When Words Do Harm

When Words Do Harm

Last year, the American Diabetes Association prohibited the use of the word “diabetic” to describe patients in its publications. And at a recent conference, the group cautioned health care providers against using the “ic” term and other words that might alienate patients.

Among the objectionable words: “uncontrolled,” “non-adherent,” and “non-compliant.” Even using words like “good” and “bad” to characterize a patient’s blood glucose levels can have a negative impact, diabetes experts say, leaving patients feeling judged and stigmatized.

Better choices, they say, would be “in range” or “out of range,” or “high” or “low” — and it’s not just a matter of semantics. How we talk about diabetes directly impacts patients’ behavior.

If this sounds a bit far-fetched, think about it this way: When you tell the night shift nurse during bedside shift report that “Mr. Smith is a 54-year-old diabetic” you’ve just defined Mr. Smith’s entire being by his disease. When you jot down that Mrs. Jones has been “non-compliant” because she hasn’t been regularly testing her blood glucose levels, she feels the sting of a scolding—and maybe a sense of personal failure, too.

At the end of the day, these judgmental words and phrases can erode an individual’s motivation and actually worsen their blood glucose control. That’s because it contributes to “diabetes distress”—the fear and futility that creeps into a patient’s head when the process of managing diabetes begins to seem overwhelming.

It’s not just in the endocrinology clinic that words can do harm. A 2010 study published in the journal Spine found that patients with low back pain had a more negative perception of their prognosis when their physicians attributed their back pain to a “degenerative” process involving “wear and tear” of the spine or “crumbling” or “collapsing” discs.  In essence, when it sounded bad, the patients viewed their condition as worse than it necessarily was—and that hopeless mindset made them more hesitant to engage in therapies that might actually improve their health.

The impact of word choice is especially evident in psychiatric care and nurses should be careful to avoid using stigmatizing language. In an article published last year in the Journal of the American Medical Association, then-drug czar Michael Botticelli and Harvard professor Howard Koh opined that it wasn’t all that long ago that individuals with mental illness were referred to as “lunatics” and the hospitals where they were treated as “insane asylums.”

Just as those insensitive terms were appropriately abandoned, we need to rethink the way we talk about problems like addiction. A patient isn’t a “drug abuser;” they’re a “person with a substance abuse disorder.” Instead of referring to drug results as “clean” or “dirty,” they should be characterized as “positive” or “negative,” or “substance-free.” The word “drug habit” is problematic too, because it can imply that a substance abuse disorder is a personal choice, rather than simply a disease.

As we incorporate a better vocabulary into our practices, we must also remember that non-verbal language can be just as powerful as the spoken word.

For me, that lesson became crystal clear several years ago while caring for a patient who’d been hospitalized for a warfarin-associated G.I. bleed.

It had been a rough 24 hours, but after several bags of vitamin K, the patient appeared to be improving significantly. His INR was coming down and the attending had just told him that he was out of the proverbial woods. So I was flummoxed when the patient burst into tears as I was taking his vital signs.

“Are you in pain? What’s wrong?” I frantically asked.

The usually cheerful, middle-aged man grabbed my hand, sniffled, and in between unrestrained, breathless sobs asked me if he was dying. “I’ve been watching you all morning,” he confided, “and every time you take my blood pressure, you have this terrible, serious look on your face—so I figured I must be dying and you’re just too nice to tell me.”

That day I learned that language is more than just words, and I began to practice my poker face.

Quality Compressions and Tips for Better CPR

Quality Compressions and Tips for Better CPR

Perhaps you give CPR (cardiopulmonary resuscitation) almost every shift, and you consider yourself a code blue champion. Maybe you work on a med-surg unit or in a surgery center that rarely has to code a patient. Despite the ACLS (Advanced Cardiac Life Support) certification card in your wallet, you may find your skills need brushing up on. Below are some tips for ensuring that you are providing excellent CPR.

1. Get your hands on the chest quickly.
As soon as you notice that a patient is pulseless, place your hands on the chest to start compressions while yelling for others to help. Minimize interruptions to CPR.

2. Use your equipment.
If possible, use a stool so that the compressor is at the proper height, and also place a backboard or use the backboard setting on a mattress to get the proper resistance for compressions.

3. Go fast, but not too fast.
Occasionally compressors get so full of adrenaline that they compress at a rate of 120-150, which is too fast to allow for ventricular filling. The rate should be between 100-120. Tip: Music services such as Spotify actually have entire playlists created for the ideal rate of CPR!

4. Depth is important.
Get the proper depth to allow full recoil of the chest. The recommended depth for adults is 2 to 2.4 inches. Sometimes this may mean lifting your hands completely off the chest after each compression.

5. Too much of a good thing.
Pause for breaths without an advanced airway, but also be careful not to “overbag” the patient. Excessive ventilation can increase intrathoracic pressure and decrease coronary perfusion pressure.

6. Use end tidal to measure your compressions.
End tidal carbon dioxide monitoring can reveal the quality of your compressions. End tidal greater than 20 is associated with greater survival outcomes. Values of less than 20 indicate that you need to adjust your rate and depth. If end tidal suddenly jumps into the 40s, you likely have return of spontaneous circulation.

7. Switch compressors to combat fatigue.
Proper CPR is exhausting. Switch every two minutes, and you can give epi every two compressors.

8. Designate a CPR coach.
If you have extra eyes or hands, designate a CPR coach who will monitor the depth and rate of compressions and who will help ensure that compressors are switching appropriately and end tidal is appropriate.

High quality compressions lead to greatly improved patient outcomes.

How Do You Handle Difficult Patients?

How Do You Handle Difficult Patients?

Every nurse has them—the difficult patients that, no matter what good is happening in their lives, are just really negative with their attitudes all the time. So what can you do to help them and to help yourself, as it’s not easy to deal with so much negativity?

Dr. Jodi De Luca is a licensed clinical psychologist who has been working in hospitals for years and currently works in an Emergency Department at Boulder Community Hospital in Colorado. She’s the “go-to” person, especially when patients are negative or challenging to work with.

“In-patient hospitalization or a visit to the ER can be a threatening and stressful experience,” De Luca explains. “From an emotional and psychological perspective, the visit can be overwhelming.” She says that everything from the loss of control, fear of procedures, fear of death, and the like can terrify patients. “Nurses in particular bear the brunt of the negative behavior.”

It’s important to know how to deal with these patients because they can cause nurse burnout, increase anger and resentment toward the patient, and other patients suffer or can be neglected because all the nurse’s time is spent on this particular patient.

De Luca has some tips for nurses on dealing with these kinds of patients:

1. Setting structure and limits are key.

Be direct when clarifying limitations, particularly in explaining to the patient what is unacceptable and disrespectful behavior.

2. Eliminate the unknown whenever possible.

Knowledge gives the patients power and control.

3. Whenever possible, offer the patient realistic options of care.

By doing so, the patient feels empowered in his/her decision making and may feel validated and more in control. As a result, the behavioral manifestations may be reduced.

4. Ask questions that elicit a sense of control for the patient.

Ask questions such as: What would make things better? What options do you propose? If this option is not possible because of (the reason), but these options are available, which do you think would be best for you?

5. If possible, have nursing and medical staff alternate work load with a negative patient.

This gives everyone a chance to mentally recharge and prevents the negative patient from monopolizing all of your time.

6. Find out what the patient’s expectations are.

Are they realistic? Can they be accommodated? Are there options?

7. Explain to them how their behavior negatively affects their overall well-being and treatment.

When patients are under duress, particularly in a hospital setting, they are often unaware of their own behavior.

8. If possible, have a third party present when you are dealing with difficult patients.

Document not only behavior, but also what the patient states verbatim. Documentation and third-party witness is our best defense particularly with regards to future potential repercussions, complaints, and litigation.

9. Consider engaging the assistance of the Behavioral Health Team at the hospital.

Psychologists, psychiatrists, case management, and social workers can help provide treatment recommendations for the staff as well as the patient and to rule out any other potential contributors to the behavioral disruption and negativity (such as medication reaction, delirium 2nd to metabolic insufficiency, infections, etc.).

Virtual Nurse Advice and Care Managers: A 24/7/365 Commitment

Virtual Nurse Advice and Care Managers: A 24/7/365 Commitment

Nurses often say to their patients, “We’re here for you if you need us.” While they mean every word, nurses also recognize that the clinic phone goes to voicemail after hours and that hospital shifts don’t last 24 hours. They also know that many patients are too overwhelmed to refill medications or schedule follow-up appointments.

Nurses become nurses to help people, and they quickly realize that it takes a team. This is even more true now that Medicare and other payers are tying reimbursement to how well health care providers can coordinate care, improve patient outcomes, and reduce unnecessary and costly emergency department (ED) visits and hospital readmissions. Today, nurses not only have to ensure their patients are getting the right care in the right way at the right time, but also that the care is delivered in the most clinically appropriate setting.

Retail health clinics and web-based telemedicine services have received a lot of attention as new consumer-oriented care approaches. But more cost-effective approaches include telehealth and care management services. These services engage, triage, support, and/or coach patients in a wide variety of settings, from telephonic to in-person to online.

Widely adopted by health plans and government payers, telephonic and locally-delivered in-person care management services give members direct and immediate access to experienced nurses and care managers. These care managers help members with a wide range of health-related issues, from coaching a mother on how to care for a baby with a fever to helping a member locate transportation to his doctor appointment. The best of these services have high member satisfaction rates, are a clinically effective way to prevent unnecessary ED visits, and coordinate care for members to improve their health and satisfaction.

From the nurse’s perspective, telephonic nursing is a rewarding and flexible career path. Many of the nurses in these positions work from home, which helps them maintain a healthy life-work balance. Every shift, the nurses get to interact one-on-one with members, and they find it very fulfilling to make a difference in these people’s lives and health status.

Sometimes Advice Is All Members Need  

It could be 2 a.m. or 2 p.m. It could be the weekend, a weekday, or a holiday. When members have access to a nurse advice line, they can reach out by phone or electronic chat with any type of health question, and a registered nurse (RN) will answer immediately. Thanks to telecom advances, members are seamlessly connected to RNs licensed to practice in that member’s state.

The nurses use computerized algorithms, or sets of prompts, to assess the member’s condition and make appropriate recommendations. When the situation warrants it, the nurse will advise the member to go to the ED. In non-emergencies, the nurse recommends specific self-care actions to take, pointing the member to helpful online resources. The nurse might also advise the member to follow up with a primary care provider or go to urgent care.

In the best telephonic nursing services, the algorithms are developed and maintained by clinical staff based on treatment protocols, reviews of medical literature, and recommendations from physician advisors. However, the algorithms are not scripts. Rather, the system guides the nurses, who rely on their clinical experience and judgement, to ask appropriate questions and give on-target advice.

For example, the algorithm might tell the nurse to consider meningitis when the mother of a toddler with a headache calls. It would be impossible for the child to describe her symptoms like an adult could. In this case, the nurse might assess whether the child has neck stiffness by telling the mother, “Have your daughter look at her belly button. Does her chin touch her chest?” The answer to this question, tailored for the age of patient, gives the nurse information needed to make an appropriate recommendation.

A study of one highly rated service showed that the advice given by on-call physicians agreed with the advice given by their nurses greater than 99% of the time.

When Patient Needs Get Complex

While nurse advice lines are useful and welcome services, they are more reactive than proactive in terms of helping members. That’s why many health plans are also enlisting teams of care managers to preemptively work with high-risk members before their health deteriorates to the point where they need to go the ED or hospital.

Typically, insurance claims data – and in some cases, additional lab, pharmacy, biometric, and consumer data – are analyzed to identify members who would benefit from care management services. Sophisticated analytics can be used to sort through the available data and identify those members who have one or more health conditions. That list of members can be further prioritized by looking at which of those members frequently visit the ED or were recently discharged from the hospital.

Care managers then reach out to these high-risk members to see how they can help them follow through on their health care provider’s recommendations. The care manager will zero in on the most vital issues contributing to the member’s poor health until a clear solution can be identified that bridges that issue. For instance, a care manager might ask a member, “How can I help you keep your physician appointments? Is the office too far away or are the hours inconvenient? Or do you not think the appointments are important?”

In this type of care management, nurses still use the telephone as a tool to communicate with members. But the best services also have nurse care managers available to visit members in their homes or accompany members to doctor appointments. This is particularly important in situations where members have mental health or cognitive issues.

For instance, one nurse care manager was assigned to a member with multiple comorbidities, including diabetes, congestive heart failure, anxiety, and depression. The member was not compliant with medications and had skipped physician visits. As a result, the member was winding up back in the ED over and over.

When the care manager became involved, she recognized that the member’s mental health issues were the crux of the problem. The nurse accompanied the member to physician visits and partnered with office staff to reduce their frustration. The nurse also arranged to have the member’s medications delivered because he had trouble moving around physically and getting to the pharmacy. The end result: By taking medications regularly and following up with physicians, this member was able to manage his conditions at home and reduce his ED visits.

A Rewarding Career 

As population health management takes hold, the need for telephonic nurses and care managers will only increase. Nurses looking for a flexible, rewarding position may want to consider this career.

Because nurse care managers need to be able to think on their feet and provide specific advice on an extensive array of health issues, they often have solid and broad clinical experience. A nurse who worked for three or more years on a hospital medical-surgical unit, in an ED, or at a busy pediatric practice is typically a good fit for these positions. Excellent communications skills and an ability to put people at ease are also needed. At the core, this work is about drawing patients out and helping them help themselves.

Speaking on Nurses in the Civil War

Speaking on Nurses in the Civil War

After Pamela D. Toler’s book Heroines of Mercy Street: The Real Nurses in the Civil War was published, she began giving talks about nurses during the Civil War as a spin-off. Toler, a freelance writer with a PhD in history and, as she says, “a large bump of curiosity,” is currently working on a global history of women warriors. She took some time to talk with us about Civil War Nurses.

You give talks about nurses in the Civil War. How did you get into doing this?

In some ways, I just fell into the project. PBS was looking for a writer to produce a work of historical non-fiction as a companion for their historical drama, Mercy Street. I had the right skills and was in the right place at the right time.

At the same time, the subject was made for me. I was that nerdy kid who hung out at the local Civil War battlefield on the weekends, learned to shoot a muzzle-loading rifle, participated in living history programs, and read and re-read the biographies of women like Clara Barton, Julia Ward Howe, and Harriet Beecher Stowe. Writing Heroines of Mercy Street allowed me to return to my first historical love:  the Civil War in general and the involvement of women in the war effort in particular.

Today, nursing is female dominated. But back then, women had to try and crack into nursing because men were doing it. How did they go about it? How did they break through the male-dominated war and get accepted? Who were the key players?

In the mid-nineteenth century, nursing as a skilled profession barely existed and most people didn’t consider it a job for a respectable woman. Before the Civil War, the Army’s Medical Bureau depended on convalescent enlisted men who were not yet well enough to return to their duties to work as nurses.

Even after Congress approved the formation of the army nursing corps, women experienced a great deal of resistance from Army doctors. They argued that women didn’t have the upper body strength to do the job. They complained women didn’t have the training to do the job—not that convalescent soldiers had any training. They were worried that women would suffer indignities in the rough atmosphere of the military hospitals. And some of them thought that the only women who would volunteer would be husband-hunters.

Civil War nurses won acceptance the only way women have ever won acceptance in male dominated fields: by changing the opinions of one man at a time. The longer a nurse was on the job, the more likely she was to conquer the prejudices of the doctors she worked with. By the end of the war, most army doctors had come to believe that the nurses they worked with were indispensable.

What are some of the most surprising things that everyday people don’t know about these nurses?

At some level, the question is what isn’t surprising about these nurses?

The most important thing is that there were no nursing schools in the United States before the Civil War. With a few exceptions, these women had no formal training as nurses. Most women of the period had some experience nursing a relative or neighbor, but taking care of someone with measles or a broken leg was no preparation for working in military hospital. When you read the letters and memoirs written by women who served as nurses, their first experiences of hospital work often made them ill and sometimes caused them to faint. They learned how to take care of patients on the job.

Developmental Care in the NICU

Developmental Care in the NICU

Developmental care is a philosophy utilized by the entire interdisciplinary team to coordinate medical, nursing, and parental interventions based on the developmental needs for a particular patient. This philosophy of care is to support the infant and their families with a focus on environmental influences affecting neurologic development. Developmental care encourages frequent assessment and responses to a baby’s needs. These responses are meant to decrease the stress of the preterm neonates in the neonatal intensive care unit (NICU), according to the Northern Neonatal Network’s guideline for family-centered developmental care.

Why use developmental care?

Neonatal medicine is an ever-expanding field. Babies born at progressively earlier gestational ages are able to survive due to advancements in modern medicine. Mortality rates have declined with the fast-paced achievements of neonatal medicine. However, evidence exists to suggest increased morbidity for neonates born prematurely or acutely unwell. Long-term studies have identified more subtle problems including neurosensory impairments such as cognitive delays and behavioral difficulties.  “These can have a significant influence on a child and their families’ way of life.” Developmental guidelines for interventions, handling, inclusion of family and nursing protocols help to optimize neurodevelopmental outcomes for NICU infants and their families.

What is the goal of developmental care?

As caregivers, we want to protect the infant’s brain and create an environment suitable for neurobehavioral development of the infant. According to the Network, the outside environment now needs to mimic the inside environment, which is crucial for normal brain development. The inside environment provides containment and allows for the baby to maintain a supported flexed posture with limited noise and light exposure, as well as, protected sleep cycles with no separation from the baby’s mother. The goal is to support more positive experiences for the baby and thus achieve more positive outcomes for even the littlest of our patients.

How do we implement developmental care?

In the NICU, we use developmental care to support the infant and their families with individualized care which focuses on the environmental influences including handling, positioning, light, and sounds. The amniotic fluid serves as tactile sensory stimulus for the infant while in utero. When the infant is in the NICU, they are exposed to various touch stimuli versus constant tactile stimulus. Studies suggest that even routine handling during procedures can have adverse effects on the infant such as bradycardia, hypoxia, sleep disruptions, increased intracranial pressure and behavioral agitation.

One way to overcome this overwhelming tactile stimuli is to swaddle the infant. A systemic review published in Pediatrics found that swaddled infants have improvement in physiological and behavioral states such as lower heart rate, alleviates pain, prevents hypothermia and calms the infant. It also induces and prolongs sleep with fewer startles. The Network’s guideline suggests that these same benefits can also be achieved by the practice of developmental positioning utilizing positioning aids. Developmental positioning also provides the musculoskeletal support of flexed & midline postures, encourages self soothing behaviors and helps to conserve the baby’s body temperature and energy thus growth and weight are promoted.

Gentle human massage and touch is another intervention that can help decrease stress levels of premature babies. A Research in Nursing & Health study found that gentle human touch increases respiratory regularity, improves sleep cycles, motor activity and behavioral distress during periods of gentle touch. Gentle massages have been reported to help improve weight gain, improved pain alleviation, reduced postnatal complications, improved physiological and behavioral states, shorter hospital stay and improved performance in developmental scores.

The NICU is quite often an overstimulating environment.  Behaviors, which should be modeled by staff and taught to the parents can ease the constant stream of auditory and visual stimulation. The NICU staff can control the lights and sounds of the outside environment. A 2013 study published in Indian Pediatrics recommends that we keep the infant on a schedule to allow for uninterrupted rest and decrease stress by using non-nutritive sucking, kangaroo care with parents, swaddling, and containment.

In summary, developmental care should be utilized for all preterm infants during their adaption to extrauterine life. Creating a positive environment and protecting neurobehavioral development is crucial to an infant’s long term outcomes. Implementing developmental care practices such as positioning, swaddling, nonnutritive sucking, gentle human touch and massage can help alleviate pain and provide better outcomes for the premature babies and their families.