According to the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. Type 2 diabetes is one of the most commonly occurring chronic diseases, which affects about 90-95% of those diagnosed. According to a 2018 study published in Health and Quality of Life Outcomes, there were over 415 million adults between 20-79 years living with diabetes globally. The American Diabetes Association estimates that over $327 billion is the annual cost of diabetes care in the United States alone.
A serious complication of diabetes is hypoglycemia, a blood sugar level less than 70 mg/dL. Hypoglycemia comes on suddenly and patients display symptoms such as profuse sweating, tremors, irritability, altered mental status, loss of consciousness, among others. Hypoglycemia has several adverse effects including cardiac arrhythmias, seizures, and can be fatal in severe cases. The fear of inadvertent hypoglycemia is among the biggest barriers patients face while working towards glycemic control. Hence, one may conclude that frequent hypoglycemic incidents are disruptive to the normal life, and may result in injury, increased medical costs, loss of wages, and the need for constant monitoring by another person.
Real-time continuous glucose monitoring (CGM) may provide an ideal solution for individuals with a high risk of hypoglycemia. CGM measures glucose levels continuously via a transdermal glucose sensor and sends data to one or more monitoring devices. It is configurable to alert the user and/or designated provider when blood glucose levels are too high or too low. In a 2017 study, David Rodbard, MD, demonstrated that the use of CGMs resulted in significant reduction of hypoglycemia risk and improved patients’ quality of life. Since the invention and subsequent improvement of the quality of monitoring and reporting, CGM systems have become very reliable tools for real-time monitoring of blood glucose and prevention of dangerous hypoglycemia. CGM systems also help reduce health care costs and improve quality of life and productivity of patients.
A Brief Introduction to CGM Systems
The first CGM system hit the market in 1999. Early CGM systems were bogged down with issues related to accuracy, delayed transmission, and patient teaching. Rapid advancements in technology have influenced development of highly accurate, versatile, and user-friendly CGM machines. In 2015, the American Association of Clinical Endocrinologists and American College of Endocrinology included CGM systems into their clinical practice guidelines. Three medical device manufacturers—Abbott Laboratories, Medtronic, and Dexcom Inc.—have emerged as leaders in today’s CGM marketplace at a global level.
CGM’s Role in Preventing Hypoglycemia and Improving Quality of Life
The main idea behind the introduction of CGM systems was to achieve enhanced real-time blood glucose monitoring of diabetic patients and prevention of abnormal glycemic highs and/or lows and its accompanying complications. Multiple studies have successfully demonstrated that diabetic patients are at a risk of undetected hypoglycemia. According to a 2017 study published in Diabetes Technology & Therapeutics, 22% of sudden unexpected deaths in persons under 40 with type 1 diabetes were due to hypoglycemia. The study concluded that using CGM systems helped reduce hypoglycemia and improve glucose control.
Inadequate glycemic control is associated with complications that lead to reduced quality of life, work absenteeism, increased hospitalization, among others. Fear of hypoglycemia and its associated costs may discourage patients from adhering to a treatment plan formulated by their primary care provider. And yet, the Diabetes Technology & Therapeutics study estimated an annual savings of $936-$1,346 per person in hypoglycemia prevention with the use of CGM systems.
A recent randomized controlled trial published in The Journal of Clinical Endocrinology & Metabolism found that type 1 diabetics on real-time CGM systems demonstrated a marked improvement in glycemic control and enhanced of quality of life in the form of reduced incidences of hospitalization, work absenteeism, and lesser fear of hypoglycemia.
Furthermore, recent advances in wireless and data-enabled cellphones have enabled medical technology corporations to improve the functionality and accuracy of CGM systems. Modern CGM systems can now send information to the patient and designated caregivers when the blood glucose levels are too high or too low. CGM systems help promote safety and efficacy of glycemic control for both type 1 and type 2 diabetics and reduces the risk of hypoglycemia significantly.
The benefits of CGM systems are yet to be completely utilized by health care providers and patients due to lack of awareness, suspicion about the safety, efficacy, and cost of these systems. Using CGM systems may lead to long-term financial savings and improved quality of life for patients. It is up to primary care providers to educate patients and families to benefit from available technologies and improve their health.
As a gay man, Austin Nation, PhD, RN, PHN, understands the health care barriers faced by many lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. As a nurse and educator, he’s working to increase awareness and address the health disparities that continue to exist in the LGBTQ community.
An assistant professor of nursing at California State University, Fullerton (CSUF), Nation lived through the 1980s AIDS crisis, and has worked with many patients in the HIV/AIDS community. While he acknowledges an HIV diagnosis is no longer a death sentence thanks to increased funding and better treatment, Nation has also seen how young gay black and Latino men continue to be disproportionately affected by HIV/AIDS. The Centers for Disease Control and Prevention (CDC) report that 1 in 2 black men and 1 in 4 Latino men will be diagnosed with HIV during their lifetime.
“We’re not reaching all of the people we need to reach,” Nation says. “In order to get to zero new HIV infections, we need to figure out how to engage these populations.”
While treatments have transformed HIV into a chronic but manageable illness, many people are not aware of how prevention efforts that use antiretroviral treatment, and pre-exposure prophylaxis (PReP), an HIV-medication that when taken consistently, can lower the risk of getting infected by more than 90%. Despite being widely available, the CDC notes that while two-thirds of the people who could benefit from PrEP are black or Latino, they account for the smallest amount of prescriptions to date.
To that end, Nation has worked to address the tenuous relationship many people of color and members of the LGBTQ community have with the health care system. Statistics from the Kaiser Family Foundation show that LGBTQ patients often face challenges and barriers in accessing health services including stigma, discrimination, the provision of substandard care, and outright denial of care because of their sexual orientation or gender identity.
“I’ve led LGBTQ cultural competency trainings to teach nurses and nursing students how to provide inclusive services and care for LGBTQ patients,” Nation says. “By knowing whether a patient is gay, lesbian, transgender, straight, or bisexual, and how to best communicate, nurses can identify potential health disparities and care for their patients more effectively.”
On the CSUF campus, Nation has also been a part of the university’s Faculty Noon Time Talks, discussing health care disparities within the African American community. In addition, he is working with faith leaders to adopt a more inclusive environment for LGBTQ individuals who may be reluctant to come out and subsequently don’t receive HIV testing or prevention counseling.
“I also teach a public health course at CSUF where we discuss vulnerable patient populations including the LGBTQ community,” Nation says. “I try to integrate real-world experiences into the course curriculum.”
Nation believes that all nurses can help to achieve diversity and meaningful inclusion, whether they are part of the LGBTQ community or an ally. “Have a voice and be an advocate,” he says. “One person can make a difference.”
Navigating Cancer Care with LGBTQ Patients
As an oncology nurse and LGBTQ advocate, Megan Ober, RN, MS, BSN, OCN, a case manager at the Palliative Care Clinic at the UC Davis Comprehensive Cancer Center in Davis, California, often finds herself bridging the gap between providers and LGBTQ patients.
“Many health care providers work under the assumption that all patients are heterosexual,” says Ober. “It’s important to create a welcoming environment for LGBTQ patients in order to educate them on cancer risk factors and ensure they receive preventative screenings.”
Ober says LGBTQ patients often feel they are being judged and are reluctant to share their sexual orientation or gender identity out of fear of being turned away from health care providers. This distrust can lead to some LGBTQ not seeing a doctor regularly for check-ups and screenings, delaying diagnoses and not receiving information on treatments that might help either their physical or emotional health.
Over the years, Ober has given presentations to staff on LGBTQ disparities in cancer care and risk factors that lead to greater cancer incidence and later-stage diagnoses. These disparities include:
- Anal cancer. It’s rare in the general population, but 34 times more prevalent in gay men.
- Cancer screenings. According to the American Cancer Society, lesbians and bisexual women get less routine health screenings than other women including breast, colon, and cervical cancer screening tests.
- Breast cancer. Lesbian women have higher rates for breast cancer including nulliparity (never having given birth), alcohol and tobacco use, and obesity.
- Cervical cancer in transgender men. Since most transgender men retain their cervixes, they are also at risk of cervical cancer but are much less likely to obtain Pap smears and regular cancer screenings.
Resources to Bring Better Care to LGBTQ Patients
For nurses who want to educate themselves further about LGBTQ health topics, the following information can help:
- Lavender Health has held virtual coffee hours for nurses working with LGBTQ populations. Their website offers events, resources, and more to help both providers and members of the LGBTQ community promote wellness.
- The National Resource Center on LGBT Aging offers cultural competency training for staff at nursing homes and others who care for seniors. They also have downloadable guides on creating an inclusive environment for LGBTQ seniors.
- The U.S. Department of Health and Human Services offers a free downloadable guide, Top Health Issues for LGBT Populations Information and Resource Kit.
- On a national level, organizations such as the National Alliance of State and Territorial AIDS Directors (NASTAD) has partnered with the Health Resources and Services Administration’s HIV/AIDS Bureau (HRSA-HAB) to launch HisHealth.org, a free online tool that helps nurses and other medical staff learn how to engage HIV-positive young black LGBTQ patients and young black transgender patients by taking a whole-health approach to wellness.
- Organizations such as the Human Rights Campaign and their Healthcare Equality Index can help with training and best practices such as making changes to electronic medical records and hospital paperwork to incorporate sexual orientation and gender identity and criteria that hospitals can use to become Equality Leaders.
- The National LGBT Health Education Center has a free downloadable guide, “Providing Inclusive Services and Care for LGBT People: A Guide for Health Care Staff.” The guide discusses using preferred pronouns and preferred names, understanding diversity and fluidity of expression, making LGBTQ patients feel comfortable, common health issues among the LGBTQ population, and much more.
While it can be difficult for nurses to begin a conversation about a patient’s sexuality and sexual health, Ober says it’s important for providers to ask in order to care appropriately for LGBTQ patients.
“Rather than assuming all patients are heterosexual, I recommend nurses introduce themselves and ask a patient how they would like to be addressed, their chosen name, and their preferred pronoun,” Ober says. “There’s a great training video on YouTube called ‘To Treat Me You Have to Know Who I Am’ that showcases a mandatory employee training program that was launched for health care providers in New York.”
Ober also cautions against assuming the personal info on a patient’s chart is correct. Often, people who are transgender may identify as a different gender than the one listed on their electronic medical record.
“Rather than greeting a patient with a title such as Mr. or Ms., I encourage nurses to ask patients how they would like to be addressed,” Ober says. “Shifting from a heteronormative model to one that is more inclusive acknowledges that patients and families aren’t all the same. The woman sitting by your patient’s bedside may be her wife, rather than her sister or friend.”
Nurses Lead the Way with Change
Caitlin Stover, PhD, RN, chair of the national Gay and Lesbian Medical Association (GLMA) Nursing group says both nurses who identify as LGBTQ and those who are allies can work to create an inclusive environment for LGBTQ patients.
“I’m an ally that joined GLMA and now I’m chair of the organization,” Stover says. “There are so many resources out there that can help nurses become better patient advocates and deliver culturally sensitive care to LGBTQ patients.”
Stover says while many nurses across the country are doing great work in creating an inclusive environment in their hospital units and establishing trust and rapport with LGBTQ patients, there are still many nurses and providers who have not received education on LGBTQ health issues.
“It’s important for nurses to strip themselves of preconceived notions, judgements, and assumptions,” Stover says. “Our job is to provide the best possible care, regardless of a patient’s age, ethnicity, gender, or sexual orientation.”
She cites the Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients downloadable PDF created by GLMA as a good starting point for nurses who are seeking advice on how to communicate with LGBTQ patients using sensitive language. The document also includes guidelines for forms, patient-provider discussions, and more.
Continued Education Leads to Better Health Outcomes
Learning about LGBTQ patients isn’t a topic that is always covered in nursing school. A national survey conducted in 2014 found that 43% of nursing faculty who taught in bachelor’s degree programs across the United States reported limited or somewhat limited knowledge of LGBTQ health. Between 23-63% of respondents indicated either never or seldom teaching LGBTQ health, although a majority of respondents felt LGBTQ health should be integrated into the nursing courses they teach.
In 2013, Columbia University Medical Center in New York launched the LGBT Health Initiative, based at the Division of Gender, Sexuality, and Health at the New York State Psychiatric Institute and the Columbia University Department of Psychiatry in association with the Columbia University School of Nursing. The goal of the initiative is to bring together research, clinical care, education, and policy to fight stigma and improve the health of the LGBTQ community.
Janejira J. Chaiyasit, DNP, AGNP-C, an assistant professor at Columbia University School of Nursing and a nurse practitioner at ColumbiaDoctors Primary Care Nurse Practitioner Group, says students at the Columbia School of Nursing receive training on LGBTQ cultural competency as part of their studies.
“We highlight the unique health disparities, risks, and health needs of the LGBTQ patient population to increase awareness, so that our future providers and care takers will offer appropriate care and ask the right questions,” Chaiyasit says.
At Columbia, Chaiyasit has seen how promoting inclusivity and culturally competent care has led to better patient care and health outcomes, and how training staff and students adequately prepares them to care for LGBTQ patients.
“If a patient doesn’t feel comfortable, how can we expect them to divulge their personal health concerns to us, and, in return, enable us to give them the best care?” Chaiyasit says.
And despite progress that has been made nationally, Chaiyasit says there’s a continued need for nurses to learn about the differing health needs of the LGBTQ community.
“LGBTQ patients have a lot of health disparities and changing the preconceptions of health care delivery for this community is a way to close the gaps—reducing ER visits, reducing the time to access health care for medical and psychosocial issues, and increasing the rate of preventative health screenings,” Chaiyasit says. “For example, many health care professionals are unaware of the health needs for trans patients, specifically these patients’ needs for transition-specific hormone therapy care and maintenance to achieve the desired gender features. This is really important as it impacts physical and mental health as a whole.”
In addition to nurses becoming more aware of gender-neutral language, many hospitals have begun customizing their patient intake forms to ensure they are LGBTQ-inclusive.
“At Columbia, we piloted intake form questions, which were ultimately implemented across the Nurse Practice Group, that allow patients to select, or even write in, their preferred gender identity pronouns,” Chaiyasit says. “A complete patient history helps to ensure each patient gets the care and services they need.”
“Diabetes is so prevalent in our society, and I feel as though I have a better understanding of my own patients with diabetes,” says Heather Weber, an RN who works in a busy outpatient GI department. She has type 1 diabetes, and she has experienced what it is like working as a nurse with diabetes. “I recently had a GI sickness at work, and as a result, my blood sugar dropped rather quickly after lunch,” she relates. “My coworkers noticed that I was diaphoretic and quickly sat me down, giving me some apple juice to drink. I ended up going home since I was sick with a GI bug, but only once my blood sugar was stable enough to drive. I was grateful for my coworkers’ assistance.”
Since diabetes is such a major problem amongst the population, it only stands to reason that nurses can have diabetes, as well. According to the American Diabetes Association, 30.3 million people in America have diabetes. In addition, 1.25 million adults and children have type 1 diabetes. How can nurses manage their condition? Nurses have a difficult time eating a balanced diet due to skipping meals. They are also on their feet most of the time, putting them at risk for complications of the foot, such as ulcers.
Fortunately, many nurses want to share their experiences to help others navigate the challenge of balancing diabetes and providing excellent patient care. Diabetes educators strive to help all people who have diabetes, and they are an excellent resource for nurses who want to manage their diabetes.
Nurses generally know how to handle their condition. They know diabetes front and back through the job, and they are intelligent professionals who know how to adapt those ideas for themselves.
“I can usually slip away for a few minutes or have a coworker cover for me so that I can test and/or eat a snack,” explains Weber. “When I worked as an ICU nurse doing twelve-hour shifts, I would typically eat snacks to prevent low blood sugars as I did my charting at the nurses’ station.”
Tips like this are invaluable because they are grounded in the actual experience of being a nurse with diabetes.
Fran Damian, MS, RN, NEA-BC, works at Boston Children’s Hospital and is a staff member at Diabetes Training Camp. She has tricks that she uses, as well. “Managing well with diabetes requires good planning and being well prepared with extra supplies all the time,” she says. “I live a healthy lifestyle as much as possible. That includes regular exercise and a well-balanced diet. I feel best when I eat a lot of fruits, vegetables, and lean protein, and I drink a lot of water …. [I] always have glucose tablets on me in case I start feeling low.”
“Our unit was pretty good if we were slammed and did not get lunch,” says Danielle Kreais, MSN, RN, CPNP-PC. She got her diagnosis and learned to cope, all while working a busy OB unit on nights. “The manager ordered lunch meat sandwiches and chips for us. There was another diabetic I worked with and the advice she gave me was to make sure I always had one of those Nature Valley bars in my work bag, in the glove box of my car, and my locker. The peanut butter ones have protein and they are a carb, so it was a great combo if lunch was missed.”
She continues: “She told me for lows to keep those peppermint striped candies [in your pocket] that are soft, and you can chew them. They are enough to bring your sugars up, plus they don’t melt.”
Nurses newly diagnosed with diabetes would do well to carry glucose tablets at all times to prevent low blood sugar. Be sure to tell your manager and your coworkers what’s going on so that they can help you when needed. Snacks and water are essential to good blood sugar control. Don’t forget to use your resources, such as endocrinologists, dieticians, and diabetes educators to plan the right meals and strategies for you to use on the job.
Although tips from nurses can be invaluable, they are nothing like the kind of focused information that can come from a certified diabetes educator (CDE). These are medical professionals who are responsible for teaching all people with diabetes in all situations how to manage their lives and prevent complications.
One such expert is Lucille Hughes, DNP, MSN/Ed, CDE, BC-ADM, FAADE, director of diabetes education at South Nassau Communities Hospital in Oceanside, New York, and treasurer of the American Association of Diabetes Educators. Considering some of the challenges nurses can face when dealing with diabetes on the job, she had tips for some of the most common ones.
Nurses often don’t get the chance to eat during a shift, and this can severely impact blood sugar levels. “When nurses with diabetes find themselves in this situation, planning and being prepared is the best medicine,” says Hughes. “Keeping snacks on hand that are a blend of carbohydrates, protein, and fats can be a tremendous help in these situations.”
“Meal planning is the secret to living with diabetes and being a healthy person,” Hughes continues. “Investing in a good lunch bag (or two) will allow you to plan and pack all the essentials to eating and snacking healthy. Being unprepared and finding yourself at the mercy of a vending machine is not a good situation to be in. It is very unlikely you are going to find a ‘healthy’ lunch or snack option.”
In addition to poor nutrition, nurses also face significant impact to their feet, and this can cause foot related complications for nurses who have diabetes. “First and foremost, investing in a good pair of comfortable shoes is essential for anyone who spends most of their day on their feet,” says Hughes. “Calluses and skin evulsions due to rubbing of a shoe on a toe, heel, or ankle area can be dangerous and yet avoidable.”
Here are six tips that Hughes has on how to find shoes that fit and how to determine if they are a healthy choice:
- When trying on a shoe in the store, make sure it feels comfortable. If it isn’t comfortable, don’t buy it.
- Many think that new shoes require a bit of breaking in and you must endure the associated pain. This is not true. If new shoes start to hurt, immediately remove them and don’t use them again.
- Don’t think that the only shoes you can wear as a nurse with diabetes are unfashionable ones. There are many options for shoes that fit, so do your due diligence and find shoes that will protect your feet.
- In addition to finding the right shoes, foot inspection is vital in protecting your feet. Check them every day. Use a mirror to see the bottoms and sides of your feet. If you notice any redness, cuts, or blisters, see your podiatrist immediately. Take care of small changes immediately before they expand into something unmanageable.
- Podiatrist. Yearly, no exceptions. More often if necessary.
- Finally, any time you see a medical professional, ask them if they will take a look at your feet at your office visit. This could be your primary care doctor, your endocrinologist, or any other specialist you may see—within reason, of course. Many dentists would have trouble with this request. Seriously, though, any professional who looks at your feet could possibly see a problem early enough to stop it. Use these resources.
Nurses spend so much time taking care of others that the self is often forgotten and ignored. Unfortunately, this is unhealthy for any nurse, but particularly troublesome for a nurse with diabetes. Yet, these challenges are not insurmountable, although they may take a little work. Planning your diets and meals are key to ensuring that you will have food on hand for sudden lows. Meal planning can also help you keep your high blood sugar under control. For your feet, planning is again essential. You must find shoes that are comfortable—no questions asked.
Following these steps, nurses with diabetes should be able to function well as nurses—and many are! If you find yourself troubled by mixing diabetes and nursing, let your doctor know. They may be able to refer you to any number of professionals who can help. The most important item, though, is to catch things early and always plan how to confront any challenges.
Recollections of the Flint water crisis are still vivid in the minds of many Americans. Responses to this crisis in the winter of 2014 needed to be swift and comprehensive. And while it may be hard to believe that access to clean, adequate, and equitable water in America remains at risk, advocates for environmental justice call for continued vigilance in ensuring access to safe and clean water. In this column, we discuss the need to ensure equitable access to this life sustaining resource through advocacy and legislative action with Katie Huffling, RN, MS, CNM, who is the executive director of the Alliance of Nurses for Healthy Environments.
Katie Huffling, RN, MS, CNM
Ms. Huffling, tell me a bit about yourself and how you became involved in addressing environmental health issues?
I trained as a nurse-midwife at the University of Maryland School of Nursing. While there, I had the great fortune to meet Barbara Sattler and Brenda Afzal. They were leading the only environmental health center at a school of nursing in the country. Through their mentorship, I learned about the many ways that environmental toxicants could affect reproductive health and the health of the growing fetus. It is an area that many of us received little or no content on in nursing school, yet they can have significant negative health impacts across the lifespan. I became very passionate about environmental health issues and when the opportunity arose to work on this full time with the Alliance of Nurses for Healthy Environments, I jumped at the chance! We are the only national nursing organization focusing solely on the intersection of health and the environment. I now work with nurses and nursing organizations around the country on a number of environmental health issues such as climate change, clean air and water, toxic chemicals, and inclusion of environmental health into nursing curriculum.
Can you give me an example of an environmental health issue that is affecting health right now?
Clean water is one of the greatest public health advancements of the 20th century. As nurses, we recognize clean water is essential to health and a basic human right. It is also essential for providing nursing care. Nurses rely on water to wash their hands, give newborns their first baths, and is essential for the clean linens utilized throughout health care.
Here in the United States we have an expectation that when we turn on the tap clean, healthy water is going to come out. Unfortunately, for many throughout the country this is not the case. Every year, millions of Americans experience waterborne illnesses. Waterborne illnesses are caused by a variety of sources, including waterborne pathogens such as viruses or bacteria, human or animal waste, heavy metals such as lead or arsenic, or industrial pollutants. Certain populations may also be more likely to be exposed to unsafe drinking water, including low-income populations and some communities of color.
I know you have been a champion for environmental justice for some time now. What are some key legislative priorities with regard to clean and safe water?
To address a number of urgent clean water issues, the U.S. Environmental Protection Agency (EPA) proposed an update to the Clean Water Act, originally passed in 1972. The Clean Water Act needed to be updated due to the great expansion of knowledge regarding upstream sources of pollution. Researchers now understand how important protecting headwaters and other upstream water sources are to clean water downstream. There was also confusion concerning which waters were protected by the Clean Water Act. This followed two Supreme Court Decisions in 2001 and 2006, directly impacting the drinking water for 1 in 3 Americans.
In 2015, the EPA and the Army Corps of Engineers finalized the Clean Water Rule (CWR). This rule was only finalized after an intensive stakeholder process in which they held over 400 meetings and received over 1 million comments, 87% of which were in favor of the rule. The Clean Water Rule clarifies which “waters of the US” will be regulated under the Clean Water Act. These include traditional navigable waters, tributaries, a small number of waters that have a significant nexus to traditional navigable waters, interstate waters, or territorial seas, and also exempts certain waters such as puddles, ornamental ponds and rain gardens, and continues certain farm exemptions.
After the rule was finalized, a number of plaintiffs sued the EPA. The rule was suspended by the Sixth Circuit court until the outcome of these suits. This stay was overruled in February 2018. During this time the Trump Administration announced they were going to suspend the rule until 2020. This suspension was overruled by the courts in August and the CWR must now be enforced in 26 states.
The issues that the CWR addresses are very important to environmental justice communities. If the rule is repealed, low-income communities and communities of color—who already face disproportionate exposures from other environmental hazards—may be most impacted. These communities, along with rural communities, are more likely to have poor infrastructure that is not able to handle contaminants in the water. These communities also may not have the resources to upgrade their water systems. They may also be more likely to rely on well water that can be more susceptible to pollution from upstream sources.
Turning to implications for nursing, why and how can nurses get involved in addressing this issue?
The EPA has announced they plan to permanently repeal the CWR; however, this repeal has not been finalized yet. If they repeal this rule, the drinking water for over 117 million Americans could be negatively impacted. Once this official announcement occurs, the nursing voicing will be crucial to protecting this vital public health regulation. There are many ways nurses can be active in this policy arena:
- Watch the new webinar from the Alliance of Nurses for Healthy Environments for one-hour free CE that reviews the CWR and provides opportunities for action (https://envirn.org/the-clean-water-rule).
- Sign this petition to Acting Administrator Wheeler asking to him to keep the CWR in place.
- Call your Senators and Congress people and ask them to support the CWR.
- Engage your professional nursing organizations—write a newsletter article and ask them to write a letter to Acting Administrator Wheeler or to Congress. As the most trusted profession, when our nursing organizations actively engage on issues such as clean water, Congress listens.
The most vulnerable among us are harmed by dirty water. By actively engaging on clean water issues, nurses can help policymakers and the public make the connection that clean water is essential to health.
Are there additional resources we should be aware of?
The American Nurses Association’s Principles of Environmental Health for Nursing Practice with Implementation Strategies (which is available online here).
The Alliance frequently offers webinars (many with free CE) on a variety of environmental health topics. We’re free to join and if you sign up for our newsletter you will be notified of upcoming webinars and opportunities for action. To learn more, visit https://envirn.org.
Technology in health care is always changing and improving—this means faster, more accurate, and safer ways to do your job. Here’s the scoop on the latest and what’s coming in the not-too-distant future.
Technology has been making our lives easier throughout history. While some people are concerned that more efficient technology prevents nurses from spending time with patients, experts say that this couldn’t be further from the truth.
“There is a fear that technology takes nurses away from the patient to spend time at the computer. As interface capabilities increase, more time can be spent with the patient,” argues Nikkia Whitaker, MSN, RN, CCRN, clinical technology integration manager at Dayton Children’s Hospital. “Having systems work together to decrease multiple workflows and eliminate manual processes is what will help nurses appreciate the emergence of technology.”
Get Ready, ‘Cause Here it Comes
Remember when you were a kid and you wondered if eventually robots would take over the world? That’s not happening exactly, but robots are being implemented in health care. And don’t worry; your job is safe.
Both large and small technologies are revolutionizing the nursing practice in so many ways, says Divina Grossman, PhD, RN, FAAN, president and chief academic officer at University of St. Augustine for Health Sciences. “One example is the deployment of robots, such as those that deliver patient medications from the pharmacy to hospital units, automate the preparation of chemotherapy and other drug admixtures, take patient vital signs, deliver food to patient rooms, or transport linens throughout the hospital,” says Grossman.
Robots, though, are just a small part of what is going on technologically in health care. Grossman says that mobile technologies, used by themselves or with other technologies, can reduce clinical errors, improve quality and safety, and reduce the physical burden of care for bedside nurses. “Hand-held devices like iPhones with different apps can be used for accessing and charting patient information at the point of care; linking barcoded drugs, treatments, and patients accurately; communicating between patients and nurses across different rooms or areas; remotely detecting motion in bed of patients at risk for falls; and obtaining diagnostic test results at the bedside are a few examples,” explains Grossman. “The tasks of lifting, positioning, and moving patients—which historically have caused frequent back strain and physical injuries for nurses—can now be done using smart technology systems and can even be operated remotely.”
Cathy Turner, BSN, MBA, RN-BC, associate vice president of MEDITECH, agrees that the use of smartphones is part of an ongoing trend to help support nurses in their delivery of care. “Nurses do many different things during a shift of care, and they interact with patients in different ways. Sometimes a device such as a Workstation on Wheels is the appropriate vehicle for the workflow, but there may be times where something smaller may be less intrusive,” Turner explains. “Smartphone devices are able to deliver that flexibility. The smaller devices may be something nurses are already using for calls, secure texting, etc. Why not be able to do a quick medication administration using scanning and documentation tools fully integrated into the Electronic Health Record [EHR]? The other advantage to this type of device is that it is similar to a patient’s use of their portal from an app on their phone. This provides a nice opportunity to share what they are doing on their device on behalf of the patient and provides a teachable moment for the patient using the portal.”
But there are even more types of technology that can directly help nurses who are working with patients. “Wearable technology, telephone monitoring, and nanotechnology further expand the ability to monitor patients’ physiologic parameters—not just episodically as snapshots, but continuously for diagnostic, therapeutic, and clinical evaluation purposes,” says Grossman. For example, “with a noncompliant patient, a sensor can detect whether and when a patient took their medication and have the information transmitted electronically to a nurse through an app on a mobile device. Medication dosages can be adjusted commensurate with serum levels throughout the day; these can also be correlated with levels of blood pressure, heart rate, oxygen saturation, stress or anxiety measured by the same wearable devices,
EHR, an Oldie, but a Goodie
While EHRs aren’t exactly from the stone age, they are the most familiar and most widely used technologies in health care today. But they have also come a long way.
“[EHRs] and Point of Care documentation devices are probably among the most adopted technologies,” says Majd Alwan, PhD, senior vice president of technology at LeadingAge, as well as the executive director of the LeadingAge Center for Aging Services Technologies. “What is new: over the past couple of years, many of these technologies have undergone significant improvement through successive upgrades. They are now much more user-friendly, touch- and even voice-enabled, mobile friendly (to provide access through tablets and smart phones), and have better clinical decision support system, information exchange, and analytics capabilities.”
“Nurses typically spend more time with patients and contribute more information to the patient record than any other member on the care team. While this entails a lot of responsibility, there is also a lot of flexibility and freedom that comes from using an integrated EHR solution. An effective EHR gives nurses more meaningful time back with their patients, and results in less time on documentation,” says Turner. “While there is perception that EHRs are too complex and impede the patient/provider relationship, an EHR designed to support nursing workflows improves both the patient experience and the quality of care that the nurse can provide.”
Turner also says that nurses no longer just enter information and observations into their patients’ EHRs. In fact, EHRs actually give back to the nursing field. “[EHRs are] providing actionable data, clinical decision support, and surveillance tools that allow nurses to proactively meet the needs of their patients,” she says.
In addition, says Turner, EHRs can suggest problems to be addressed as well as the actions that can then be taken. “They can ensure that patient safety protocols are in place, allowing the nurse to focus on more of their time and energy on the patient,” she says. “Surveillance tools monitor EHR data and identify patients at risk. Nurses spend a great deal of time documenting the care a patient receives. The surveillance tools analyze that documentation along with lab results and other data, and push notifications and actionable items to the nurses, giving them that time back.”
These surveillance tools are also able to monitor many patients through watchlists and let nurses know who needs immediate attention. “Watchlists can be built around fall risk, sepsis, CLABSI, VTE, or other potential risks that may affect a patient’s health. These lists give back to nurses, saving them time and giving them the most up-to-date information needed to effectively treat their patients,” says Turner. “I remember reading a heartbreaking story of a parent who lost their child to sepsis. The words that stuck with me: the parent implored that clinicians ask: ‘What if it’s sepsis?’ Surveillance will ask. And direct, appropriate care actions can be taken.”
Learning Via Simulation
While nursing students will always work directly with actual patients before they graduate, the use of simulations beforehand enables them to practice different procedures safely and to learn about rare procedures or cases that they may not often see. “Students are able to learn in a safe environment and can pace their learning activities; not all students learn the same way,” says Nadia Sultana, DNP, MBA, RN-BC, clinical assistant professor and nursing informatics program director at NYU Rory Meyers College of Nursing. “Simulation centers have been planned to include technology that is similar to the work environment.”
Grossman gives an example of how simulation can help nurses learn without an increased risk for patients. “Nurse practitioner students can learn complex skills such as suturing or draining wounds, placing central lines, or inserting of chest tubes before they perform these procedures on live patients in real health care environments. Faculty also have the ability to create dynamic computer-based simulation scenarios to enable nursing students to learn how to adapt their clinical treatment decisions to fluctuations in the patient’s condition,” she says. “With simulation, the ‘patient’ can be of any age and racial background since human patient simulators can be infants, children, or adults and come in different skin tones and physical features. Through computer-based scenarios, simulated patients can become hypotensive, tachycardic, or hypoxemic, and nursing students can learn how to tailor or adapt clinical treatment decision accordingly.”
Students can also be acquainted with rare conditions via simulation. “They can learn how to assess those patients using simulators. For example, a student may not be able to encounter a live patient with Tetralogy of Fallot in the clinic during the semester, but he or she can auscultate, palpate, and assess the relevant findings using the Harvey cardiology simulator. This simulator can mimic 50 different cardiac conditions and also simulate any cardiac disease in a realistic way,” Grossman explains. “The ability to learn interprofessional practice and teamwork using simulated case scenarios like a post-disaster situation or an acute stroke patient in the ER with teams of students from multiple programs—nursing, medicine, PA, et cetera—is also possible with simulation. Thus, nursing and other health care students can learn how to communicate with each other and collaborate in the care management of an individual patient or groups of patients through simulation before they are assigned to care for live patients.”
An even more advanced type of simulation is coming—virtual reality—and both student nurses and experienced ones are going to be stunned with how realistic it will be.
“Virtual reality or augmented reality simulation…depart from the conventional treatment simulation with three-dimensional image data and computer software. Implementation of virtual simulation requires the ability to transfer the planned treatment geometry from the computer to the treatment room in a way which is accurate, reproducible, and efficient enough for routine use,” says Grossman. “Haptics are an example of virtual reality technology where the nursing student can do patient assessment and examination and feel the virtual patient’s skin and body, with the ability to perform clinical interventions. Using engaging and immersive technology like Google Glass or HoloLens, the student can feel being in the real-world health environment, move around freely, interact with the patient and others, carry out tests and treatments, and learn from their mistakes while in the lab or simulation center without compromising patient safety.”
Have no Fear
If the thoughts of working with some of this technology scares you, don’t worry. The facility will provide you with the training you need, and the technology will make health care safer and allow you more time with patients.
“It is easy to be afraid of change, but you must always keep in mind what is best for the patient. Put yourself in the patient’s position and imagine how much safer they must feel to know that so many systems are working to support their care,” says Whitaker. “Do not be afraid to advance. A nurse’s touch will always be valued and needed, but technology can help bring nursing care to the highest level.”
Most registered nurses are familiar with the rights of patients under their care and work hard to alleviate suffering and maintain respect for human dignity. They advocate on behalf of patients, their families, the community, and society as a whole. But many nurses do not know their own legal rights and responsibilities as health care professionals.
Nurses with knowledge of whistle-blower laws, for instance, may be more likely to press administrators to end patient-care abuses or fiscal fraud. Standing up for what’s right is tough in any case, but especially for women and minorities, who make up a majority of the profession. Yet, minority nurses have historically demonstrated heroic activism for community health and social justice, during the civil rights era and the AIDS epidemic, for instance.
Nurses face the same legal issues as many other employees, such as sexual harassment in the workplace. But they also must protect against career-specific liabilities, such as being accused of violating the nurse practice act or similar regulations.
“There are three major concerns for nurses,” according to Gerard Brogan, RN, lead nursing practice representative at California Nurses Association and National Nurses United. “I travel and talk to nurses across the country and union or not, I hear the same things. The first concern is nurse-to-patient ratio, two is violence in workplace, and three is scope of practice.”
This article, then, will focus on legal issues that are unique to nurses.
Nurses across the country have expressed overwhelming concerns regarding these roadblocks to patient care and safety: short staffing on overcrowded units, limited ability to take even short breaks due to scheduling gaps, floating nurses without the proper training for certain departments, and so on.
According to Brogan, California is the only state in the country that has nurse-to-patient ratios. “Massachusetts and Arizona have them for the ICU only,” he says. “Nurses are working in understaffed hospitals, which are dangerous for patients and everyone else. We now have two nurse-to-patient bills in Washington. One is a house bill and one is a senate bill. They would require every hospital to adhere to ratios similar to the California bill.”
Brogan says that he often sees on social media the phrase “nurses should not be political.” But he believes that’s a naïve and possibly dangerous position. “Health care employers are heavily involved in politics, so as an organization and profession we have to also be involved in politics ourselves.”
Other aspects of staffing include how hospital plans are created and implemented allowing direct-care nurses to play a role. “The Oregon Hospital Nurse Staffing Law gives power to the hospital staffing committee,” says David Baca, RN, BSN, an emergency room nurse at Asante Rogue Regional Medical Center in Medford, Oregon.
The law is also a legal measure regarding rest-breaks and specialized staffing on specific units and departments. “The phrase ‘A nurse is a nurse is a nurse is a nurse’ is common, but that kind of thought process needs to go away as it becomes clear that appropriate education and training are needed,” says Baca.
The nurses at his hospital also recently won a new contractual right: break-relief nurses on units, when necessary, to allow nurses to schedule earned breaks and meals. Baca estimates that only 30-40% of nurses at his hospital know about the new staffing laws. “A little more education is needed,” including the hospital and individual nurse’s unit. “Standards and practices in the ER should be something we’re aware of. If not, we should be asking: ‘What does the ENA say about staffing and nurse patient ratios?’”
“When it comes to workplace violence, nurses have been in the top five forever,” says Baca. According to an U.S. Bureau of Labor Statistics analysis, 52% of all incidents of workplace violence in 2014 involved workers in the health care and social service industry. “The ER is open to everybody. We serve everyone, including the intoxicated or those with mental issues, so nurses are assaulted. It happens on almost a daily basis.”
“A few years ago, we had a huge problem with psychiatric crisis patients. We couldn’t secure them in appropriate rooms for their own safety and ours. They’d either elope or assault. That’s a huge risk, so the hospital invested a million dollars into ER security for the safety of everybody,” says Baca.
“Most assaults in the ER go unreported. If you regularly see colleagues assaulted, it becomes the norm,” warns Baca. “Maybe we need to prosecute more patients who assault nurses, medics on ambulances, or technicians. There’s a very low prosecution rate and almost no legal ramifications for patients who assault. We need to change the workplace culture that accepts violence.”
In 2014, California enacted a trailblazing law to reduce workplace violence incidents in health care facilities. “Every hospital has to develop a comprehensive workplace violence program to protect the safety of patients and employees,” Brogan explains. “We’re not just interested in working on the welfare of nurses in California or nurses in the union. Our efforts are for nurses across the nation.”
Then there’s the more common, less intense form of violence: bullying…
Brittney Wilson, BSN, RN, a social media influencer also known as The Nerdy Nurse, started blogging as a response to the stress of nurse-on-nurse bullying as a newly graduated floor nurse.
“What I learned from my experience with lateral violence is that in a right-to-work state it is very difficult to make a stand for yourself,” Wilson explains. “I did learn that in order to build a strong case for yourself you should keep notes including dates/times/names of incidences. You should also report incidences as soon as they occur. But if your hospital does not have a union, it is pretty much your word against another employee.”
In Wilson’s case, the nurses who witnessed the bullying weren’t her allies, and neither was management. “My employer didn’t support me and believe me enough to address the work environment, pursuing the issue just made things more difficult for me and lead to me being forced to take a different position and a pay cut until I ultimately left the organization,” she adds.
Though nurses have a right to be treated with dignity, respect, and civility, they sometimes must fight just for an environment that isn’t downright hostile. Wilson advises nurses in that situation to “find new employment and an organization that will support and value them. We are living in an economy where there are more jobs than there are nurses. If you aren’t being treated respectfully, you owe it to yourself to remove yourself from a damaging situation.” That’s just what Wilson did, parlaying her newly accrued digital skills into a well-paying and satisfying career in nurse informatics and technology product development.
It goes without saying, but nurses must themselves also avoid those types of uncivil, hostile, bullying, or intimidating behaviors that show disrespect for patients or colleagues. Otherwise, they put themselves at risk of censure for trampling the rights of others.
Scope of Practice
“There are fifty states and 50 different nurse practice acts,” says Brogan. “Hospitals don’t really educate employees on the legal scope of practice. I’ve been educating nurses for 20 years and find that hospitals see nurses as a unit of labor, not as a professional.”
In today’s fiscally-focused health care landscape, there is always a concern that the scope of professional nursing practice is at risk from understaffing, de-skilling, and other encroachment, warns Brogan.
“The hospital industry is trying to expand the scope of nurse’s aides and medical assistants. Nurses are professionals with independent judgment,” he says. “If they are given too many patients to care for, as is often the case in non-unionized hospitals, they have to take them or they can be fired.”
All nurses need to remain current, competent, and within their scope of practice, or risk losing their license—and their career. Protect yourself by taking continuing education courses in nursing (online or in-class) or enrolling in an advanced degree program. If further formal education is problematic, you can learn informally through a professional nursing association, either for your particular minority group or one in your specific area of
Rachel Seidelman, RN, a direct care nurse at Providence Health & Services in Portland, Oregon, has been a nurse for eight years and continually updates her understanding of the law. She knows her state nurse practice act rules and reviews them regularly to ensure she protects her practice and her license. “The biggest thing that’s helped guide me comes through my union; there’s a branch for practice. I know state and federal law and the overlap. I make sure I know who I can delegate to, because it’s all on me if a colleague messes up under my umbrella.”
“How I was precepted really helped me as a young nurse without much work experience,” Seidelman says. “Part of the onboarding process is to ensure they understand the wage scale, the contract and their rights within it, and a lot of other things, too. I’m a preceptor now and will never stop because I learn so much from doing it.”
One example of how Seidelman expands her knowledge of issues related to nursing practice concerns the opioid epidemic. After reading a series about it in the state’s major newspaper, she wondered what her response should be as an off-duty nurse encountering a stranger overdosing. Should she carry the opioid antidote naloxone as a precaution? “That question led me to the Oregon Nurses Association, my employer, and discussions with pharmacists and mentors.” She couldn’t obtain the antidote without a prescription, but new laws enacted in 47 states make it more freely available. The surgeon general recently urged opioid users, concerned family members, and professionals to keep it on hand.
“In this day and age, it’s important to protect our own license and also protect our patients and colleagues. I advise fellow nurses to ask good questions, be curious, find answers, and then tell others,” says Seidelman.
Advocating for Your Patients, Community, and Profession
Nurses have long participated in the political process and sought to shape health care legislation that supports nurses as well as benefiting patients and communities.
Martese Chism, RN, a Chicago nurse, is inspired by the example of her great-grandmother, Birdia Keglar, a civil rights activist in the 1960s. “She marched in Selma with Rev. Martin Luther King Jr. and lost her life because of it. Dr. King, in his speech, said he would like to have a long life, but that wish didn’t stop him from protesting,” she says.
Chism explains that her first college degree was in accounting, but she discovered “my calling is advocating for patients,” so she went back to school to become a nurse. “We’re supposed to advocate for our patients… I believe my fiduciary duty is to my patients, not the hospital. I advocate for my patients, but in the back of my mind, I worried about job security. I was single and didn’t have a family to support, but if I had, I wouldn’t have been so vocal without my union,” she explains.
One matter that Chism has spoken out about is the closure of public hospitals and other health care facilities in minority communities. “When elderly patients with no insurance need skilled nursing care our hands are tied [because of the closures] so now our uninsured patients have nowhere to go,” she says.
Some of Chism’s patients were retired public employees who aren’t eligible for Medicaid or Medicare. “They’re now turning 70 or 80 and they have no insurance. That’s why I’m fighting for Medicare for all,” she says. “As nurses, we’re supposed to advocate for our patients, but I don’t feel like I can without union protection. If I do, I’m branded a troublemaker. I’ve been speaking out in public for a long time and I could never get a promotion. If it wasn’t for the support of my patients, and union, I wouldn’t have lasted this long on the job.”
According to The Code of Ethics for Nurses (2001), nurses do have the right to advocate for themselves and their patients, and to do so without fear of retribution. Each state’s nurse practice act varies, but Chism was outraged when Illinois tried to remove “advocacy” from its nurse act. “They tried to say that your duty is to your employer, but our union fought to stop that. We don’t know about the future, though, especially with the recent [Supreme Court] Janus decision. The union movement might be weakened even more.”
Finding an Attorney to Explain Your Rights or Represent You
Even though you do your best to learn the laws related to nursing, you can’t always avert legal trouble. There may be a claim of professional negligence, say, and then you’d need to retain a qualified attorney in your area to defend you.
“Generally, look for an employment lawyer, they will understand the federal and local laws on wages, overtime, discrimination,” says Jeffrey M. Edelson, JD, attorney at Markowitz Herbold in Portland, Oregon. “They’re often divided by union and non-union. The tradeoff with collective bargaining is that an agreement could be in conflict with state law.”
If facing disciplinary action with the nurse licensing board, you may require an attorney who specializes in licensure protection.
Or your case may call for an attorney with experience in an entirely different area of practice. “For example, in the case of the Utah nurse [Alex Wubbels refused to draw blood from an unconscious patient], you’d need a criminal lawyer,” he explains. Or, if you work at a state hospital and are fired for expressing an opinion or acting on a matter of conscious, “you may need a constitutional lawyer in that you may have additional first amendment rights, versus if you’d worked at a private clinic,” Edelson adds.
A common way to find an employment lawyer is to checking profiles in listings such as “Best Lawyers in American,” he suggests. Or use your personal network of nurse colleagues, friends, or family to find an attorney. “Call your family lawyer, the one who does wills, and ask ‘do you know an employment lawyer?’” You’ll likely be referred to an appropriate attorney. Plus, “you’ll get that lawyer’s ear because you’ve been referred,” says Edelson, and they’ll each want to protect their professional relationship. Ask about their experience with your type of legal trouble or concern. Then inquire about fee structure. Some will charge for an initial consultation, while others won’t, and most work on a retainer basis, though some will take a case on a contingency basis.
Other resources for finding local attorneys: your professional nursing organization or union, the American Association of Nurse Attorneys (TAANA), and the State Bar Association.
In addition, you may want to purchase malpractice insurance (including license defense coverage) in advance of any need. Some professional nursing associations even offer a discounted rate, making it a prudent and affordable option.