It’s no secret that our elderly are the fastest growing segment of the U.S. population, fueled largely by aging Boomers. So it’s simple to deduce that nursing careers in adult-gerontology can offer many opportunities for growth and nursing leadership. However, working effectively with this demographic requires specific skills for success.
Nursing competencies should include a BSN and a minimum requirement of a firm base of experience in general medical-surgical nursing to care effectively for the disease processes that affect the elderly. Cardiac and respiratory conditions, diabetes, and cognitive impairments are among the most common pathologies troubling people over 55. Nurses must be adept with assessment skills to detect condition changes in their patients. Nurses advancing to management roles will be better prepared with their MSN, NP, and even a DNP.
You’ll need capable skills for working with the most common psychosocial issues of those in their later years. Many elderly patients suffer from social isolation and depression, which can exacerbate physical issues they may be dealing with. Nurses will also need to demonstrate empathy and patience when working with those suffering from cognitive impairments such as dementia or Alzheimers. They must also demonstrate the ability to anticipate their patients’ needs when the patients aren’t able to articulate their needs themselves.
The health of elderly patients can be mercurial. Their
immune systems are no longer as robust as they once were, and they’re often
further influenced by other disease processes. Something seemingly routine and
easily treated in younger patients, such as a urinary tract infection, can
trigger a cascade of symptoms that can send many clinicians scrambling. A nurse well-versed
in the care of the elderly will quickly identify the more subtle changes with
A good geriatrics nurse also knows about the best resources to
guide their patients to wellness. For example, making a patient or their family
aware of adult day care centers in their neighborhood can lighten the load of
caring for them during working hours. Asking the physician for a consult with a
neurologist or psychologist for developing cognitive issues, or a urologist for
intractable urinary infections facilitates the patient’s access to timely
treatment. Requesting a referral to a social worker to address neglect or abuse
issues in the patient’s home keeps the patient in a safe environment.
The first book to encompass adult-gerontology practice guidelines for primary care, this comprehensive resource is useful as both a clinical reference and as a text for health care practitioners working with this population. The second edition features 27 completely new entries associated with the aging population, an entirely new section on geriatric syndromes, and multiple updates to guideline changes for screenings.
It is no surprise there is often confusion between the concepts of experience and engagement. Tack the word “patient” to the front of either, and you’ll likely become even more confused as to the difference in meaning between the two. The difference, however, becomes significant when we look at the current state of health care. The reality is, participants in the health care industry are dedicating significant resources to enhancing the patient experience.
Equally, investments in technology and labor are being made to
improve engagement with patients, both prospective and current. This shift in
patient engagement has stemmed from an increasing number of patients playing a
more active role in managing their health affairs through digital platforms. While
both patient experience and patient engagement contribute equally
to patient loyalty, there are key differences worth noting.
Patient experience can be summed up as the cumulative experiences a patient encounters throughout their dealings with a health care provider. This begins with the initial phone call and continues right through administering care to the patient and the routine after-care checkups. A patient’s experience is a journey that is often comprised of:
The initial phone conversation or online booking made to schedule an appointment with the health care provider.
The patient’s visit to the premises, including the interaction between the receptionist staff and the patient upon arrival and departure.
The level of care provided by the health care provider to the patient, and the quality of the health care staff who administered the care.
Whether the patient’s experience was comfortable, this includes the gown they were provided with and the appropriateness of the uniforms worn by the health care provider.
The patient’s billing experience, such as the ease, convenience, and flexibility of payment.
The after-stay experience with the health care provider—for example, did they make a follow-up call to the patient to gauge how they were feeling and whether the provider could have improved on any aspect of care?
In summary, every encounter the health care provider has with the patient contributes to the overall patient experience. Patient experience places the onus of care mostly on the health care provider, meaning the provider is responsible and accountable for the patient’s experience from start to finish. Understanding the touchpoints of this experience is critical to enhancing the overall relationship between the patient and the provider.
The Center for Advancing Health defines patient engagement as the “… actions individuals must take to obtain the greatest benefit from the health care services available to them.” Patient engagement puts the onus of health care back on the patient. Patients are afforded an opportunity to enhance their health and well-being through various health care services on offer. However, the patient must act for engagement to take place. This shift in onus from provider to patient is the main differentiating factor between patient experience and patient engagement. Some examples of patient engagement are:
1. Patients and their families engaging in wellness programs, health-based courses, and initiatives provided by health care providers.
2. Patients registering for, updating, and regularly using online health care records. The introduction of online health care records offers significant convenience and control for patients who traditionally would not have documented their health history.
records enable patients to manage their health information,
including advanced care plans or custodian details.
Online health records also allow patients to add personal notes regarding any allergies and allergic reactions they may have previously had and set up text or email notifications to notify the patient that a health care provider has viewed their record.
Patients concerned about security can configure their security settings to restrict access to their records and who can and can’t view their health records online.
3. Provide input into patient engagement surveys or broader initiatives. Surveys on patient engagement have been used previously to gauge the services that can be undertaken by a patient as opposed to health care providers. This, in turn, allows the health care provider to devote resources to segments of the patient experience cycle that require more attention.
Achieving Both Patient
Satisfaction and Engagement – Is It Possible?
Patient experience focuses on the steps taken by the health care provider to enrich a patient’s experience, whereas patient engagement centers on the actions taken by a patient to engage in the services provided by the health care professional. While differences between patient experience and engagement are apparent, the two operate hand in hand when understanding the full gambit of a patient’s interaction with health care providers in the modern-day health care landscape. The question is, can a health care provider serve both sides of the spectrum? Can this utopia of patient interaction be achieved? Essentially, the answer is yes, it can, but only by understanding some fundamental levers. Some of these levers are:
Defining the patient. Is the patient one person or should this comprise the patient’s family, friends, and caregivers? When assessing experience and engagement, should experience be focused on the individual’s experience with the provider or on how a patient and his/her family interact with health and wellness programs?
Defining the degree of control. What control does a patient under the “patient engagement” umbrella have in determining their quality of care and level of engagement? When we speak about engagement, how much choice does the patient have? Conversely, does the patient experience relinquish all control, or can there be some middle ground, where the patient can provide input into the patient experience cycle by, for example, completing surveys?
The degree of engagement. If a health care provider has patients who are highly engaged, completing most tasks themselves, is this the ideal degree of engagement? For example, is having patients schedule appointments themselves, leverage technology to pay for bills, and update their health care records the proper amount of engagement? Some believe so and argue patient engagement allows that other elements of care, such as the actual health care service, should be left to the patient experience cycle.
There is undoubtedly an opportunity for health care providers and patients to work within the confines of the patient experience and patient engagement concepts. Advancements in technology, such as online health care records and increased availability of health programs, have created the platform for patient engagement and made it easier for a patient or a patient’s family member/caregiver to manage their health affairs. This has reduced administrative dependency on providers, who can now focus on more pressing facets of the patient experience, such as the level and quality of care provided to patients.
Overall, the outlook appears positive and, in time, health care providers and patients will likely find a comfortable medium between bearing the burden of patient engagement and patient experience.
Nursing services are critically important at the U.S. Department of Veterans Affairs (VA), as they are at any healthcare organization. But thanks to VA’s Nurse Executives and a commitment to collaboration, nurses are always at the table when decisions are made about Veterans’ healthcare.
For Cooke, that equality extends to anyone knocking on his door to discuss a clinical practice challenge, innovation or another matter.
“We can walk into anyone else’s office and discuss a situation freely and without prejudice,” he said of his staff. “It’s not ‘my’ problem or ‘your’ problem. If we have a situation, it’s our problem or our issue to resolve together.”
Collaborating nationally to improve care locally
VA Nurse Executives, stationed around the country, are highly respected and skilled, and together lead VA’s nearly 100,000-strong nursing service. Whether they’re serving as Chief Nurse, Director of Nursing Services or Associate Director of Patient Care Services, each nurse leader is working toward improved nursing care for the nation’s Veterans.
Despite being located in nearly every state and the territories, VA encourages Nurse Executives to learn from each other through national email groups, comprehensive national and local nursing websites, and internal networking and discussion boards.
“One of the most rewarding aspects of being a VA Nurse Executive is having 141 fellow Nurse Executives as colleagues who serve as subject matter experts in every domain of professional practice and leadership,” Barry said. “The ability to reach out and easily collaborate is wonderful!”
VA’s Nurse Executives consult on the Nursing Executive Leadership Board and Field Advisory Committee, where they share information and contribute to decision making. VA Nurse Executives also have access to peers nationwide to ask consultation and practice questions, develop research and contribute to quality improvement.
“VA Nurse Executives participate on nurse-specific committees as well as interprofessional programs and task forces at the local and national level to develop innovative and progressive approaches that influence the practice and delivery of care, not just within VA, but potentially on a national level,” Barry said.
Shaping the quality of care
Nurse leadership is also nurtured among VA’s front-line nurses. Nursing personnel are encouraged to share their ideas and concerns, serve on national and local decision-making committees and become educated and trained nurse leaders in their own right.
Overall, this cooperative environment positively impacts the quality of healthcare and reliability of service at VA.
VA’s system also fosters the leadership skills and sense of duty prevalent among VA’s nursing and other healthcare professionals — thousands of whom are Veterans, in the reserves or come from families who served and all of whom view working at VA as a career with a mission to give back.
Choose VA today
Nurse Executives who work in the private sector are taking notice of the opportunities to lead at VA and the benefits of VA careers, Cooke said.
Lauren Bond, a traveling nurse, has held licenses in five states and Washington. She maintains a detailed spreadsheet to keep track of license fees, expiration dates, and the different courses each state requires.
The 27-year-old got into travel nursing because she wanted to work and live in other states before settling down. She said she wished more states accepted the multistate license, which minimizes the hassles nurses face when they want to practice across state lines.
“It would make things a lot easier — one license for the country and you are good to go,” said Bond, who recently started a job in California, which does not recognize the multistate license.
Nurse Licensure Compact
The license, known as the Nurse Licensure Compact (NLC), was launched in 2000 to address nursing shortages and enable more nurses to practice telehealth. Under the agreement, registered nurses licensed in a participating state can practice in other NLC states without needing a separate license. They must still abide by the laws that govern nursing wherever their patients are located.
About half of the states joined the original compact, which was modeled on the portability of a driver’s license. Some states that declined to sign on cited a major flaw: The agreement didn’t require nurses to undergo federal fingerprint criminal background checks.
Last month, the National Council of State Boards of Nursing launched a new version of the NLC that requires those checks. Twenty-nine states have passed legislation to join the new agreement.
Jim Puente, who oversees the compact for the council, said he expects even more states to sign the agreement now that criminal background checks are required. He noted that nine states have legislation pending to join.
Among states participating in the new nurse licensing compact are Iowa, Kentucky, Tennessee, Delaware, Idaho, and Arizona.
California does not plan to join the new compact, largely because of concern about maintaining state training and quality standards. The state, like many others, already requires nurses to undergo background checks. Washington, Oregon, and Nevada are among the other states that do not accept the multistate license.
Proponents of the nurse licensing agreement — both the old and new versions — argue that it helps fill jobs in places where there aren’t enough nurses and enables nurses to respond quickly to natural disasters across state lines.
Similar cross-state agreements exist for physicians, psychologists, emergency medical technicians, and physical therapists.
In some states, the multistate nursing license is helpful because it streamlines the process for nurses doing case management or telehealth, said Sandra Evans, executive director of the Idaho Board of Nursing. Getting nurses to work in the rural areas of Idaho is a challenge, and hospitals often rely on telemedicine in places where the closest healthcare facility might be in Montana, she said.
Before Idaho joined the original NLC in 2001, nurses doing telehealth or case management needed numerous licenses to work across state lines, but now they “can travel virtually — electronically or telephonically — to help their clients,” she said.
Joey Ridenour, executive director of the Arizona State Board of Nursing, said one of the biggest advantages of the compact for her state is that it allows authorities to share information and collaborate with other states to investigate and discipline problem nurses. “We are able to take action faster,” she said.
‘Competent and Qualified’
Opponents of the compact argue that states have different standards, course requirements, and guidelines and that nurses licensed in one state may lack the necessary knowledge or experience to practice in another one.
Nurses in California have similar concerns. “We really want to make sure that nurses who are entering our state and taking care of our patients are competent and qualified,” said Catherine Kennedy, a Sacramento-area nurse who is secretary of the California Nurses Association. Some traveling nurses haven’t been, she added.
Kennedy said California does not have difficulty recruiting nurses, even without the compact, because of the state’s relatively high salaries and strict nurse-to-patient ratios in hospitals.
Research has shown that California’s minimum nurse staffing requirements, which were the first in the nation, can reduce workloads and burnout, improve the quality of care and make it easier for hospitals to retain their nurses.
Massachusetts, which has never participated in the nurse licensing compact, requires nurses licensed there to take courses on treating victims of domestic violence and sexual assault, said Judith Pare, director of the division of nurses for the Massachusetts Nurses Association. If the state allowed out-of-state nurses to practice in Massachusetts without getting a license there, they wouldn’t necessarily have that training, she noted.
Jenn Stormes works as a nurse and formally cares for her 18-year-old son, who has a severe seizure disorder and developmental disabilities. Stormes is licensed in Colorado, which participates in the multistate compact.
She has been able to use that license in some states. But she has also had to get several individual licenses so she can continue serving as her son’s nurse in other states where the family travels for medical care. Stormes estimated she has spent about $2,000 on licenses.
“It took me over a year to get all these licenses,” she said. “I had to prove to every state the same education, the same experience, the same fingerprints. I think it is a duplication of efforts and is a waste of everybody’s time and money.”
my nearly 20 years of experience as a registered nurse, I’ve learned that
simple steps make a significant difference. Fast-paced clinical settings make
the procedures and protocols that all medical staff are familiar with
incredibly important. Proactive steps, as simple as remembering to always wipe
down all patient areas and keep them clear of unnecessary or unused supplies,
have the ability to keep both patients and medical staff safer.
nurses, patient safety is fundamental to what we do. It’s the first thing that
we think about when we get up in the morning, and the last thing we think about
before we go to bed. But no matter what your role in the organization, patient
safety must be the priority.
This is especially true when caring for patients with chronic
diseases, who are at an even higher risk given their weakened immune systems. At Lung Health Institute, we
specialize in treating patients with chronic lung disease, such as COPD and emphysema,
and we’re proud to have earned The Joint Commission Gold Seal of Approval® for
ambulatory health care accreditation.
Because we are continually evaluated, this recognition reflects our longstanding
commitment to The Joint Commission’s National Patient Safety Goals focus on
identifying patients correctly, using medicines safely, preventing infection
and providing appropriate treatment.
that vetted protocols and procedures are in place across your organization
is the first step to providing the safest environment possible for your
patients. Formal accreditation is a great way to ensure this exists, but
you should also revisit and review your procedures regularly. Health care is dynamic, and these
processes need to constantly evolve along with the industry.
At any stage of the process in your organization, here are a few tips that nurses caring for patients with chronic disease should follow to ensure the safest environments:
Never stop learning: Best practices and industry
standards are always changing, so you should strive to stay on top of the
latest and greatest. I would recommend getting involved with local or national
nursing organizations and attending any relevant conferences.
Lend a helping hand: With more young nurses in
the field than ever before, experienced nurses need to lead by example, taking
the extra time to demonstrate the right procedures and protocols can go a long
Open the doors of
Patients are often scared when in a health care setting and taking the time to
ask them questions about not only how they’re feeling physically — but mentally
— can ensure you’re adjusting treatment plans appropriately and collaborating
with physicians in real time to problem solve. A safe environment for patients
takes into account both their physical and mental health.
Slow down and think: It’s incredible how many
errors can be prevented by taking the time to think, without rushing through your
Speak up: If you’ve observed standards
and protocols and think something could be done differently, say so. Real life
experiences help shape and create the best processes, and every operation is
unique and should be tailored appropriately. Following a challenging situation,
take the time to debrief with your peers — those more experienced and less
experienced than you. Talk about what happened, and how you can work together
to make it better or more efficient moving forward. Update procedures and
When transplant cardiologists at the Debakey Heart and Vascular
Center at Houston Methodist Hospital, began to use percutaneously placed
axillary intra-aortic balloon pumps (PAxIABPs) in 2007, there was one problem.
Not with the procedure, which would act as a bridge to heart transplants. But
rather, with the nursing care that would take place after. When CICU nurses
searched for literature on the subject, there was one problem.
There wasn’t any.
The procedure was so new, so no patient care protocols existed. So they developed them. And now an article about the problems and solutions developed by the nurses is out.
Frederick R. Macapagal, BSN, RN, CCRN, RN, Cardiac Intensive Care Unit, Houston Methodist Hospital, was a part of that team and is a lead researcher on the article. What follows is an edited version of our interview with him
Q: Were you on the original team that discovered that no nursing literature existed on PAxIABPs in 2007?
I was part of the team at Houston Methodist Hospital that
searched the literature in 2007 and did not find any nursing articles about
caring for patients with PAxIABPs. Medical journals had a few articles about
similar procedures, but they focused on the surgical intervention with nothing
about nursing care.
Since this was a relatively new procedure, the lack of
nursing articles was not surprising. Our protocols were developed over time,
using evidence-based nursing care and lots of “learning by doing.” After about
10 years of developing, reevaluating, and taking care of more than 100 patients
with PAxIABPs who are awaiting heart transplant, our staff has become more
competent and comfortable taking care of these patients.
Q: Explain how the
nursing and medical teams collaborated to develop these protocols. Did you work
together to determine what to try and what not to? Please explain.
The cardiologists informed us about the new procedure and
what the change meant for the patients. They gave us parameters and guidelines
on what to do and not to do to take care of the balloon pump and the insertion site.
Overall, the doctors trusted the nursing staff to figure out how to walk these
patients safely and provide the care needed at the bedside. The
multidisciplinary team of nurses, doctors, physical therapists, and ancillary staff
collaborated to devise interventions to mitigate the problems that arose and
incorporate them into the standard of practice.
Q: How did you decide
how to develop and implement clinical practice guidelines if there was no
previous literature with evidence-based practice backing it?
We did not have a choice. Our patients with intra-aortic
balloon pumps needed us to find a way to get them moving. Our patients needed to
walk to keep up their strength while waiting for a transplant, and we had to
develop our own nursing care protocols based on existing evidence-based
practices in order to safely incorporate walking and mobilizing into their care.
Q: What are the
resulting clinical practice guidelines that reflect nursing care practice and
The mobility guidelines we developed address issues such as where
patients walk within the cardiac care unit, for how far, and how long. We
defined the number of staff who need to walk with the patient, based on each
one’s individual strength. The guidelines also cover how often laboratory tests
and x-rays need to be completed. For example, laboratory tests such as complete
blood count and basic metabolic panel are obtained every other day to minimize
blood loss and the need for blood transfusions. On the other hand, chest
radiographs are obtained every day to determine the PAxIABP position.
Our nursing team also developed a PAxIABP repositioning kit so
that transplant cardiologists can perform simple repositioning of the PAxIABP
at the bedside as needed. This kit
contains sterile gloves, masks, surgical cap, stabilization device adhesive,
CHG scrub stick, and a prepackaged central catheter dressing kit. The kit,
stored in a clear plastic bag, is hung on a pole attached to the IABP console
for easy access.
Q: The article lists
some really interesting morale boosters used. Why are these so important to patients
in these situations?
Our pre-heart transplant patients with IABPs wait anywhere
from a few days to months for a donor heart. Anyone would get depressed with waiting
for so long under such stress. So the nursing staff came up with different ways
of helping our patients cope.
We consider these patients part of the CCU family and treat
them as such. We call them by their first names, chat with them about anything
and everything whenever we pass by their rooms, and get to know their family
and other visitors. We celebrate birthdays, anniversaries, holidays, and other
special occasions. We’ve found ways for patients to enjoy the occasional
home-cooked meal, have their pets come for a visit, and more, in an effort to
keep their spirits lifted.
Our patients from 10 years ago regularly come to our unit
when they are in town, chat with us, and offer to visit with current patients
who might need a pep talk and some cheering up. Patients appreciate the extra
effort we put into making their stay with us enjoyable.
Q: What else is important
about the nursing protocols for patients with PAxIABPs?
We started with existing evidence-based practice, but our journey didn’t end there. Whenever a challenge arose, we found solutions to address the situation. We documented each lesson learned and worked through the unique challenges encountered with our patients. We gained confidence throughout this process in our ability to innovate and improve the care we provide to all of our patients. We hope that this article helps other nurses who are caring for patients with PAxIABPs or who may do so in the future. In addition, we hope it inspires nurses to trust in their abilities to be innovative and courageous as they strive to provide the best care for their patients.