CBD (cannabidiol) oil is a popular cure-all that you may have seen hyped or scrutinized by the media. But what exactly is it, is it safe, and how is it different from the use of medical marijuana?
THC, CBD, and Hemp
Marijuana comes from the leaves of the Cannabis plant, which produces a variety of active chemical compounds referred to as cannabinoids. There are dozens of cannabinoids; THC (tetrahydrocannabinol) and CBD are two of the more widely studied. THC is the psychoactive compound in marijuana that causes intoxication, or a high, by activating the brain’s reward and pleasure center, causing the release of dopamine. By contrast, CBD is not psychoactive and therefore does not cause a high. It is also not believed to be addictive.
Hemp also derives from Cannabis, but generally refers to plants cultivated for non-drug use. Hemp also contains much higher concentrations of CBD and a much lower concentration of THC (<0.3%). Historically, hemp has been used to make rope, fabrics, or textiles.
Medical marijuana is now legal in 33 states and the District of Columbia. For recreational use, marijuana is legal in 10 US states and in DC. In recent years, the number of patients who are turning to Cannabis for medical treatment is increasing. Marijuana has been a therapeutic treatment for cancer patients; it has been shown to treat pain, nausea, and cachexia. Marijuana is also now used as a treatment for Alzheimer’s disease, chronic pain, Crohn’s disease, and many other conditions.
CBD is generally sold formulated into an oil and has been touted as a solution to pain, insomnia, anxiety, and a wide range of other medical conditions. CBD oil is expected to become a billion-dollar industry in coming years. It is important to note, however, that despite the oil’s growing popularity, it remains largely unstudied and unregulated.
CBD is readily available for purchase online, but it has varying levels of legality in the United States. Although several US states have specific laws regarding CBD, it remains a controlled substance by the Drug Enforcement Agency, and is classified as a Schedule I drug. This designation remains despite the passage of the 2018 Farm Bill (which legalized the broad cultivation of hemp, under outlined restrictions).
There is a lack of high-quality, large-population studies on CBD use in humans. Large-scale, randomized clinical trials are needed, but it has been proposed as a potential therapy for a range of conditions, including anxiety, Parkinson’s, chronic pain, schizophrenia, and multiple sclerosis. Many users anecdotally claim it has pain-relieving benefits and use it as a treatment for muscle aches, inflammation, and pain. Other people use it to ease anxiety and insomnia.
There currently exists only one FDA approved medication that contains CBD: a seizure medication called Epidiolex, which is used to treat two particularly severe seizure disorders in children.
CBD is most commonly available in the form of an oil or drops. It may also be formulated into a balm, patch, or topical. There are also edible formulations, such as chewing gum, gummies, cookies, and brownies.
It is not likely that a patient will mention the use of CBD oil during a medication reconciliation, so it is important to ask patients about all products they use, including herbs, supplements, and oils. Patients should know that CBD oil may interact with other medications (such as blood thinners), and it could potentially increase the level of certain drugs in the bloodstream. Although side effects are anecdotally infrequent, it may cause sedation, fatigue, or nausea or diarrhea.
Patients should be informed that the concentrations of CBD oil vary widely, not just from product to product but also from bottle to bottle. A 2017 study published in JAMA found that of 84 different CBD oils purchased through online retailers, 18 actually contained THC. Moreover, 43% of the products were underlabeled (that is, the concentrations of CBD were lower than listed on the product), and 26% were overlabeled (the concentration was higher than listed).
Additionally, because there have been no large-scale studies of CBD in humans, there are no recommended safe or effective dosages.
Nursing is a unique profession, with major psychological stressors and equally great emotional benefits. Who would have better self-care tips for you than a psychiatric nurse practitioner and DNP candidate? Jonathan Llamas DNP (c), BSN, RN-BC, PHN, is all that, plus a freelance writer for MinorityNurse.com.
Llamas is pursuing his degree at Loma Linda University while also working full-time as a psychiatric-mental health nurse at Kaiser Permanente in Los Angeles, CA. (Obviously, he knows a thing or two about workplace stress!) He is a Filipino-American, a first-generation college graduate, and an emerging nurse leader who aims to help educate the next generation of nurses.
In this Q&A interview, Llamas suggests ways for nurses to practice self-care, while at any point in their career journey.
Jonathan Llamas DNP (c), BSN, RN-BC, PHN
How did you become interested in psychiatry?
I ended up choosing psychiatry because at an early age, I have always been fascinated by the miraculous wonder of the human mind and the inherent beauty and evolution of life that emanates from the adept functioning of the brain.
I developed a profound passion to better understand and treat the psychological, emotional, and spiritual ailments that are often associated with mental illness in contemporary society.
What have you learned—related to stress, self-care, avoiding overwhelm, depression, or burnout—from your psychiatric nurse training that you wish all nurses knew?
The most important concept that I have learned so far during my experience working as a psychiatric-mental health nurse is the importance of self-care. The concept of self-care was never really endorsed until recently, because of the overwhelming influx of individuals suffering from mental illness in recent years.
The interesting part about mental illness that many people tend to forget is that it is non-discriminatory—meaning that it can affect anyone regardless of their race, gender, creed, or socioeconomic background.
I often make it a point to encourage my fellow nurses and colleagues to not be afraid to care for their mental health and address any issues that may produce additional stress and anxiety in the future.
What personal benefits (emotional, psychological, spiritual, etc.) have accrued to you from pursuing this specialty?
Working in psychiatry is a unique experience because it teaches you a lot about the interplay between the emotional, physical, and psychological components of holistic treatment. As a result of this realization, I try to make a concerted daily effort to continue to develop not only creative approaches to my nursing care, but also empathetic techniques that ensure patient safety and satisfaction is achieved across the patient gamut.
You also have previous experience in ICU/trauma and ER settings—what did you learn from those roles, related to stress, overwhelm, and so on?
Although it can be physically and emotionally draining, working in the ER and ICU/Trauma settings—[they] taught me the significance of perseverance, collaboration, and patience.
I have come to learn that the best way to combat stress and burnout is to surround yourself with people and hobbies that energize and remind you as to why you chose to be a nurse in the first place.
Do you have favorite techniques for de-escalating difficult situations, with patients or coworkers?
In the past decade or so, violent incidents have increased dramatically and are now four times more likely to occur in health care than in any other private industry.
Because of this unfortunate reality, one of my favorite de-escalation techniques that I continually perform on a consistent basis is the LOWLINE Model. (Described by Mike Lowry, Graham Lingard, and Martin Neal in a 2016 Nursing Times article.)
LOWLINE is a mnemonic that stands for (L)isten, (O)ffer, (W)ait, (L)ook, (I)ncline, (N)od, (E)xpress.
How has being a minority (gender or racial, ethnic, etc.) nurse played out in your career?
Surprisingly, being a minority male nurse in a predominantly female driven profession has been a positive experience for me thus far. Although I can only speak on my own personal experience, I consider myself blessed and fortunate to be able to care for my patients without fear of being judged or discriminated for my racial, ethnic, gender, or socioeconomic profile.
Since I do work in psychiatry however, I do experience the occasional irreverent name calling from highly psychotic patients, but I do my best to not let it affect me and compromise the type of nursing care I provide.
Listen to Jonathan Llamas on mental health nursing in an “Alumni Spotlight” video clip.
Changing perceptions of risk could improve compliance with infection-control measures
It’s often said that knowledge is power. But a new study finds that when it comes to nurses’ compliance with infection-control measures, it’s more appropriate to say attitude is everything.
The study, published in the American Journal of Infection Control, examines the relationship between infection-control compliance, knowledge, and attitude among home healthcare nurses. Researchers surveyed 359 home healthcare nurses in the U.S., and evaluated their knowledge of best practices in relation to their compliance with infection-control measures.
Over 90% of nurses self-reported compliance for most of the measured behaviors. The researchers also found there was not a direct correlation between knowledge of infection-control practices and compliance with those practices. However, there was a relationship between the level of compliance and the participants’ favorable attitude toward infection control.
“This study tells us that knowledge is not enough,” said one of the lead authors, Jingjing Shang, PhD, of Columbia University School of Nursing in New York City. “Our efforts to improve compliance need to focus on ways to alter nurses’ attitudes and perceptions about infection risk.”
The authors suggest that efforts to improve compliance with infection-control practices should focus on strategies to alter perceptions about infection risk. Changes should start on an organizational level, and seek to create a culture of positivity in relation to infection-control compliance.
Among other takeaways from the study:
- Protective equipment lapses: While most of the participants reported compliance on most issues, many reported lapses when it came to wearing protective equipment; only 9% said they wear disposable face masks when there is a possibility of a splash or splatter, and 6% said they wear goggles or eye shields when there is a possibility of exposure to bloody discharge or fluid
- A culture of “presenteeism:” Presenteeism, coming into work despite being sick, has become a patient safety issue over the last few years, especially as it relates to infection control; only 4% of participants felt it was easy for them to stay at home when they were sick, which could be a major contributor to rates of infection
- Hand hygiene is still an issue: 30% of respondents failed to identify that hand hygiene should be performed after touching a nursing bag, which could transport infectious pathogens as nurses travel between patients
“Infection is a leading cause of hospitalization among home healthcare patients, and nurses have a key role in reducing infection by compliance with infection-control procedures in the home care setting,” Shang said.
This story was originally posted on MedPage Today.
As we described in Part 1 of this series, there are important ways for nurses to speak with other providers in order to keep their patients safe. Likewise, there are crucial strategies for them to use when speaking with the patients themselves.
Again, Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can safely communicate with patients.
What strategies can nurses use when communicating directly with their patients in order to keep them as safe as possible?
Effective communication with patients is just as important to ensuring positive outcomes in high-risk situations. Patients seek out health care for personal and often complicated medical conditions. They can be fearful, concerned, uncomfortable, worried, or even terrified when they visit a health care facility. Be mindful of your patients’ emotions and how these emotional states will affect the way they describe their symptoms and problems, how they interact with you, and how information and instructions are received.
The following list of patient communication strategies is straightforward and can be incorporated into any conversation with a patient:
- Start with a warm introduction. Some providers walk into a waiting room and introduce themselves to their patients. This makes patients feel important. It indicates that the provider is not in a rush and is taking the time to greet them rather having them ushered into an empty exam room by office staff.
- Greet the patient by name. Greet patients by their formal name. “Hello Mrs. Jones, I am Cathy and I’ll be your nurse today.” If you prefer to be less formal or you know the patient well enough, use first names. By nature, people like to hear their own names. When you know and use patients’ names throughout the medical process, stronger bonds and relationships are created.
- Make eye contact. This feature of a personal interaction cannot be underestimated! If you don’t make eye contact with patients, they may assume that your thoughts are elsewhere or you are not interested in their medical issue. Eye contact is a sign of confidence, and patients want to feel confident that they are in good hands.
- Be engaged. Patients know when you care, patients know when you are prepared; and patients know when you are authentically engaged. Consistency of communication is an art. Whether you are stressed, fatigued, or otherwise preoccupied due to any number of reasons, you must learn the art of being consistently engaged with all patients.
- Listen to and acknowledge patient concerns. It is important that you listen, understand, and acknowledge what patients are saying. Take time to ask appropriate questions to ensure that important pieces of information were not overlooked by the patient. When you take the time to listen, miscommunication is–for the most part–averted and medical errors are significantly reduced.
- Avoid interrupting the patient if possible. Allow the patient to finish explaining. Physicians and nurses often interrupt patients with questions in the middle of a conversation. Let patients complete their thoughts before questioning further. If patients go off on a tangent, politely interrupt and refocus them on what needs to be communicated.
- Confirm understanding via “teach-back.” Rather than asking patients if they understand their health issues, intervention plans, or any aspect of their care, it is often more efficient to use an easy technique such as “teach-back” to confirm full comprehension–have them repeat what they understood. Simply ask the patient something like: “Mrs. Jones, since you will be taking home three different medications, just to be sure you fully understand the instructions, please explain to me how and when you will take each one.”
- Provide patients with written instructions. Patients are often overwhelmed with news of a diagnosis or the seemingly complex plans for home- or self-care, which includes taking medications. Preparing and distributing written instructions will help avoid misunderstanding of the treatment and follow-up plans.
What else do nurses need to know about communicating effectively to improve patient safety in high-risk situations?
Data from The Joint Commission consistently reveals that poor communication is a leading cause of medical mistakes that result in patient harm. In fact, during the years 2014 and 2015, communication was the third most frequent “root cause” of all sentinel events reviewed.
Medical errors continue to plague our health care system. Many of these mistakes cause significant patient harm and often result in malpractice litigation. Communication breakdowns, rather than a lack of provider skill and/or medical training, are responsible for far too many adverse events. The good news is that we now have simple techniques that can be easily utilized to improve nursing communication and decrease medical errors.
Nursing, as defined by the World Health Organization, encompasses care for people of all ages, families, groups, and communities, sick or well and in all types of settings. Nursing includes health promotion, illness prevention, and care of the ill. Regardless of your nursing role, or type of patient population you care for, health literacy is an essential competence necessary to effectively communicate and truly provide person-centered care. Health literacy is a precursor to health and considered a social determinant of health due to its influence upon health outcomes. It also includes engaging and empowering patients to access services and act upon health information to make informed decisions.
Early definitions of health literacy primarily focused on the skills or deficits of individuals when obtaining, processing, or understanding basic health information and services. The term has continued to evolve to reflect the complex, dynamic, multidimensional context-related components of health literacy. And while nurses have such a vital role in the promotion of health literacy, there is often a lack of understanding that health literacy is much more than the reading level of patient education material.
Nurses have a vital role in partnering with the 88% of the U.S. population that are not having their health care needs met. Nurses can make a difference beginning today!
Begin by checking out the 5 basic health literacy strategies every nurse should know.
1. Promote a shame-free environment.
Health literacy is the foundation to a successful nurse-patient interaction and necessary to promote patient safety. Writing all patient forms in plain language, providing assistance with paperwork, offering free interpretation services, and involving members of your community when designing materials or programs will assist with promoting a shame-free environment.
2. Use a health literacy universal precautions approach.
Always assume that everyone might experience difficulty understanding health information or navigating the complex health care environment. Even a well educated patient can have difficulty understanding the medical information provided.
3. Speak in plain language.
Plain language or “living room language” is beneficial for everyone! Using “everyday” words rather than medical jargon will allow you to meet your patients where they are and help clearly explain more involved concepts.
4. Confirm understanding with Teach-Back.
Respectfully ask patients to explain a concept or direction back to you. This helps ensure you were clear in all patient communications. It also gives you the opportunity to clarify any misunderstanding if needed. Teach-Back is not mimicking what you said—patients should use their own words to explain understanding.
5. Ask open-ended questions.
For example, “What are your questions?”, “What questions do you still have?, or possibly, “We just reviewed a lot of information. What parts would you like me to go over with you again?” Each of these examples can help encourage questions rather than “do you have any questions?, which often results in a quick response of “no”.
Learn more about health literacy and health literacy strategies in this award winning book, Health Literacy in Nursing: Providing Person-Centered Care. For additional resources or to request health literacy services, contact Health Literacy Partners.
Nurses are always concerned about keeping their patients safe. Besides doing so by being professional with caring directly for them, nurses also need to be aware of how communication—with other health care providers and patients—can either keep patients safe or put them at risk.
Arnold Mackles, MD, MBA, Patient Safety Consultant for Innovative Healthcare Compliance Group and member of The Sullivan Group’s RSQ® (Risk, Safety, Quality) Collaborative took time to answer questions about exactly how nurses can do this.
In Part 1 of this series, we address what high-risk situations could be as well as how nurses can safely communicate with other health care providers. Part 2 will cover specific ways in which nurses can communicate with their patients while keeping them safe.
What is a high-risk situation and what kinds of patients could be involved in these?
High-risk clinical presentations occur throughout multiple areas of medical care. Medical errors in these critical situations can induce significant patient harm or even death. You might find a high-risk scenario:
- In the emergency department as you care for all comers presenting with a wide variety of complaints from back pain and chest pain to headaches and injuries to extremities
- In the ICU when caring for fragile patients with a life-threatening infection
- Before, during, or after a surgery
You might also encounter groups of patients that are inherently more high-risk. These include:
- Patients with multiple comorbidities
Effective communication between nurses and other clinical providers plays a vital role in the effective management of high-risk clinical situations. Unfortunately, traditional nursing and medical school programs do not include training in techniques to ensure successful communication in health care. As a result, a significant number of patients are harmed by breakdowns in communication.
What are the best ways for nurses to communicate with other providers to best keep their patients safe?
A study of over 23,000 malpractice claims by CRICO, the medical malpractice insurer of the Harvard medical institutions, revealed that “communication failures were linked to 1,744 deaths in five years.” The study also found 7,149 cases where communication breakdowns caused patient harm, and 26% of those breakdowns involved a miscommunication of the patient’s condition among providers.
One critical strategy to improve communication among providers is the use of the “read-back” method. In high-risk clinical situations, physicians often give verbal medication orders to nursing personnel. Such orders must be “read back” or “talked back” to the ordering physician or practitioner to confirm accuracy. This same technique should be utilized when receiving verbal lab and test results as well.
In one case, a nurse answered a telephone call from the lab with a patient’s biopsy test. The pathologist called in the result as being an “adenocarcinoma,” a type of malignant cancer. However, perhaps due to a poor phone line, the nurse thought the pathologist said the specimen “had no carcinoma.” A simple “read-back” would have avoided the error. “Doctor, did you say that the biopsy did not have a carcinoma?” The pathologist could then have then replied, “No, it is an adenocarcinoma which is malignant,” and the error would have been avoided.
Fortunately, there are a variety of simple techniques that nurses can employ to improve communication in clinical settings. It has long been known that nurses and physicians often describe the same patient situation in different ways. Nurses have been trained to give detailed, specific descriptions of a patient’s condition. Physicians, on the other hand, speak in bullets or quick lists of clinical findings. This mismatch in communication style can easily lead to misinterpretation and misunderstanding.
One simple method to overcome this communication barrier is the use of CUS – concerned, uncomfortable, and safety – to demonstrate an increasing severity of a patient’s condition. For example, if a postoperative patient is running an elevated temperature, the nurse could say, “Doctor, I am concerned about Mrs. Jones, as she has a temp of 102 degrees.” The next level of severity would be, “Doctor, I am uncomfortable with Mrs. Jones as she is spiking a temp to 103 degrees and is tachycardic.” As the condition worsens, the conversation might be, “Doctor, I am worried about the safety of Mrs. Jones. She is febrile, tachycardic, and complaining of severe abdominal pain.”
Many medical errors are caused by the reporting of incorrect or incomplete patient medical information during a handoff. Health care handoffs are an extremely common time in which communication mistakes occur. Fortunately, the health care industry now has access to easy-to-use handoff techniques. The SBAR method was originally created to ensure correct communication on nuclear submarines and has been adapted for health care use. The technique utilizes a handoff worksheet that is created by the sender of the clinical information, and then discussed with and handed off to the receiver of the information.
The simple mnemonic SBAR to be completed on the worksheet represents:
S – Situation: “What is going on with the patient?”
B – Background: “What is the clinical background or context?”
A – Assessment: “What do I think the problem is?”
R – Recommendations: “What would I do to correct it?”
Although the SBAR system is widely used today, some health care organizations are moving to a handoff technique that integrates the electronic medical record. One such method is I-PASS, in which the computer creates and prints out the handoff work sheet. The I-PASS worksheet mnemonic contains:
I – Illness severity
P – Patient summary
A – Action list for the next team
S – Situation awareness and contingency plans
S – Synthesis and “read-back”
Check out Part 2 for information regarding communication skills for nurses to safely speak with their patients.