While some nurses have an ardent passion to become
researchers, Elizabeth Johnston Taylor, PhD, RN, FAAN, a nurse researcher at
Loma Linda University Health in Southern California, admits that she kind of fell
into it. But that doesn’t mean she doesn’t love her job. In fact, it’s quite the
“I find great joy in doing research,” she says.
According to Taylor, nurse researchers will begin a
research project by looking for an answer to a problem. For example, she says, “How
can we improve the quality of life or decrease depression among people with
disease X? or “How can the health care system better provide care for those
with condition S?” S/he will identify something that needs further study. She
says that once they decide what question needs to be answered, they design a
study using scientific methods that will best answer it—whether they are
quantitative or qualitative, use a small sample or big data, are biological in
nature or psychological, etc.
“Each phenomenon you want to study obviously is going to
require its own unique approach,” explains Taylor.
Oftentimes, nurse researchers will get others to help them with data collection, and then may work with a statistician or a team to analyze the data that is collected. Once they’ve found information that may or may not completely answer the question, it’s important to write about the results to disseminate the findings. “What good is it if you don’t share it with the world and allow the world to benefit from it?” she points out.
Taylor’s program of research—which is a researcher’s area of expertise or what s/he often studies—explores patients’ spiritual responses to illness and how nurses can support or nurture spiritual well-being. “From attending some conferences and just having conversations with chaplains, I got anecdotal evidence that some chaplains believe nurses are inappropriately providing spiritual care and/or doing things with patients that they think are within their purview, but a chaplain doesn’t think it is,” explains Taylor. “I’m doing an exploratory study where I’m asking chaplains to tell me more about these kinds of phenomena.”
For nurses thinking about getting into research, Taylor says that they need to realize that this isn’t a part-time job or something you take on with only minimal interest. They will need to earn a PhD and then obtain funding to pursue a program of research. “It really takes a lot of effort,” says Taylor. “Most academics who have a successful program of research probably work anywhere from 40 to 60 hours plus a week. So it really requires a great deal of commitment as well as a great deal of curiosity and passion.”
Low complication rates for procedures performed by advanced practice providers
Advanced practice providers (APPs) performed office-based neonatal circumcisions with results comparable to those of physicians, according to two studies reported here.
A circumcision clinic led by nurse practitioners (NPs) had a 5-year complication rate of 4.1% as compared with 3.4% for circumcisions performed by physicians. Neither the overall rate nor any of the rates for specific types of complications differed significantly between NPs and MDs, reported Jonathan A. Gerber, MD, of Texas Children’s Hospital (TCH) in Houston, at the American Urological Association annual meeting.
The second study showed a 3-year complication rate of about 5% for circumcisions performed by a specially trained physician assistant (PA). That compared with complication rates of 4%-5% in published reviews of physician-performed circumcisions. The PA-performed circumcisions also generated substantial revenue for the urology practice, said Kaity Colon-Sanchez, PA-C, of Nemours Children’s Hospital in Orlando.
“We felt that utilization of advanced practice providers in our newborn services clinic has allowed pediatric urologists to focus their attention on the most complicated cases in the practice, while the more simple newborn circumcisions are being performed safely and effectively by advanced practice providers,” said Gerber. “Additionally, the results suggest that the longstanding age and weight cutoffs for newborn circumcisions need to be reconsidered, because our study shows similar outcomes in older and heavier children.”
About 70%-80% of newborn male infants undergo circumcision, making it the most common urologic procedure. An ongoing shortage of pediatric urologists has created a significant imbalance between the need for circumcision and the resources to provide the service. To address the problem, TCH established an APP-led newborn circumcision clinic, said Gerber.
One previous study documented results of a service wherein NPs performed minor urologic procedures, but the procedures all occurred in an operating room. The TCH service is provided in an outpatient setting.
Pediatric urologists trained APPs to perform Gomco clamp circumcisions. The training consisted of observing 10 newborn circumcisions, assisting in 10 procedures, and then performing 10 circumcisions under direct supervision of a pediatric urologist. Thereafter, a pediatric urologist was on call for all APP-performed circumcisions. APPs were limited to performing circumcisions for infants <30 days old and weighing <10 lbs.
Investigators retrospectively reviewed records for circumcisions performed over a 5-year period, which allowed for comparison of outcomes before and after implementation of the APP-led clinic.
Gerber reported data for 314 APP-performed circumcisions and 237 performed by pediatric urologists. The analysis focused primarily on complications. The study population had a mean age of 23.8 days and mean weight of 8.6 pounds. Physicians performed circumcisions on older (28.4 vs 20.3 days, P<0.0001) and heavier (8.9 vs 8.4 lb, P<0.0063) infants and used more lidocaine per procedure (0.96 vs 0.8 mL).
Overall, 21 complications occurred, with no significant differences between the APP and physician procedures:
- Total: 13 (4.1%) vs 8 (3.4%)
- Revision circumcision: 1 each
- 30-day return to emergency department (ED): 2 vs 0
- Other penile surgery: 2 vs 4
- Intraprocedure bleeding: 11 vs 4
The data showed no difference in outcomes for patients <30 vs ≥30 days or weight <10 vs ≥10 lbs, the traditional age and weight cutoffs for uncomplicated circumcision.
Colon-Sanchez reported her 3-year experience performing clinic-based circumcision in a pediatric urology service. She evaluated 371 infants for neonatal circumcision. They had a mean age of 7.8 weeks (range of 1 to 13 weeks) and weighed an average of 5.2 kg (11.4 lbs) and had a weight range of 3.2-7.5 kg. Subsequently, 95 infants did not undergo circumcision, 91 because of an abnormal genital exam. Colon-Sanchez performed 272 circumcisions with the Plastibell device and four with the Gomco device.
The clinic charged $366 for families that paid for the procedures themselves, and billed $722 when procedures were covered by insurance. Colon-Sanchez noted that the 95 patients excluded from the analysis did not represent lost revenue, as the office visit was considered billable and many of the patients required additional surgery.
Records revealed a complication rate of 6.43%, consisting of retained Plastibell device in 1.80% of cases, swelling in 1.40%, adhesions in 1.10%, cosmesis issues in 0.73%, and ED visits for bleeding in 1.40%.
The results compared favorably with those from studies of circumcisions performed by physicians, said Colon-Sanchez. A study of more than 1,000 circumcisions performed by pediatricians and ob/gyns showed an acute complication rate of 3.9%, all involving bleeding. A study of 9,000 surgeries at a pediatric urology service showed that 4.7% of the procedures involved late complications of circumcisions. Additionally, 7.4% of visits to the pediatric urology outpatient clinic during a 1-year period involved concerns related to newborn circumcisions.
“Well-trained physician urology physician assistants can perform neonatal circumcisions,” said Colon-Sanchez. “The data support low complication rates with well-trained PA providers. Urologist back-up is readily available. Office-based neonatal circumcisions provides an additional revenue stream.”
In response to a question, she described a training program similar to the one the APPs in Gerber’s study completed. She said she felt comfortable with her abilities after about 30 procedures.
Gerber and Colon-Sanchez disclosed no relevant relationships with industry.
This story was originally posted on MedPage Today.
But low-ranking hospitals had nearly double the risk
The estimated number of avoidable deaths in U.S. hospitals each year has dropped, according to updated analysis prepared for The Leapfrog Group by Johns Hopkins University School of Medicine researchers.
Matt Austin, PhD, an assistant professor in the school’s Armstrong Institute for Patient Safety and Quality, and Jordan Derk, MPH, used the latest data from Leapfrog’s semiannual hospital safety grades to estimate that there are 161,250 such deaths each year, down from the 206,000 deaths they estimated three years prior, according to their report.
Austin and Derk said they used 16 measures from Leapfrog’s 2019 data to identify deaths that could clearly be attributed to a patient safety event or closely related prevention process. The reduction is the result of two main factors, they wrote: One, hospitals have made some improvement on the performance measures included in Leapfrog’s safety grades. And, two, some of the measures “have been re-defined and rebaselined” in the past three years, they wrote.
Furthermore, these data likely represent an undercount, Austin and Derk wrote, noting that other studies have estimated anywhere from 44,000 to 440,000 deaths due to medical errors.
“The measures included in this analysis reflect a subset of all potential harms that patients may encounter in U.S. hospitals, and as such, these results likely reflect an underestimation of the avoidable deaths in U.S. hospitals,” they wrote.
“Also, we have only estimated the deaths from patient safety events and have not captured other morbidities that may be equally important,” they added.
The updated analysis was released to coincide with the latest release of Leapfrog’s controversial scores, which assessed quality data from more than 2,600 hospitals and assigned each an “A” through “F” letter grade.
“The good news is that tens of thousands of lives have been saved because of progress on patient safety. The bad news is that there’s still a lot of needless death and harm in American hospitals,” Leapfrog Group President and CEO Leah Binder said in a statement.
Less than one-third (32%) of hospitals secured an “A” grade. More than a quarter (26%) earned a “B.” The group gave a “C” to another 36%, a “D” to 6%, and an “F” to less than 1% of hospitals.
The analysis from Austin and Derk found that the rate of avoidable deaths per 1,000 admissions was 3.24 at “A” hospitals, 4.37 at “B” hospitals, 6.08 at “C” hospitals, and 6.21 and “D” and “F” hospitals combined. That means patients admitted to a “D” or “F” hospital face nearly double the risk of those admitted to an “A” hospital, the Leapfrog group said.
This story was originally posted on MedPage Today.
Years after “To Err is Human” report, studies show marginal improvement
Failure to improve working environments for nurses poses a threat to patient safety, a speaker said at a panel discussion hosted by Health Affairs.
In addition, clinician delays in recognizing emerging complications, and communicating concerns effectively with other medical staff, can increase postsurgical mortality, explained another presenter at the briefing Tuesday, which explored progress in patient safety since the 1999 release of the landmark report “To Err is Human: Building a Safer Health System” by the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine).
According to the report, 44,000 to 98,000 deaths each year result from medical errors.
“Everyone agrees we haven’t made as much progress as we’d like to make [with reducing medical errors], and the improvements have been uneven,” said Linda Aiken, PhD, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia.
In a recent Health Affairs study, Aiken and colleagues assessed safety at 535 hospitals in four large states during two time points between 2005 and 2016, and reported that the results were “disappointing.” Only 21% of the hospitals showed “sizeable improvements” in “work environment scores” while 7% saw their scores worsen, Aiken said.
Another 71% of hospitals “basically remained the same,” she said.
Aiken also reported a similar lack of improvement in patient safety measures at hospitals that showed little improvement in their work environment. In the study, about 30% of nurses graded their own hospitals “unfavorably” on measures of patient safety and infection prevention and about 31% of nurses had high scores on the Maslach Burnout Inventory.
Aiken pointed out that “To Err is Human” specifically identified “transforming the work environment of nurses” as an evidence-based strategy to improve patient safety and highlighted the need for “staffing adequacy,” as well as environments that enable nurses to conduct effective “patient surveillance and timely intervention[s].”
And despite the “blame-free culture” espoused by the 1999 report, which stressed that errors are due to problems with systems not individuals, 50% of the nurses in the study by Aiken’s group reported that they believed their errors would be held against them, she said.
Aiken said the recommendation for how to fix the situation hasn’t changed since it was outlined in the 1999 report — “identify safe nurse staffing and supportive work environments as patient safety interventions.”
In another Health Affairs study, Margaret Smith, MD, of the University of Michigan Medical School in Ann Arbor, and colleagues examined the interpersonal and organizational factors that may increase the chance of “failure to rescue,” or deaths following a major surgical complication.
“We decided to take a slightly different view and look at interpersonal, organizational dynamics and their relationship with rescue,” she explained at the Tuesday panel.
Recent studies have explored targets for interventions that could improve rescue, and focused on resource-heavy solutions, such as increasing ICU staff or improving nurse-patient ratios. While important, these factors only account for a proportion of the variation seen in rescue rates among hospitals, Smith noted.
The typical course of events is an operation, followed by a seminal complication, then a domino effect of other complications, which ultimately end in a patient’s death, she added.
Smith’s group conducted 50 semi-structured interviews at five hospitals across Michigan with a range of providers (surgeons, nurses, respiratory therapists), and asked what they felt were the greatest contributors to effective rescue. The study was done from July to December 2016.
After recording and transcribing each 30-60 minute interview, Smith and colleagues identified five core elements as being part of the “successful rescue” of surgical patients:
- Teamwork: working well together in moments of crisis
- Action taking: responding swiftly after identifying a complication
- Psychological safety: ability of all clinicians to feel comfortable expressing their concerns regardless of where they fit in the clinical hierarchy
- Recognition of complications
The interviewed clinicians said they generally felt they performed well on the first three measures, but said early recognition of complications and effective communication were areas that needed improvement, Smith stated.
For example, attending surgeons said they did not think complications were spotted early enough. “When we’re talking about early recognition, people have this kind of clinical hunch [that] ‘something’s wrong’… [and] how that’s communicated is often very poor,” Smith said.
The challenge is how to communicate these “hunches” in a way that everyone understands them and ways that trigger actionable steps, she added.
In terms of communication, a senior nurse reported that when more providers cared for a single patient, it was more challenging to pass information along, or have information miscommunicated or misinterpreted.
Smith recommended that hospitals focus upstream of these potential crises by providing all clinicians, regardless of their experience, with the tools to know when a patient is deviating from a normal trajectory.
Her group also stressed the need for more effective language in communicating concerns.
“We need to ‘tool and task’ these providers with the skill-set to work on these multidisciplinary teams to communicate and identify developing complications,” she said.
Smith said her group is developing pilot programs to help clinicians recognize when patients are deviating from a traditional course.
If a patient completes a procedure without a complication, certain daily benchmarks should be expected. These benchmarks would be given to junior nurses and night staff, so that even without years of experience, they can recognize when a patient is not on track, Smith said.
This story was originally posted on MedPage Today.
A new report from the Robert Wood Johnson Foundation (RWJF) looks into how nurses in the United States can help boost health and well-being for all Americans, but data shows that those in the field are concerned about being able to do all that they can.
Despite wanting to put their skills to use to help communities as care providers, community educators, and policy advocates, nurses across the US are held back from all they can do by challenges like outdated nursing education, looming staffing shortages, and a steep lack of resources for the healthcare system. These difficulties cast a shadow on the future of nursing in the United States.
“There are many issues affecting the health of our nation—opioids, measles outbreaks, low literacy rates, untreated mental illness, lack of affordable housing, and many others. Conversations with hundreds of nurses made it clear that they are willing to help people face these challenges, but they can’t do it alone,” said Paul Kuehnert, DNP, RN, FAAN, associate vice president at RWJF. “Nurses need support from their employers, other health care professionals, community organizations, and government entities to better address unmet needs.”
The nurses interviewed shared that nursing as a profession must evolve to meet the ever-growing needs of patients, as well as the shifts within the industry that hinder nurses from learning and helping to the best of their abilities. They also provided their points of view regarding how prepared nurses are after their training and education, and what resources are provided to them by their employers. Interviewees also discussed that while patient needs are expanding, there is not enough focus on them in health care settings.
“Nurses are uniquely qualified to address many of the unmet needs of people and communities, and this research shows they have a strong desire to do that,” Kuehnert shared. “Nursing is consistently ranked among the most trusted professions, and nurses have firsthand knowledge of what patients and communities need to be healthier.”
To download the report, visit the RWJF website and click the link that says “Nurse Insights on Unmet Needs of Individuals” under the Additional Resources sidebar.
Our Nurse of the Week is Paige
Niepoetter, a senior nursing student at Southern Illinois University
Edwardsville (SIUE) who aspires to become a life-changing cancer researcher.
Her drive and academic experiences during her undergraduate years have positioned
her to achieve her dream of becoming a surgical oncologist specializing in
During nursing school, Niepoetter took
advantage of the opportunity to work alongside faculty mentor Chaya Gopalan to
conduct research through the university’s Undergraduate Research and Creative
Activities (URCA) program. Her scholarly work, which studied intermittent
fasting and eating patterns in obese and non-obese rats, has received national
Niepoetter was one of 50 student researchers selected from a pool
of more than 5,000 abstracts to present at the Federation of American Societies
for Experimental Biology DREAM Program’s Experimental Biology 2019 Meeting
She tells advantagenews.com, “Winning the FASEB DREAM travel award was a blessing. Research is a passion of mine, but without proper funding, I wasn’t sure if I’d be able to attend the entire conference. This award made it possible for me to attend various sessions of interest, connect with fellow researchers and gather ideas for new research directions.”
Gopalan also spoke to Niepoetter’s achievements: “Paige is a wonderfully focused student who works hard and is incredibly responsible. She has been in my lab for three years, is on two major research projects, and has been able to secure four abstracts and one manuscript for publication. This is only the beginning, as we will be writing several papers by the end of the summer. Paige will surely do amazing things in her future.”
Niepoetter attributes her success to Gopalan’s mentorship, which
helped her develop her passion for research and clarify her decision to apply
to medical school. The URCA program allowed her to go beyond what she learned
in the classroom and develop her leadership skills and gain a sense of
confidence she wouldn’t have without Gopalan’s mentorship.
To learn more about SIUE senior
nursing student Paige Niepoetter and her aspirations to become a surgical
oncologist specializing in breast cancer, visit here.