line staff, hospitals can dramatically increase their chances of success with technology adoption.
For example, consider medical devices with alarm capabilities. Nursing staff are charged with the proper setting of the alarms and the prompt response when any of the devices send an alert. As the presence of alarm equipment continues to grow, nurses find their workflow and ability to engage with patients disrupted as they chase down hundreds of (often non-actionable) alarms. Without proper education and implementation of alarm devices, it’s all too easy to imagine clinical staff arbitrarily adjusting alarm settings—or even turning them off entirely.
Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made—at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end-users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.
Environmental and Workflow Assessments
Hospitals each have their own unique characteristics, culture, and needs. Identifying and documenting those attributes are critical to any successful health IT implementation. To achieve measurable progress in health IT adoption requires that hospitals identify and support internal champions in all relevant departments.
For hospitals and health systems, especially those that are breaking ground on new technology integration, the first step is an assessment of needs and potential impact to workflow. The formidable task list that comes with any technology implementation requires the input and expertise of a project team, which ideally, should be comprised of leadership from myriad stakeholders, including IT networking, facilities, patient safety experts, educators, informatics nurses, laboratory staff, pharmacists, electrical engineers, biomedical engineers, quality improvement specialists, vendors, and direct-care clinical staff . This team will be responsible for every phase of deployment—evaluation, acquisition, rollout, implementation, and transition to live operations. They will determine the hospital’s objectives and integration goals, as well as vendor evaluations, business and clinical requirements, risk management concerns, patient safety goals, and costs.
The project team will also be charged with identifying the departments or units the integration will first impact. Big bang, enterprise integrations are not unprecedented, but a phased roll out in a single department or set of departments with the highest acuity, such as the surgical suite, allows more time and space for assessments, lessons learned, and best practices, which can be applied as the integration spreads to the rest of the enterprise.
One aspect of integration that is often overlooked is the value of clinical workflow, which can vary among hospitals and individual units. Workflow should not be minimized because it will largely define how data is collected, how it is displayed, and what is displayed. Hospitals should incorporate clinical workflow as quickly and as early as possible in the process.
Designating a nursing champion—or super-user—at the outset allows other nurses and direct-care clinical staff to receive information, training, and support during all phases of adoption. These super-users would be working closely with the interdisciplinary team assembled for the implementation project.
Health IT implementations can be expensive, complex, involve dozens of stakeholders, and are often up against aggressive deadlines. Technology can also be disruptive and bring new uncertainties to the entire organization. However, the quality of the relationship with the vendor supplying the solution can make a huge difference.
Any hospital or health system has business and clinical needs and cultures that make them different from other organizations. A partner with deep knowledge of the unique aspects of your organization not only will help you avoid common mistakes, but also keep you focused on detailed integration points and workflows.
A partner that knows your organization also helps other vendors get acclimated, provides guidance, and ensures everyone stays accountable. A positive and fruitful collaboration allows hospitals to establish benchmarks and ensure that configurations and interoperability are optimized and seamless.
An excellent vendor also acts as a consultant and educator, making hospital staff comfortable with new technology and uncovering strategies for optimizing workflow. The importance of evaluating the vendor as much as the product they are delivering cannot be stressed enough. Vendors that lack expertise, training capabilities and clear steps toward go-live and beyond are critical red flags.
Can the vendor explain their process? Can they share metrics? Do they offer continued training and support after the implementation is complete? Answers to these questions will give your project team keen insights into the potential challenges of a technology implementation.
If your vendor supplies references, ask their customers specifically about their specific challenges and the vendor resolved them. Setbacks are a natural part of any implementation, but the true difference maker is determining the level of support and collaboration provided to overcome it.
A team approach to health IT doesn’t guarantee that technology adoption and implementation will be a success—but it will significantly increase its chances of sustainability. Today’s nurses have neither the desire nor the option to be passive consumers of health care technology. The seamless integration of technology requires that direct-care clinical staff have influence in the design and testing of equipment and applications. Involving end-users in the early stages of system analysis and design specifications can lead to better adoption of new technology, as well as identifying how current technology can be adapted for greater user acceptance.
Nurses make up the largest segment of the health care workforce in the United States. There are more than 3.1 million registered nurses nationwide and about 85% of these RNs are employed in nursing. Yet, some states are predicted to experience a nursing shortage during the next decade as the result of changes in health care policy, an aging population, and nursing schools struggling to make space for more students.
A report from the Georgetown University Center on Education and the Workforce titled, “Nursing: Supply and Demand Through 2020,” predicts a shortage of approximately 193,000 professional nurses by 2020 based on the age of the current nursing workforce, the size of graduating nursing classes, and nurses’ career decisions. A 2012 report titled, “United States Registered Nurse Workforce Report Card and Shortage Forecast,” concurs. It predicts a nursing shortage by 2030 throughout the country, especially in the West and South, because of projected changes in population.
[email protected] online FNP program created the graphic below based on data from a 2014 HRSA report, “The Future of the Nursing Workforce: National- and State-Level Projections, 2012-2025,” to show which states will have a shortage of nurses and which will have a surplus.
To learn more about the nursing landscape, visit [email protected] website to read the original blog post.
Ever wonder why you might think about earning a certification? In honor of Certified Nurses Day, we asked Karen S. Kesten, DNP, RN, APRN, CCRN-K, CCNS, CNE, associate professor at George Washington University School of Nursing in Washington, DC, as well as the chair of the American Association of Critical-Care Nurses Certification Corporation board of directors her opinion on the matter.
What follows is an edited version of our Q&A.
How long have you been in the nursing field and what certifications do you hold?
I have been a nurse since 1974. My first certification was in 1980 as a CCRN. Now I hold these certifications:
- CCNS (Acute/Critical Care Clinical Nurse Specialist, Adult) – 2004 to present
- CCRN-K (Acute/Critical Care Knowledge Professional, Adult) – 2015 to present
- CNE (Certified Nurse Educator) – 2012 to 2017
Why do you think it’s important for nurses to get certifications? What does it do for them? For the field?
It is so important that nurses become certified because it demonstrates that they have the knowledge, skills, and attitudes to provide high quality care to patients and their families. A certified nurse is a lifelong learner who cares about the quality of care they deliver. Nurses who are certified feel more confident that the care they are delivering is based on the most up-to-date evidence. Certified nurses are proud of their achievement and are role models for nurses and other health care professionals. Certification shows that nursing is a profession that cares about safety, quality, and excellence of health care delivery.
What’s the difference between board certification and being certified in a specialty?
Board certification means that certification is required for licensure, such as in the example of advanced practice registered nurses (APRN). In this case, a board of experts at the state level in the field of nursing examines the credentials and qualifications of a nurse in order to determine eligibility for licensure. Certification in a specialty indicates that a nurse has acquired additional knowledge, skills, and expertise in a specialty area of nursing such as acute and critical care.
How do you know you’re ready to become certified?
Preparation for certification requires that the nurse meet the eligibility requirements such as gaining experience in providing direct care for a required period of time for the relevant patient population. It also involves setting certification as a specific target goal, studying, and acquiring the knowledge needed to pass the certification exam. There are courses, study materials, and practice tests that can help a nurse to prepare for certification. Progress on self-assessment practice exams can help nurses know if they are ready to sit for the exam to become certified.
Do you need additional education to become certified? What are the requirements to apply?
To become certified as a critical care nurse (CCRN) or progressive care nurse (PCCN), a nurse does not need additional formal education. However, it is helpful to prepare—and there are prep courses, study materials, and practice tests that can help prepare for certification. You do need additional education at the master’s or doctoral level in order to become certified as an advanced practice registered nurse (APRN), such as an adult-gerontology acute care nurse practitioner (ACNPC-AG) or adult-gerontology clinical nurse specialist (ACCNS-AG).
What does it take to maintain your certification?
Nurses who maintain their certifications must meet renewal criteria that involve continuing education and, in some cases, continuing practice experience and an unencumbered nursing license.
What have been the greatest rewards for you that happened because you earned your certification?
Earning my certification makes me feel proud of the care that I deliver; it makes me feel more confident and self-assured. Certification enables me to feel more satisfied with my career—that I’ve provided competent care. It’s also opened doors to opportunities that I might not have had otherwise. Certification has introduced me to knowledgeable compassionate nurse mentors and to a community of nurses who care about delivering excellent care to acutely and critically ill patients and their families.
What would you say to someone considering becoming certified in any field?
I would encourage anyone to seek certification in their field to demonstrate they have the competence, knowledge, and skills to excel in their profession.