Unprecedented numbers of patients have been placed on mechanical ventilators during the COVID-19 pandemic. Being connected to a ventilator can take a massive toll on the body and mind, and we know that the ordeal can contribute to Post-ICU Syndrome (PICS). Making a human connection with a patient in this state is challenging, but it is not impossible–in fact, a 2015 study found that over 50% of ICU patients on ventilators are capable of communicating.
DailyNurse asked the co-author of that 2015 study, Mary Beth Happ, PhD, RN, FAAN, FGSA, for advice on how to communicate with patients on ventilators (last week, Dr. Happ, who specializes in patient-provider communication, shared her tips on communicating while wearing PPE). Dr. Happ offered a number of suggestions:
What to Expect When a Patient is on a Ventilator
Patients are unable to vocalize during mechanical ventilation due to the breathing tube. Also, ventilated patients may be sedated or have fluctuating consciousness; their ability to comprehend or attend to communications may also fluctuate. Patients often have other pre-existing communication impairments – many will be hard of hearing and approximately 80% will be glasses wearers, however, most will not have glasses or hearing aids readily available at the bedside. Writing may be impaired due to swollen hands/fingers, muscle weakness, or lack of coordination.
Assessing the Patient’s Communication Abilities
Assume that all mechanically ventilated patients need support for understanding your message to them. I suggest beginning with your assessment of cognitive (following commands, attention/inattention, consistent yes/no signal) and language abilities (reading, writing, limited English proficiency), sensory deficits (such as hearing and vision), and the patient’s upper motor strength and coordination (holding a marker or pen, pointing, activating touchscreen on an electronic tablet).
Tips for Communicating with a Patient on a Ventilator
Get the patient’s attention by touch and maintain eye contact
Have glasses and hearing aids or amplifiers, large print if needed,
Have notebook and marker available to write key words or phrases that emphasize or reinforce your message,
Use picture boards in addition to your words to explain medical procedures,
Use pointing and gestures as you speak
Speak slowly, over enunciate, and in short sentences or phrases
Pause 10 seconds to wait for the patient’s response before going on
Consult with your hospital’s speech-language pathologists. SPLs are skilled in assessment of communication-impaired patients and can recommend low tech and electronic augmentative communication tools.
Helpful Online Resources
Use picture word-phrase boards or tablet applications designed for patient communication that are matched to the patient’s abilities and preferences. The SPEACS-2 training program and website has these assessment and tool selection guides available https://go.osu.edu/speacs2.
Dr. Mary Beth Happ, PhD, RN, FAAN, FGSA is a specialist in patient-provider communication and has conducted extensive research on the issues associated with communicating with patients on ventilators.
Dr. Happ is the Nursing Distinguished Professor of Critical Care Research and Associate Dean for Research and Innovation at The Ohio State University College of Nursing. She and her team developed the SPEACS-2 online training program to reduce misinterpretation of patient messages and facilitate ICU liberation for mechanically ventilated patients.
Starting a new nursing job can be both exciting and nerve-wracking. You have to learn where everything is and get to know your new coworkers while trying to do your job. If you’re starting a new position and wondering how you can adjust, read these 11 tips before your first day of work.
1. Come prepared.
Be ready to hit the ground running at your new job. Read over the hospital’s policies and procedures ahead of time, so you’re not trying to learn on the fly. Clean your house, do your chores, wash your cotton scrubs, and cook all the food you’ll need so you can concentrate on your first week or two on the job. It takes a little work, but you’ll be grateful when that first week of work starts.
2. Get to know your facility.
Learning where your team stores various equipment is one of the most important and practical things to do when you first start your job. You’ll need to know what is kept in the supply room and where your team stores the Crash Cart. Being able to retrieve items quickly will make your job easier, and those precious extra seconds can make a difference in a true emergency. So take yourself on a tour of your floor and figure out where everything is!
3. Ask smart questions.
Some nurses hesitate to ask questions at a new job because they’re afraid that it will make them look ignorant. However, asking smart questions will show that you’ve been paying attention and are actively engaging with the team. If you need to, carry around a little notebook where you can jot down the various answers and refer back. This way, you don’t end up asking the same question a dozen times over.
4. Listen to the gossip (but don’t participate).
While it’s important to know the official policies and procedures, a lot of the important knowledge is passed along through word of mouth. If your coworkers start chit-chatting with you, pay attention to see if you can glean any information about how the unit works. You may learn by hearing about past events. However, it’s usually best not to participate in the gossip yourself, especially before you know your coworkers well. You don’t want to ruffle any feathers.
5. Stay positive.
There are bound to be some mishaps and miscommunications during your first weeks on the job. While you might be tempted to get down on yourself, try to look for the bright side and stay positive. You’ll likely be stressed from the new job, which makes you more vulnerable to small mistakes. So cut yourself some slack and try to stay upbeat.
6. Reach out to coworkers.
Having a friendly, open demeanor can go a long way toward helping you establish good relationships with your coworkers. Make an effort to participate when they engage you in conversation and say “yes” when they invite you to lunch. As you get to know people better, you can take the initiative in starting conversations or asking if they want to grab coffee together on your breaks.
7. Find a good mentor.
Having a good mentor is crucial to succeeding at your job. In a perfect world, this mentor will be your direct supervisor, but you won’t always end up with a great boss. If your nurse supervisor is less than ideal, seek out a mentor who you don’t report to but can trust. This person can be someone at the facility or someone else.
8. Be a team player.
Nurses do have a lot of autonomy and often work independently, but they also operate as a unit. The best nurses can work well on their own or with their team members. It’s also important to be able to work well with doctors and other health care providers. Make it a point to be a team player and work well with your new coworkers. If you prefer to be a lone wolf most of the time, see this as an area of growth and set a goal for yourself to improve your teamwork skills.
9. Give yourself time.
It’s normal to feel a bit unbalanced as you adjust to a new job. Not only are you in a new environment surrounded by new people, but you might also be taking on new duties. If you moved cities on top of getting a new job, you’re going to feel even more frazzled. Give yourself at least six months to get settled into your new role. It takes a while to feel comfortable at a new job. Be aware that it may take longer, especially if you’re dealing with other changes.
10. Stay confident.
As part of that adjustment period, you might feel like you don’t belong at your new job and wonder whether you’re truly qualified for the position. These feelings are totally normal and especially common if the new role is a promotion. Remind yourself that your employer wouldn’t have hired you for the role if you weren’t qualified. Everyone takes some time to get settled into a new job.
11. Advocate for your patients.
In the stress and confusion of a new job, don’t lose sight of why you go to work in the first place: your patients. Patient outcomes should always be the priority for both you as an individual nurse and your facility. Whenever you feel overwhelmed by all the new changes, focus on caring for your patients and providing the best care possible. You can’t go wrong with this attitude.
If you follow these 11 strategies, you’ll be able to don your scrubs and your nursing shoes with confidence on your first day. Good luck at your new job, and congrats on finding a new nursing position!
In the age of EHR, storing info on a cloud, and working on smart phones, it’s also a prime time for hacking. Nurses need to protect the security and privacy of their patients’ personal and health care-related info so it’s important to educate yourself about cybersecurity best practices. So, how do you go about it?
What are the best ways for nurses to protect their patients’ information?
One of the best ways that nurses can protect their patients’ personal and health care-related information is to inform themselves about cybersecurity best practices. If your organization doesn’t offer cyber awareness training, request that they do so. This type of training can help you understand cyber threats like malicious websites, phishing emails, and other tactics that cybercriminals use to carry out attacks.
Here are a few other good cybersecurity best practices that you can use right away:
Always use unique passwords for your accounts.
One of the biggest mistakes that people across all industries make is using the same password for multiple accounts. A poll from Google and Harris shows that 52% of users reuse passwords across multiple accounts, and another 13% indicate that they use the same passwords across all accounts.
This means that all of your accounts should have unique passwords. This prevents hackers from using the same password to access multiple accounts in the event that one of your accounts becomes compromised.
Never plug personal devices (or unauthorized devices) into workstations or work devices.
Don’t click on attachments or links in emails without first inspecting the messages.
Check to see if the sender’s name and email match, and if any links are legitimate. If the name and email don’t match, or if the link is from some unknown web address, that should send up a red flag. For example:
If you normally get emails from your boss (email@example.com) but suddenly receive an email from an email address like firstname.lastname@example.org or email@example.com, that would be suspicious.
If there’s a link embedded in the email, hover your mouse over the link (without clicking on it!) and it should display the true web address where the link would take you.
If you receive an email from a suspicious address that contains a PDF, Excel file, or Word doc, don’t click on it. It’s possible that the file may contain malware.
If you receive an unusual or urgent request, call to confirm.
A common tactic that cybercriminals use to get you to do something or to provide information is to create an urgent situation. If you get an email or phone call from someone asking (or demanding) that you send them sensitive information, tell them you’re going to call them back to confirm. Use the contact information that’s provided through your organization’s official contact directory—never respond using an email address or phone number provided by the person who reached out to you!
Be aware of what’s going on around you.
Not all data breaches occur because of cyber attacks—sometimes, they come in the form of physical security breaches. Is there someone hanging around the nurses’ station that you don’t recognize or who doesn’t belong there? Ask them if they need help. This proactive approach can help to prevent cybercriminals from gaining physical access to records and other data by accessing computers at those stations or stealing portable devices from the area.
Much like how you sanitize your hands and wear protective gear to keep yourself and your patients healthy, having strong “cyber hygiene” is what keeps your organization (and your patients’ data) safe and secure.
Why do nurses need to protect their own email accounts, social media accounts, or their phones? Why do hackers start there?
Your personal email and social media accounts are a goldmine of data for cybercriminals. They can use information that they learn about you through those channels to guess your work account passwords. It also serves as fodder for social engineering tactics.
Nowadays, people tend to use their mobile devices and apps for banking, sending emails, and for handling other sensitive data. If a cybercriminal gets a hold of your cell phone or another mobile device that you use to access those accounts, then they have control of those accounts.
What are the most common tricks that hackers use?
Cybercriminals use the tactics that demonstrate the best outcomes with the least amount of effort. Needless to say, it’s a lot easier to trick someone into handing over their credentials than it is to hack through their organization’s network security defenses.
That’s why phishing is among the most common tactics used by cybercriminals. Phishing relies on the use of social engineering tactics, which often involves them pretending to be a colleague, manager, or another authority figure. Cybercriminals use strong social skills and charm to disarm you while also evoking a sense of urgency, fear, or curiosity that compels you to act. Their ultimate goal is to trick you into doing something you’d normally never do.
For example, you’d never just give a stranger your employee credentials or a patient’s health records or personal information. But if you receive a fraudulent email from someone pretending to be your organization’s IT team saying that your password has been compromised and that you need to reset it via a link they provide, you may be doing precisely that without even knowing it.
Cybercriminals use phishing emails to get users to download malicious software or to click on malicious links. Continuing with the previous example, if you enter your username and password in a password reset form on a fraudulent website that looks like your organization’s site, then you’re giving them the ability to log in to your accounts and access any systems your account touches.
What kind of information are hackers trying to get? What do they do with it?
Hackers love all types of data. They can choose to use it themselves to carry out crimes or sell it to other cybercriminals through a market known as the dark web for profit. Some of the types of data they look for include:
Personally identifiable information (PII) such as names, phone numbers, addresses, social security numbers, etc.
Financial information such as credit or debit card information, bank account numbers, etc.
Protected health information (PHI) such as health records and insurance-related information
Proprietary data and intellectual property
Usernames, passwords, and other account credentials
User credentials and passwords are particularly valuable to cybercriminals. If they have your username and password, then they have the virtual keys to the kingdom. Hackers can use this information to access your organization’s network, databases, patient files, or any other systems that your account touches.
What would readers be most surprised about regarding cybersecurity?
Unless an organization chooses to eliminate everything digital within their environments, there’s no way to prevent every cyber attack. Hackers are always going to find vulnerabilities and weaknesses to exploit. But what you can do is follow cybersecurity best practices to make yourself and your organization tougher targets.
Firewalls, antivirus software, and other technologies can protect your organization from some threats but not all. You and your fellow health care providers are what constitute the “human firewall” of your organization.
Is there anything else that is important for our readers to know?
Data from Black Book Market Research shows that “Over 93% of healthcare organizations have experienced a data breach since Q3 2016 and 57% have had more than five data breaches during the same timeframe.”
Researchers at Vanderbilt University believe that there may be a link between ransomware attacks and data breaches and an increase in heart-related deaths among patients at hospitals hit by those attacks. According to Brian Krebs, a cybersecurity expert and author: “Hospitals that have been hit by a data breach or ransomware attack can expect to see an increase in the death rate among heart patients in the following months or years because of cybersecurity remediation efforts.”
You can complete cyber awareness training on your own. The U.S. Department of Defense offers free cyber awareness training online in the form of its DoD Cyber Awareness Challenge.
Having to wear PPE creates a communication barrier that imposes a heavy burden on nurses. Patients look to nurses for information, help, and comfort, but now—at a time when they depend on nurses more than ever—you have to interact while swathed in protective gear. It is nice to be acknowledged as a “hero,” but being a masked hero makes the job a bit harder, doesn’t it?
What can you do to communicate more effectively and connect with patients while wearing PPE? DailyNurse sought guidance from patient-provider communication specialist Dr. Mary Beth Happ, PhD, RN, FAAN, FGSA.
Dr. Happ outlined the problems: “[PPE can cause] muffled voice and conceals facial features, particularly the lips and mouth. We give each other important communication cues through facial expressions (such as smiling) as well as mouth and lip movement when talking. This is particularly important for patients who have any hearing impairment, delirium, or dementia. The patient may not realize that the nurse is speaking or may be confused by the sound of the nurse’s voice without seeing mouth movements. Another way that we communicate is through human touch. Unfortunately, reduced contact time and wearing protective gloves limits touch communication.” Here are Dr. Happ’s tips for nurses seeking ways to connect across the PPE barrier:
1. Use your eyes, your hands, and a notepad to communicate
“Getting and maintaining eye contact with the patient as much as possible is so important. ICU patient survivors have told us how frightening it is when the eyes are their only way to connect with the humans caring for them (due to intubation, physical restraints or weakness) and the nurse or therapist does not make eye contact.
Nurses can allay patient anxiety by using special communication tools and techniques to augment or assist a patient’s understanding of the nurse’s messages. For example, we recommend always keeping a notepad and felt tip pen or marker at the bedside. Write key words or phrases as you are speaking to reinforce and help the patient understand your message. Use picture communication boards to emphasize your meaning if patients have low literacy or English proficiency. Also, gently touch the patient’s shoulder or arm when you speak to get their attention and connect.”
2. Make it easier to identify the person behind the mask
“Over-enunciate, deliberately slow the pace of your speech, and keep each message short. Breathe in and out through your nose. Allow pause time for the patient to process what he/she thinks you said. Validate that they understand – ex: what did you hear me say? What do you understand will happen now? Try not to appear rushed. This is a good quick resource: https://torontoadultspeechclinic.com/blog/2020/3/30/speaking-with-a-mask-on.”
4. Communicate with hand and arm gestures, or use a form of sign language to help convey your meaning
“We recommend simple but consistent (repeated) gestures and the use of referential pointing – that means pointing to objects or parts of the body that you are talking about. By consistent gestures, I mean that you should use the same gesture for particular words (such as, yes/no, okay, pain medicine, hot/cold, tired, turning/repositioning in bed) repeatedly to avoid confusion. We recommend posting a sign at the bedside with frequently used gestures and their meanings (sometimes patients have idiosyncratic gestures) so that others will use the same lexicon or “gesture dictionary.” Family members may be able to help identify meanings for individual gestures or expressions.”
5. Use audio and video technology to help patients stay connected with loved ones
6. Follow some basic communication “dos and don’ts”
Dr. Happ’s list:
Do get the patient’s attention, make and maintain eye contact for as much of the interaction as possible.
Do establish a clear Yes-No signal with the patient (ex: head nods – shake; thumbs up – fist closed; eye blinks – eyes shut tight).
Do post the patient’s Yes-No signal and communication plan (tools, favorite topics, common gestures) at the bedside and pass this info on in shift handoffs and interdisciplinary rounds.
Do have communication supplies (paper, marker, clipboard, communication boards) ready at the bedside anticipating the need.
Do always confirm or validate your understanding of the patient’s message.
Don’t assume that patients who are quiet or have eyes closed have nothing to communicate. The eyes closed behavior may be their way of coping.
Don’t encourage patients who are orally intubated with an endotracheal tube to mouth words. This action is can cause bronchospasm and airway irritation.
Don’t assume that you can lip read a patient’s silently mouthed words with high accuracy. Lip reading is a difficult skill and prone to misinterpretation. For example, a request for “pants” was interpreted as “pain” and the patient received unnecessary sedating narcotics. A patient tried to tell his nurse about a problem with the “urinary bag” but the nurse walked away thinking he said, “you are bad.” The YouTube videos that replace nonsense words in politician’s speeches are evidence of the dangers of lip reading. If you must lip read, always confirm your understanding with the patient.
Dr. Mary Beth Happ, PhD, RN, FAAN, FGSA, is the Nursing Distinguished Professor of Critical Care Research and Associate Dean for Research and Innovation at The Ohio State University College of Nursing. Dr. Happ’s research focuses on improving care and communication with communication-impaired patients.
This is part of a monthly series about side gigs—nurses with interesting side jobs or hobbies. This month, we spotlighta nurse’sfamily farm.
For 40 years, Eileen Shlagel, RN, CEN, has worked as a nurse, the last 30 of them in the Emergency Department of University of Maryland Charles Regional Medical Center in La Plata, Maryland.
“I feel honored to be able to work in a career that I love and in a hospital that I love,” says Shlagel, who now works part-time. Another added bonus? Her only daughter also works there.
That’s not Eileen’s only job, though. Since the mid-1980s, Shlagel and her husband have been operating the family farm, Shlagel Farms, LLC. Located in Southern Maryland, Shlagel Farms is a Century Farm—this is a title of recognition given to any farm that has been operating continuously for at least 100 years. Shlagel says that in the state of Maryland, there is a ceremony every couple of years, at which the Governor presents the farmers with a sign and a certificate.
By 1990, the Shlagels had five children, and they would work with their parents every day. Today, they grow many different kinds of fruits and vegetables. They raise cattle, turkeys, chickens, and a few pigs, and also grow horse-quality straw, wheat, and hay. Shlagel says that in addition to operating a farm store, they also sell their goods at 10 Farmers Markets in the Washington, DC/Baltimore area. They also provide their produce to two major grocery chains and to a broker who sells supplies to area restaurants.
Three of her sons work at the farm full-time, and, overall, the farm supports 12 families.
“I personally take care of the 19 bee hives, go to Farmers Markets, schedule and run the field trips that we host for kids, do payroll, keep the books, schedule the employees, and wash all of the chicken eggs. I’m in charge of the USDA Certified Food Safety Program,” says Shlagel. “When you live on a farm, you work there full time. There is always something that needs to be done—from first thing in the morning until dark.”
Shlagel believes that people would be surprised how scientific farming is. “It’s so much more than putting a seed in a hole and giving it water. We attend classes every winter to learn the latest techniques, updates, and legislative issues that could impact our business from the USDA, FDA, or the Maryland Department of Agriculture,” Shlagel explains. “A farmer must be a biologist, a chemist, a vet, a careful money manager, and you have to be really adept at prioritizing. You can do everything right, but if it’s at the wrong time, it’s worthless. Timing is everything.”
The most rewarding part of the job for Shlagel is spending time with three of her sons as well as her 13 grandchildren. “It’s rewarding teaching them how to complete jobs that will make them feel successful and proud of themselves. Recently, I took three of them to the green bean field to pick a mess for dinner. They picked them and snapped the ends off and then we cooked them together and they ate them for dinner. Additionally, I love to show them all of the beauty in nature. We take walks around the farm, and we might spot a frog or a snake or a turtle and we talk about it and then they research it later,” says Shlagel.
The greatest challenge that Shlagel has faced on the farm was learning to care for and expand their Apiary. “I took a class and read two books, but that in no way prepares you to be surrounded by 50,000 stinging insects! I had assumed incorrectly that you put them in a box, and they go pollinate and everything is lovely,” admits Shlagel. “They require inspections every two weeks, which still take me five to six hours. You have to make adjustments in their living area, give them water and food in the winter, and make sure their Queen is alive and happy. Most of what could go wrong, did for me in the first year, but I have learned to fix the problems before they get bad. And I have certainly learned to take a sting!
Even though she worked two full-time jobs for many years—nursing and farming—Shlagel says she wouldn’t have it any other way. “I love every single day that I go to work at the hospital, and I am very happy at home, working outside with my family.”
With no injured students appearing at their door, no pupils with chronic conditions arriving for a visit, why would school nurses be needed in a virtual learning environment?
“There’s a lot that a school nurse can do virtually,” says Linda Mendonca, RN, MSN, PHNA-BC, NCSN, FNASN, president-elect of the 17,000-member National Association of School Nurses (NASN). Even with virtual learning, school nurses provide a variety of important health services.
For instance, school nurses can provide health education to the school community, she notes. They can also monitor immunizations. Some data suggests, Mendonca says, that during the pandemic children are not being kept current on their immunizations. Whether the child is sitting in a school building or at home, school nurses need to be connected to parents to make sure that the children have all of their immunizations up to date.
School nurses can also provide referrals and connections to resources. If a family needs help due to food insecurity or access to any kind of social services, “the school nurse can be an advocate in providing those contacts and making those connections for them.”
With the fears and anxieties the pandemic causes, school nurses can also assist with mental health, “offering information to families about mental health concerns and again making contacts and referrals.”
Besides these types of assistance, school nurses, says Mendonca, can work with students with chronic health conditions, “continuing that care coordination.” They can help ensure that these students are following up on medical appointments.
As for reductions in school nurse staff, the NASN does not have specific data on that topic. Mendonca notes that in Rhode Island, where she lives, she was aware of school nurses being given pink slips in May, with some not being called back. In Florida, a story in The Palm Beach Post stated that the Palm Beach County’s Health Care District furloughed health care personnel, including school nurses. The reason cited, according to the story, was that the school year would start with remote learning with no end in sight.
At the same time, notes Mendonca, school nurses are in short supply. Statistics from a 2018 report in NASN’s The Journal of School Nursing indicate that 25% of schools did not employ a school nurse and 35% employed a school nurse only part-time.
The safety of students and staff must take priority in making the decision for a safer return to in-person learning, according to a statement released by the NASN in July. The decision-making process, the statement says, must be based on accurate public health data at the national, state, and local levels.
“School nurses want to get back to school, want to be part of that community in person, but we want to make sure that that we can do it safely,” Mendonca says. That decision to return to school needs to be based on public health data, including data at the community level, because community transmission rates vary, she notes. Also, adequate resources and plans need to be available, such as PPE, cleaning and disinfecting supplies, testing strategies and contact tracing.
“School nurses,” says Mendonca, “are the public health experts in the school community. And they are certainly going to be key to a successful reopening of schools in this country.”