Opioid addiction is an epidemic in every US state. A new study in the New England Journal of Medicine has linked opioid-addicted patients to the very first provider who prescribed the medication. The researchers found a correlation between the pain-prescription habits of emergency room physicians and the frequency of their patients becoming opioid-addicted. (You can read an article in the New York Times about the research here.) The bottom line? The risk of opioid addiction begins with a single exposure to narcotic pain medications—which frequently occurs during an emergency room (ER) visit.
Naturally, prescribers are in the most control: They can limit the quantity of pills prescribed after an incident, or change their prescription habits to restrict the instances warranting their use. For example, instead of patients leaving the ER with a prescription for 30 oxycodone tablets after a sprained ankle, they can prescribe 5 pills. Better still, they can prescribe ibuprofen, ice, and rest; if that becomes insufficient for pain control at home, pharmacologic methods can then be addressed.
Although physicians and advanced practice providers write the prescriptions, it is the nurses who most often provide medication education to patients at the time of discharge. It is therefore the nurse’s responsibility to ensure adequate patient education and to stress the dangers of taking opioids to their patients—even before they ever start taking the medication. Now more than ever researchers are discovering that a single exposure to these dangerous medications is enough to put opioid-naive patients at risk for addiction.
Set expectations. Patients may have a right to pain control, but they also have a right to know just how many risks opioids bring. After an injury, many patients seem to think they will be instantly pain free. It is important to manage expectations that some degree of pain after an injury or illness is normal, as their body heals and recuperates. It is when the pain become unbearable that they should turn to pharmacological relief.
Discuss alternatives. After a musculoskeletal injury, other methods of pain control can be useful. Consider teaching patients to RICE (rest, ice, compress, and elevate) their injuries, and offer other methods of pain control such as distraction, positioning, massage, heat, and ice.
Lay out the risk of addiction. Narcotic drugs are very risky medications. Teach your patients that they are dangerous and may cause addiction even in small uses. Tell your patients to take the medications very sparingly, and be firm with your language. Patients trust nurses, and their cautious attitudes can affect patient perceptions and behaviors.
Review the unpleasant side effects. Opioid pain medications have a number of serious side effects and complications. Emphasize that your patient may experience sedation, constipation, dry mouth, tolerance or dependence, confusion, nausea, dizziness, or itching as a result of using the drug. Remind them that they cannot drive while taking the medication. Teach also that they may experience withdrawal symptoms after use.
Teach the symptoms of overdose and addiction. If the patient feels like they need more of the pills to feel normal or relief, this is a sign of increasing dependence and tolerance on the drug, and they should seek medical advice. If the patient has slurred speech; feels lethargic, foggy, or confused; is difficult to arouse or has loss of consciousness; or experiences a decreased respiratory rate, small pupils, or cold clammy skin, they may be experiencing an overdose and need immediate medical attention.
Nurses may think that since they do not prescribe the medications, they have no contribution to the opioid epidemic in this country. However, as some of the most trusted professionals in health care, it is the nurse’s role to properly educate, set realistic pain management expectations, and relay the serious risks of taking these medications.
Surgeries often involve a number of nurses, all with specific duties to perform in order to ensure the safety and care of each patient. Theresa Clifford, MSN, RN, CPAN, CAPA, is the perioperative nurse manager at Mercy Hospital in Portland, Maine. In honor of PeriAnesthesia Nurse Awareness Week, she shares a little information about what it’s like to be a perianesthesia nurse.
As a perianesthesia nurse, what does your job entail? What do you do on a daily basis?
For the past 26 years, I have been privileged to call the PACU my “home” and have functioned in a variety of perianesthesia roles, including a clinical bedside nurse, a clinical resource nurse and most recently as a perianesthesia nurse manager.
As the manager for perioperative services, I am responsible for the staff and the quality of care that the staff provide throughout all phases of perianesthesia care. First, I manage the staff in a preoperative clinic. This unit is responsible for the preanesthesia assessment of all surgical patients. As soon as a surgery is booked, the work of putting together the preoperative story of the patient begins by a gathering of relevant patient data and calling the patient for an extensive nursing history. The workflow includes an algorithm that helps to identify patients at high risk for surgical or anesthesia-related complications. The main objective throughout this process is to help optimize the patient’s baseline status for the safest perianesthesia experience.
I also manage the staff in the same-day “Ambulatory Care Unit.” Here, we greet the patients on the day of their surgery and continue the process of providing high-quality preoperative care that includes verifying patient information, confirming surgical consents and procedures, and initiating the IV and preoperative therapies. Some of the preoperative interventions are aimed at preemptive pain management and include the provision of preoperative nerve blocks. This is also the unit where patients returning home on the same day of their procedure will be brought for discharge preparation and teaching following recovery from anesthesia (the Phase II unit).
The last unit I manage is the post-anesthesia care unit (PACU) where patients receive Phase I level of care. In the 1960s, the courts deemed the PACU as “the most important room in the hospital,” and I could not agree more! During this phase of care, the nurse is responsible for monitoring patients for airway, ventilation, and hemodynamic stability. In addition, the ongoing management of pain and comfort is actively carried out by the PACU nurses. Once the criteria for safely moving the patient from this intensive level of care has been met, the perianesthesia nurse will hand off care of the patient to the next level of care required.
Why did you choose this field of nursing?
“Curious indeed how these things happen. The wand chooses the wizard!” (J.K. Rowling). I always knew that I would be a nurse. My mother was an incredible nurse, and while I knew I didn’t want to work in her specialty field, I knew I wanted to grow up to be able to help people and touch their lives the way she did.
What are the biggest challenges of your job?
Honestly, the most difficult part of my job in health care today is remaining current with constant external and internal pressures to provide high quality, safe patient-oriented care within restrictive budgetary rules.
What are the greatest rewards?
The surgical experience for most patients is at the least, a memorable event, and at the most, life changing. It is a privilege to be able to participate in the experience as a guide, a knowledgeable professional, and as a source of compassion and care during a time when an individual can be most vulnerable.
What would you say to someone considering this type of nursing work?
I think perianesthesia nursing is a well-kept secret within the profession of nursing. There is a saying—do what you love, love what you do. There are a wide variety of opportunities within the perianesthesia practice to find a niche, a chance to “do what you love!”
Is there anything I haven’t asked you about being a perianesthesia nurse that is important for people to know?
It’s also important, as it is within any nursing specialty, to become aware of your specialty practice organization and to be an active member of your local and institutional work teams. The network built among specialty practice nurses, like perianesthesia nurses, allows for the opportunity to share knowledge and experiences and to participate in best practice and educational programs. The American Society of PeriAnesthesia Nurses (ASPAN), is the premiere organization for this specialty and provides an incredible source of information and support for the practice.
Perhaps all professions have stereotypes. For instance, the Italian chef, the cocky policeman, or the disgruntled cashier are all possible types in these professions—and they do nothing for the people who actually work in those professions. Unfortunately, nursing is the same way, having a bevy full of stereotypes that describe different types of nurses. However, with nursing, the stereotypes are something different. They are skewed, insidious, and dangerous.
On the website, TruthAboutNursing.Org, Sandy Summers, RN, MSN, MPH, and her group help to dispel some of the myths surrounding the stereotypes that nurses must endure. The nurses that these stereotypes are supposed to represent are completely at odds with what nurses actually do. They are introduced and perpetuated by the media so that the general public thinks this is what nurses are. For nurses to be respected, though, we must overcome these stereotypes and show what nursing really is. Not only does our profession depend on it, but the lives of our patients may depend on it, as well.
All nurses are angels. We are sent from above to provide other worldly care and make our patients feel like they are in heaven. The angel is unassuming, flinches at the sight of blood, and usually needs help finding their way out of a paper bag. Not only is this a sexist idealization of nursing, it is completely misguided. Yes, nurses save lives, and yes, nurses are often called angels by their patients. However, nurses are professionals.
We are not ones to shrink from a situation, and we certainly don’t need to turn to anyone other than our fellow nurses when there is a problem with a patient. The angel stereotype assumes that the nurse is a shrinking violet, most likely a female, who fluffs pillows and hands out orange juice. This is not nursing. Nursing can be surprisingly violent and dirty. It isn’t angelic to clean a trach or to perform post-mortem care. However, performing these duties are part of the sacred trust of the nursing profession, they don’t fit the stereotype of the sweet, clean, perfect, and unsullied angel that the media would have you believe that nurses are.
The battle-axe is the nurse intimidator, so aptly portrayed by Nurse Ratched in One Flew over the Cuckoo’s Nest. Surprisingly, this stereotype is seen in many different media outlets, and patients tend to believe that there are these super angry, sadistic nurses that are just waiting to pounce on them. Of course, the battle-axe runs in direct conflict with the angel. While one is sweet and kind, the other is the bitch. It should be noted that all of these stereotypes are distinctly female, keeping men from even considering nursing as a viable profession.
Nurses are not battle-axes any more than they are angels. Again, we are professionals, just trying to do a job. There are no angry, sadistic nurses who would treat patients poorly simply because they are having a bad day or because they’ve “been around the block.” The battle-axe stereotype is probably the most inexplicable. Who came up with this idea that nurses could be mean-spirited bitches? Nursing is hard work, and many of us are frustrated with the profession. However, that would never translate over into patient care. If it did, we shouldn’t be nurses.
3. Naughty nurse
Perhaps the most derogatory stereotype is the naughty nurse one. If you go into any Halloween store, you will find the costumes with the tight white dresses and the short white skirts. It is embarrassing to nurses and completely degrades the profession. The naughty nurse image turns nurses into a sexualized stereotype that is completely at odds with what nurses actually do in their job. Furthermore, it projects the image that female nurses are sex objects and can be treated as such by patients in the hospital setting.
Another byproduct of this issue is that men may not want to enter the profession because they don’t want to be a naughty nurse. They don’t want their own sexuality questioned because the general consensus is that a nurse is primarily a female sex object. This means that a great deal of male candidates would rule out nursing as a profession, and that can weaken nursing as a whole. You don’t need to be a feminist to see that the naughty nurse stereotype is dangerous. It is not just good clean fun. Nurses are put down by this view of them, but they can also be put in danger by men who think they are nothing more than sexualized, bed bath giving creatures of pleasure – not the medical professionals that they are.
A handmaiden is someone who is at the beck and call of someone else—in this case, the doctor. Nurses are sometimes seen as the ones who are commanded to do what the doctor says and run to fetch. The problem with this stereotype, besides being wrong, is that is sets up a situation in which nurses are seen as only doing work that is manual in nature. For instance, a nurse can give a bed bath, but not make a decision on holding a benzodiazepine on a confused patient. A handmaiden can fill water pitchers, but not listen for lung sounds and determine the difference between rales and rhonchi. Handmaidens do physical work, not mental.
The public doesn’t understand what nurses do when it comes to the real intellectual work of the profession. Nurses use critical thinking as much as doctors. They often have to make decisions on the spot. They have to determine when to involve the doctors, and then they have to decide what the salient points are to relate to the doctor. Nurses are far more than handmaidens because they are far more than people who do physical work. While the physical work will always be a part of nursing, it is only a small part in this changing profession. In the past, it had a far more prevalent role, but the media has not caught up to how nursing has changed. The public just doesn’t really know what it takes to be a nurse in today’s health care world.
Finally, the stereotype that ties all of them together is that nurses are generally unskilled. Everyone knows that doctors go through an intense amount of training and that they give orders. Everyone has this sense that there is a hierarchy in the medical system and that doctors head it. As a consequence, the public thinks that nurses are at the bottom, and they are therefore unskilled. As with any unskilled laborer, they would deserve less respect and would be replaceable. Of course, none of this is true because there is a marked difference in the skill set of a doctor and a nurse. It takes particular types of skills to work as a nurse, and saying a nurse is unskilled shows complete ignorance of what a nurse actually does.
Nurses assess, meaning that they look at a patient and determine health or disease. Nurses make independent diagnoses of their own and act on them, measuring the outcome of their actions. For instance, if a patient is suffering from chest congestion, in conjunction with the other health care professionals, nurses can implement treatments such as incentive spirometry and ambulation as allowable. They can also suggest to the health care team the possibility of starting albuterol treatments if they are not contraindicated. These are not the actions of an unskilled laborer. It takes a great deal of thought and skill to assess, diagnose, and treat these conditions, and this is only one example. Nurses are skilled in helping patients holistically, and this makes them vital cogs in the great machinery of health care.
In conclusion, nurse stereotypes are dangerous to nurses and the public alike. They are dangerous to nurses because they take away from the profession. People who may want to become nurses may not because they feel that nurses actually are this way. The media does nothing to change how nurses are portrayed and actually perpetuates these stereotypes. They do nothing to find out the truth. It is harmful to the public because nurses don’t get the funding, respect, or help they need to protect their profession. When nurses are degraded, patients suffer. Management sees nurses as expendable, and this means patients don’t get the best nurses or even enough nurses. In the end, stereotypes hurt patients, and it is time for the media to get it right. The health of millions literally hangs in the balance when nurses are disrespected.
Evidence-based practice. Those three words seem to be all the buzz in health care in recent years, and there is a good reason why. Evidence-based practice (EBP) is the science of our nursing care: It keeps us current, up-to-date, and providing the best care to our patients for the best reasons.
When you break EBP down to its core, it’s an approach to making decisions and providing nursing care not just on the most current research, but also on the basis of personal clinical experience. It’s the why for your nursing care, validating your decision-making for certain tasks on the basis of outcomes and research. It incorporates the most relevant studies, literature reviews, and clinical cases, but it also emphasizes observations made in your own care over the tenure of your own practice. It aims to incorporate what you and others have found to be the most effective treatments, practices, and ideas. EBP improves patient outcomes and patient safety.
How can you bring EBP to your unit?
Use the Internet
It can be as simple as a Google Scholar search, checking Up-to-Date, or reviewing some of the recent articles from your nursing specialty’s society journal. Changes are easy to implement on the unit, whether you’re a staff nurse or a manager. Do you feel that shift report is rushed or could be improved for better patient safety? Take a look at what the literature says about the topic and what the evidence supports to increase patient satisfaction, outcomes, and safety. It’s often surprising just how much information is already published on a topic you may be interested it. Would your unit benefit from a subscription to the Annual Review of Nursing Research, the Journal of Perinatal Education, or Neonatal Network? Ask your manager to subscribe, or whether your hospital system can provide physical copies for unit reference.
Start a Unit Council
Evidence-based practice is best incorporated into nursing units with a dedicated safety nurse, educator, or EBP leader. In units without such a position, clinical practice councils can be formed by any nurse on a unit to bring together a core team of individuals to tackle unit-based issues and find literature-supported solutions. It is difficult to imagine a unit leader or manager who wouldn’t welcome this type of employee engagement in both patient safety and unit success.
It is easy to be discouraged when one considers the breadth of nursing research about a given topic. But the root of evidence-based care is in the real-world, at the bedside, and on the unit. It starts with the observation of a problem, and the drive to find the best way to fix it. You don’t have to fix the problems plaguing nursing as a profession; you are just aiming to fix issues on your own unit and in your own practice.
The PICO model can help you define a clinical question you’re attempting to address. It stands for problem, intervention, comparison, and outcome. Well-built questions identify all four components when reviewing the literature on a certain topic. It can help format your study, research, and plan of attack.
Involve New Graduate Nurses
Oftentimes, the nurses most familiar with research and clinical questions are the new graduates. New graduates today are given the tools to conduct EBP research, and have been taught the most cutting-edge and up-to-date recommendations for practice available.
Maryland resident Dawn Silverthorn-Cerra, RN, BSN, has been a nurse for more than 30 years. For about the last five, she’s worked in home health care. She currently works for BAYADA Home Health Care. “I have to say it’s the best company I’ve ever worked for,” says Silverthorn-Cerra. So what’s it like to work as a home health care nurse? Silverthorn-Cerra took time to let us know. What follows is an edited version of our interview.
As a home health care nurse, about how many patients do you see each day, on average?
On average, I see 4 to 5 patients a day. That number can change, though.
Describe for me a typical day in the life of a home health care nurse?
The day of a home care nurse actually begins the day before. Home care nurses organize their day according to a variety of factors—geography of their patients, etc. Once the day is organized, each patient gets a phone call to confirm the approximate appointment time; I usually give them a 1- to 2-hour window regarding my arrival time.
I am blessed by this job to have flexibility. I drop my daughter off at school and then I head off to see my first patient. Each patient is unique. Some have wounds that need a skilled nurse assessment and wound care, i.e. if they have a wound vac. Many of our patients have just been discharged from the hospital because they have a chronic disease, such as congestive heart failure. These patients often require a lot of education regarding their disease process and medications in order to stop the cycle of them going in and out of the hospital. All of our patients receive education regarding their disease process, their medications, and how to live safely and independently in their homes, among other topics. Our teaching not only involves the patient, but also any family or caregivers that are involved with assisting the patient.
What are the challenges to this type of nursing?
There are always challenges with any type of nursing. Our care of patients is directed by their physician(s), physician orders, and, of course, insurance.
One challenge is communication with a physician. If the patient needs something or if there is a change in their condition, I am responsible for communicating with their physician. Sometimes, it may take a few days before they return my call. Thankfully, this is very infrequently an issue. I am fortunate that I feel like I have a lot of support from my clinical manager and office staff. They are always available to advise me when I am facing a challenging situation. In home care, you never know what you could face when you enter a patient’s home, so it’s good to know you have support when you need it.
Another challenge is the amount of time that documentation of your visits take. Although I have to say that BAYADA is diligently working on this. Every week, I get emails about how the documentation system is being modified to make it more user-friendly. I think this is pretty impressive that BAYADA listens to their clinicians regarding problems we find in the documentation program.
What skills do you need to have for this particular type of nursing?
Organizational skills are important as are strong interpersonal skills. You will come in contact with a lot of personalities, and you need to be kind, caring, and respectful regardless of your patients’ moods or attitudes. Patients are generally very nice and grateful for your help.
You must be able to function independently and have confidence in yourself. You should have excellent physical assessment skills. Venipuncture skills and IV therapy skills are necessary because many of our patients are able to come home and receive their IV antibiotics because of our presence and care. Patience and flexibility are on the list, also.
What kinds of people would do well here?
People who are enthusiastic about nursing and caring for patients, and nurses who like autonomy.
What do you love most about what you do?
Without a doubt, it’s my patients. You develop a relationship with them, and a mutual trust develops. They know you are there to help them, and they appreciate your efforts. We serve a lot of elderly patients, and many of them are on the verge of not being able to live independently any longer. Nurses teach patients about their medications, the purpose and action of them, and what possible side effects may affect their safety. We can make recommendations for assistive equipment that will make them safer in their home and also for other disciplines like physical and occupational therapy.
What do you wish more people knew about your job?
I wish people knew how great it is to be a home care nurse!
National Certified Registered Nurse Anesthetists Week lasts from January 22-28. To recognize those who work in this segment of the nursing field, we interviewed Dan Lovinaria, DNP, MBA, MS, APRN, CRNA, who works at the Minneapolis Veterans Affairs Health Care System (MVAHCA) to find out more about it what it’s like to work as a Certified Registered Nurse Anesthetist (CRNA). Lovinaria has been a nurse for more than 25 years, has been practicing anesthesia for more than 15 years, and is also a clinical assistant professor and an associate program director at the University of Minnesota Doctor of Nursing Practice Nurse Anesthesia Program. What follows is an edited version of our interview.
As a CRNA, what does your job entail? What might you do on a daily basis?
As a VA CRNA, my top priority every day is to provide access to safe anesthesia care for the amazing Veterans who fought for our freedom. I am humbled and honored to hear the Veterans’ stories about their deployments in Vietnam, Iraq, Afghanistan, and the Gulf War, to name a few.
Being a VA CRNA comes with a tremendous responsibility and a great deal of accountability. Patients are often anxious and nervous about their surgical procedures. It is my duty to set the tone and make an immediate connection with my patients upon their arrival in the preoperative phase. Something as simple as providing warm blankets to my patients goes a long way. The little things that make a significant impact.
I also ensure that my patients are well-informed about their procedure, and I answer their questions and reassure them I will be with them from the beginning to the end of the procedure. I will be carefully and vigilantly watching their every vital sign and breath during, and adjusting their anesthesia as necessary.
On any given day, I provide anesthesia care along with my physician anesthesiologist colleagues to our Veterans needing cardiac bypass, joint replacement, cataract extraction, endoscopy, or urologic procedures. We provide various types of anesthesia including conscious sedation as well as regional and general anesthesia techniques.
Why did you choose this field of nursing?
As a young immigrant from the Philippines, I always wanted to pursue a career in health care. Many of my relatives were nurses, physicians, and dentists. It’s in the blood.
When I was a sophomore in college at the University of Hawaii at Manoa, my father was diagnosed with stage 4 lung cancer. I drove him to his radiation treatments. The dedicated nurses who cared for him left an indelible impression on my mind and sparked my passion for nursing. After my father’s passing, this experience solidified my desire to pursue nursing.
What are the biggest challenges of your job?
In today’s ever-changing and ever-evolving health care landscape, it is a challenge finding balance to provide the best and most appropriate anesthesia care while considering the high costs associated with services rendered.
Another challenge with my job is that health policies continue to change and can vary drastically in some instances. Governing bodies continue to dictate what should be done for our patients versus what is the appropriate care for these patients as determined by the providers who care for them.
What are the greatest rewards?
There are many intangible rewards associated with the nurse anesthesia profession. First of all, having the opportunity to care for our nation’s Veterans is the ultimate reward. They are very special, gracious, and always thankful for the care received.
Another reward is when you witness a baby being born and held by their parents for the first time. It is very emotional. I keep telling myself that I am making a difference one baby, one mother, and one Veteran at a time.
What would you say to someone who is considering this field?
Being a CRNA is the best profession. It is challenging, rewarding, and fulfilling all at the same time. CRNAs provide the majority of the 40 million anesthetics in the country and are often the only anesthesia providers in rural America and other medically underserved areas around the country.
CRNAs are highly educated and trained to administer safe and effective anesthesia in every health care setting and situation. CRNAs are no longer the best kept secret in health care.