Disadvantages of Nurses Strategies That Would Assist the Military With Post-Traumatic Stress Disorder (PTSD) In Veterans of Foreign Wars.

“Among American Vietnam theater veterans 31% of the men and 27% of the women
have had PTSD in their lifetime. Preliminary findings suggest that PTSD will be present in at least 18% of those serving in Iraq and 11% of those serving in Afghanistan,” (National Center for PTSD, 2005, p.4). As troops return from deployments in Iraq and Afghanistan, the need for post-traumatic stress disorder treatment is expected to increase.
Due to the ongoing war in Iraq and conflict in Afghanistan, nurses needs to implement strategies that assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans.
Combat linked trauma has existed as long as humans have made war. In the U.S., the problem was first identified among World War I, World War II, and Korean War vets (National Center for PTSD, 2005, p.4). According to American Journal of Nursing, in World War I it was called “shell shock”; in World War II, “combat fatigue.” Although the difficulties combat veterans experience have long been recognized, it wasn’t until 1980, the year posttraumatic stress disorder (PTSD) was added to the Diagnostic and Statistical Manual of Mental Disorders, third edition ( Kaiman, 2003, ¶ 3). Families welcoming soldiers home encountered profoundly damaged men: chronically tense, clinically paranoid, and often unable to maintain jobs or carry on social relations—some prone to violence (National Center for PTSD, 2006). In today’s era of global conflict, the number of patients with war related trauma has soared. Their wounds are not just physical, but mental. Despite the soaring numbers of war related trauma among veterans returning from Iraq and Afghanistan, there are not near enough programs that effectively identify and treat Post Traumatic Stress Disorder among these veterans after deployment. Such programs are an important part of identifying the mental health burden of the current war and ensuring that there are adequate resources to meet the mental health care needs of veterans returning from Iraq and Afghanistan. Unfortunately, individuals with PTSD are often undiagnosed, which highlights the importance of proper recognition, assessment, and diagnosis. Providers need a quick, readable, accessible reference guide and annual education (Guess, 2006, ¶1).
There is current evidence determining what prerequisites are necessary to provide a firm basis for implementing a military psychological screening program. “Screening programs need to be acceptable: clinically, ethically, and socially, to the soldiers being screened. Screening programs also need to be simple, precise and validated in order to accurately identify psychological problems such as Post Traumatic Stress Disorder. Unlike anonymous surveys, it is likely that current pre-deployment and post-deployment questionnaires under identify psychological problems,” (Rona, 2005, ¶ 7). Nurses can play a critical role in determining that program prerequisites are met by organizing an active committee that will validate current screening programs. Nurses must take into account that surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments (National Center for PTSD, 2005, p.8). Early recognition of PTSD signs and symptoms are important for the most effective treatment (Guess, 2006).
To be diagnosed with Post Traumatic Stress Disorder, patients must meet four criteria: a history of “reexperiencing” the trauma (with associated panic symptoms such as dyspnea and palpitations) along with chronic social avoidance and withdrawal, emotional numbness, and hyperarousal (amplified startle reflexes or hypervigilance in anticipation of flight or fight) (Hoge, 2006). Although written psychological questionnaires have not been proven to be an effective tool on determining Post Traumatic Stress Disorder, it is the primary tool being used. “The Fort Lewis Soldier’s Wellness Assessment Pilot Program (SWAPP) has been developed to identify the susceptibility of returning troops to mental health ailments through questionnaires and face-to-face on-site interviews with nursing staff. This pilot program is giving nurses the ability to identify soldiers that are at risk of having Post Traumatic Stress disorder. Nurses are scheduling follow-up appointments immediately if a soldier is identified as at risk of having Post Traumatic Stress Disorder. Although this is a test site for such a program, on-site SWAPP assessments have helped improve access to health care and are working to breakdown the fear of soldiers not wanting to ask for help,” (Cantwell, 2006). By nurses having the proper education and access to more programs like SWAPP, nurses can continue to work together with each other, other health care professional and soldiers to deteriorate this fear that soldiers have developed.
Treatment for Post Traumatic Stress Disorder starts with education. Knowledgeable nurses can play a major role in the recognition and treatment of Post Traumatic Stress Disorder while in primary care settings or in such programs as SWAPP. Soldiers and their family members need to be educated by nurses on the development of the disorder, effects that Post Traumatic Stress Disorder has on the soldier and family, and effective treatments available. Nurse can provide patients and their family members with educational materials that help them understand that their effected family member’s feelings are related to the Iraq war and its consequences (Schnurr, P., 2004, p.59). Treatment for PTSD is really very practical and involves common sense. Soldiers have regular conversations with a trained counselor, in order to think about their situation and how the soldier wants to change it (National Center for PTSD, 2005, p.8). Through this form of psychotherapy the soldier learns more about what PTSD is and how it affects them . Although psychotherapy along with medication seems to work best for most, there are many other treatments available. While in a safe environment exposure therapy helps patients confront trauma-related situations, people, objects, memories, or emotions that evoke intense fear. Cognitive therapy helps patients identify and change assumptions, beliefs, and thoughts that lead to disturbing emotions and impaired functioning. Anxiety management, also called stress inoculation training, teaches patients skills they can use to reduce both the distress and the intensity of PTSD symptoms. In hypnotherapy, also know as eye movement desensitize and reprocessing (EMDR), the patient recalls traumatic memories while the therapist elicits eye movements that are similar to those that occur naturally during REM sleep. (Neason, 2006)
As returning PTSD-affected soldiers face their ghosts, RNs across the country will be involved in their struggle to regain their lives. “By recognizing patients with PTSD and other trauma related symptoms nurses can validate patients’ distress, and help them know that their feelings are not unusual” (Schnurr, P., 2004, p.59). Since there seems to be no ending to the current war in Iraq, implementing strategies that will assist the military with effective screening, identifying tools, and methods to managing and treating post-traumatic stress disorder in the United States military and veterans is a crucial need of nurses. If we are lucky, as a nation, we will not lose quite the generation like we have in the past to Post Traumatic Stress Disorder.

“Many soldiers wounded in Afghanistan or Iraq who would have died in prior wars now survive. However, they may sustain lasting injuries resulting in disfigurement or loss of function.
A recent study of combat troops following return from deployment to Afghanistan or Iraq found postwar rates of posttraumatic stress disorder (PTSD) ranging from 12.2% to 12.9% and rates of depression from 7.1% to 7.9%. Higher rates of PTSD were associated with higher levels of direct combat exposure and minor wounds or injury,” (Grieger, 2006). These are the type of statistic that one may come across when researching posttraumatic stress disorder, also known as PTSD. There are studies that show that posttraumatic stress disorder is nothing more than an attempt to medicalize a response to trauma. Further research also debates the usefulness of certain treatments that are meant to help victims of posttraumatic stress disorder.
“The predominant view in psychiatric publications is that post-traumatic stress disorder is a medical disorder, characterized by particular psychobiological dysfunction. Although the question of what constitutes a medical disorder is still debated, the identification of both psychobiological dysfunctions and medical interventions that can reverse dysfunctions, provide an important basis to legitimize the medicalization of a disorder (Stein, 2007). Studies show that post traumatic stress disorder may not be a medical disorder after all but an increasing medicalization of a problem that has been brought into the limelight by recent events such as the terror attacks on 9/11 and the ongoing war in Iraq. A more radical view is that post-traumatic stress disorder is merely a social construction, a label that has been applied to distress, for particular sociopolitical reasons. (Stein, 2007)
“Veterans may resist attempts to participate in treatment because they may associate authority figures with distrust. Angry veterans may also become impatient during the treatment process due to their desire to gain relief from their anger problems and their general heightened level of hostility and frustration. They may become easily frustrated when changes do not immediately occur as a result of therapy, and may become hostile or otherwise resistant to therapy,” (National Center for PTSD, 2005). This is a situation that clinicians might find themselves facing when treating service members returning from a combat zone. This is only a few disadvantages that come up when treating service members with therapy alone. Posttraumatic stress disorder therapies include psychotherapy, cognitive therapy, anxiety management, and hypnotherapy. Surrounding circumstances such as anticipated leave, concerns of confidentiality, and shame influence soldiers that are being screened are other disadvantages that effect a service member’s treatment. Soldiers feel that admitting that they may have Post Traumatic Stress Disorder will ruin their future career prospects in the military, such as being denied promotions, awards or future reenlistments. It has also been discussed that therapy alone may not help victims of posttraumatic stress disorder.
“There is a strong rationale from laboratory research to consider antiadrenergic agents. It is hoped that more extensive testing will establish their usefulness for PTSD patients. Hypotension and sedation needs to be monitored. Patients should not be abruptly discontinued from antiadrenergics. Despite suggestive theoretical considerations and clinical findings, there is only a small amount of evidence to support the use of carbamazepine or valproate with PTSD patients. Further, the complexities of clinical management with these effective anticonvulsants have shifted current attention to newer agents (e.g., gabapentin, lamotrigine, and topirimate), which have yet to be tested systematically with PTSD patients,” (National Center for PTSD, 2005). There have not been enough studies on successful treatment of posttraumatic stress disorder with only pharmaceuticals. There are many disadvantages for the pharmaceutical treatment. Side effects and improper dosage for such a disorder are those that are brought up most often.
Despite the ongoing war in Iraq and service members returning with symptoms of PTSD, there is a lack of studies on posttraumatic stress disorder. Further studies need to be conducted in order to determine whether posttraumatic stress disorder is in fact a medical disorder. Once this is established than proper treatment is than needed to treat service members that are returning from the combat zone that have posttraumatic stress disorder symptoms.


T. Grieger, S. Cozza, R. Ursano, & C. Hoge. (2006). Posttraumatic Stress Disorder and Depression in Battle-Injured Soldiers. The American Journal of Psychiatry, 163(10), 1777-83. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

D. Stein, S. Seedat, A. Iversen, & S. Wessely. (2007). Post-traumatic stress disorder: medicine and politics. The Lancet, 369(9556), 139-144. Retrieved October 10, 2007, from Platinum Full Text Periodicals database.

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf



Cantwell, M. (2006). Cantwell Calls for Extensive Mental Health Screenings for Soldiers Returning from Iraq. Retrieved on May 01, 2007 from http://cantwell.senate.gov/news/record.cfm?id=262201

Guess, K. (2006). Posttraumatic Stress Disorder: Early Detection is Key. The Nurse Practitioner: The American Journal of Primary Health Care, 31(3), 26-33. Retrieved on May 26 2007 from http://www.nursingcenter.com/pdf.asp

Hoge, C., Authterlonie, J., & Milliken, C. (2006). Mental Health Problems, Use of Mental Health Services, and attrition From Military Service After Returning From Deployment to Iraq or Afghanistan. The Journal of the American Medical Association, 295(9), 1023-. Retrieved on November 7, 2006 from
http://jama.ama-assn.org/cgi/content/full/295/9/1023?eaf

Kaiman, C. (2003) PTSD in the World War II Combat Veteran. American Journal of Nursing, 103(11), 32-40. Retrieved on May 26, 2007 from http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=429109

National Center for PTSD. (2005). Returning from the War Zone: A guide for Military Personnel. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforMilitary.pdf


National Center for PTSD. (2006). Returning from the War Zone: A Guide for Families of Military Members. United States Department of Veterans Affairs. Retrieved on May 26, 2007, from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/GuideforFamilies.pdf

Neason, K. (2006). PTSD: Help patients break free. RN Professional Journal, RN/AHC Media Home Study Program CE CENTER. Retrieved on October 1, 2006, from
http://www.rnweb.com/rnweb/article/articleDetail.jsp?id=375524

Rona, R., Hyams, K., Wessely, S. (2005). Screening for Psychological Illness in Military Personnel. The Journal of American Medical Association, 293(10), 1257-. Retrieved on November 7, 2006 from http://jama.ama-assn.org/cgi/content/full/293/10/1257?eaf

Schnurr, P. & Cuzza, S. (Eds). (2004). Iraq War Clinician Guide (2nd ed.) (pp. 58-61). Retrieved November 7, 2006 from http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/iraq_clinician_guide_v2.p

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Combating the Nursing Shortage

Because today's nursing shortage not only affects the work environment of the employee, but also the safety of the patient, nurses must take an active role in determining safe staffing levels to decrease burnout and job dissatisfaction. There is a nursing shortage with widespread effects, both for the well being of the patient, and burnout rates of nursing staff (Aiken, et al. 2002). Because of this, nurses must take an active role in determining safe staffing levels, and provider to patient ratios. Leaving these decisions to hospital management will allow the shortage to continue. However, if nurses take charge and encourage management to increase staffing to safe levels more trained staff will remain in the profession (Laschinger & Finegan 2005).

Since burnout rates increase with lower staffing levels, nurses must look to their own well being. As experienced nurses are in high demand currently (and into the foreseeable future), they have much more power over their own destiny than previously. Making the nurse a powerful advocate for increased staffing to reduce burnout rates. Because of the severity of the shortage, there not only exists a need to train new nurses; but also to retain the ones currently in the profession (Upenieks 2003). Unless the current nursing staff want to continue with the status quo of increasing burnout rates, they must become their own advocacy group. Some of the methods used could include collective bargaining, as well as bargaining on an individual basis in specialty areas.
Besides the harm done to the nurse, there is a very real danger to the patient (Beyea, 2002). With increasing patient loads, the nurse has less time to anticipate the need of the critically ill patient. This has shown as increased mortality rates in complicated patients with decreasing staffing levels (Aiken, et al. 2002). As the nurse is the primary caregiver, they are the patients best advocate. Along this line there is good reason for safe staffing levels to decrease the risk of patient harm. One of the primary functions of the nurse has always been that of patient advocate. Along these lines, the question of safe staffing becomes a moral duty of the nurse; rather than simply a question of economics and numbers (Aiken, et al. 2002). Using the current research on mortality and staffing ratios, nurses can effectively advocate for these changes by demonstrating the benefits to the health care facility facility, and the patient’s right to safe, competent care.
Significant data exists to provide answers to the question of safe patient to nurse ratios. Using this data nurses can establish (through contract bargaining and other means), safe ratios that cannot be exceeded. Creating, and indeed, mandating these limits, will benefit the facilities caring for acute patients. Both in decreasing burnout rates of existing staff, and increasing patient safety (Beyea, 2002). Nurses must take a leading role in the debate over safe staffing requirements, and hold fast to these for their own benefit, and the benefit of the patient. When staffing decreases, patient mortality increases (Aiken, et al. 2002).
One of the most effective methods of decreasing the current nursing shortage, is the creation of magnet hospitals. These are facilities where the nurse is supported as the most important provider, and their profession autonomy is valued highly (Upenieks 2003). They also must create an environment that fosters nursing practice. With more facilities attempting to become magnet hospitals, the hope is that more nurses will be draw into the profession, and fewer will leave prematurely (Upenieks 2003). Nurses may petition their current facilities to achieve magnet status, and adopt the guidelines established for these nursing-centric hospitals. When younger individuals look into a profession, they see nursing as a high-stress, low- reward profession. If nurses take an active role in the determination of facility policy, and advocate for increased patient safety, and nurse autonomy, perhaps the image of nursing will change in the near future (Shirey 2004).


Intervention 1: Increase staffing to mandated levels to decrease burnout rates.
Disadvantage #1: By increasing staffing, costs may go up per patient.
And with increased costs associated with seeking medical care, fewer patients in low-income situations may seek care (Weinick 2005). With increased staffing levels the overall care level increases, but the cot per patient has the possibility to increase, therefore making modern health care even more unavailable to low income and uninsured patients (Donley 2005).
Disadvantage #2: Patients may be diverted to a facility further away in some cases. And in some cases mandated staffing levels cannot be safely maintained.
With mandated staffing levels there is the benefit of never having fewer nurses per patient, but there is also the risk of having to divert critical patients to a facility further away, thereby risking further patient harm by delaying care. Furthermore, in cases where there is risk of further harm to the patient emergency departments are not diverting, but rather are often unable to divert when they feel it is needed. Epstein (2001)

Intervention 2: Turn more hospitals into Magnet facilities.
Disadvantage #1: Magnet Hospital characteristics are already in place in facilities that may seek this accreditation.
Because a Magnet hospital is seen as the golden standard, many organizations are seeking that status to gain respect and as a way to decrease the nursing shortage locally. However, studies have shown that in the facilities that gain magnet status, the differences sought were already pre-existing, meaning that the facilities seeking to become Magnet facilities already perform as such (Smith 2006). Also, because these facilities already meet the criteria for becoming Magnet hospitals, there are no clear methodologies to instruct other facilities to become Magnet facilities. In short, if they are seeking magnet status, they are already there, and if not, there is no clear plan to get there.
Disadvantage #2: Even with more hospitals achieving magnet status, there are not enough nurses.
As the numbers indicate, there simply not enough nurses to go around, showing us that even with more Magnet facilities the nursing shortage will not suddenly decrease in the short term. Although Magnet hospitals seem to solve many of the critical issues facing todays nurses, they cannot solve that most basic of issues, simply not having enough bodies. So although in the long term the increased job satisfaction and other associated benefits will serve to draw new nurses into the field, there is no immediate cure to the shortage (Upenieks 2005).

Reference Page:

Aiken, L. H., Clarke, S. P., Sloan, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. The Journal of the American Medical Association, 288, Retrieved 10-28, 2006, from: http://jama.ama-assn.org/cgi/content/full/288/16/1987?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=nursing+shortage+mortality&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.

Beyea, Suzanne C. (August 2002)AORN's response to the nursing shortage in perioperative settings. (Headquarters Report).  In AORN Journal, 76, p236(4). Retrieved October 02, 2006, from Expanded Academic ASAP via Thomson Gale: (A90749847)

Donley, Sister Rosemary. (2005) Challenges for Nursing in the 21st Century. Nursing Economics. Nurs Econ.  2005;23(6):312-318.

Epstein SK, Slate DH (2001) The Massachusetts college of emergency physicians ambulance diversion survey. Acad Emerg Med 8:526–527

Shirey, M. R. (2007). Social support in the workplace: Nurse leader implications. Nursing Economics, 22 (6), 313-319. Retrieved January 5, 2007 from Medscape. http://www.medscape.com/viewarticle/497035_print

Smith, Alison P. (2006) Paving and Resurfacing the Road to Magnet: The Perspective and Wisdom of Magnet-Designated Coordinators -- Part I. Nursing Economics, Volume 25, Number 5.

Spence-Laschinger, H. K., & Finegan, J. (2005). Using empowerment to build trust and respect in the workplace: A strategy for addressing the nursing shortage. Nursing Economics, 23 (1), 6-14. Retrieved January 5, 2007 from Expanded Academic ASAP database.

Upenieks, V. (2005). Recruitment and retention strategies: A magnet hospital prevention model. MedSurg Nursing, 14 (2), p. 21. Retrieved January 5, 2007 from Expanded Academic ASAP database.

Robin M. Weinick, PhD; Sepheen C. Byron; Arlene S. Bierman, MD. (2005). Who Can't Pay for Health Care? Journal of General Internal Medicine. (ISSN: 0884-8734)

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Prayer in Nursing

With spiritual care being a part of holistic care, nurses need to utilize prayer more effectively for spiritual well being, through implementation of guidelines to help nurses utilize this very important role in nursing care. There are many components of holistic care, and all of them should be recognized and implemented in care for the patient.
Nurses seem to be lacking the comfort and usage needed in spiritual care to give total holistic nursing care. Assessment of the patient’s desire for prayer or spiritual care can help solve this problem. Many nurses may not have the time or familiarity with prayer and other forms of spiritual care, therefore implementing guidelines for prayer and spiritual care are necessary to insure that all patients receive the best experience they can get. If the nurse does not have the time or knowledge, then pastoral services are available and a good resource for the patient’s spiritual needs.
Although prayer is a long established nursing intervention, praying with patients is still very controversial. It has been asked if praying with patients is ethical. The answer is that it is, if the nurse is true to the patient and themselves. Evaluation of the nurse’s own spiritual beliefs and comfort in spiritual care is essential to being sincere in providing this form of care. Taylor (2003) suggests that nurses should also seek to understand the relationship between prayer in care giving and patient/family coping. Maintaining integrity in spiritual care is important and essential in maintaining ethical standards. The question according to Wallace (n.d.) is, “Should we pray with their patients”? According to Taylor (2003) a considerable number of studies have identified prayer as a frequent and favored coping strategy among patients. Which answers the question of if nurses should pray, but a personal assessment is still necessary in each individual case. Prayer works. In recent research studies it is indicated that prayer reduces complications in CCU patients (Wallace n.d. para 2&3). According to Maier-Lorentz (2004) “The prayer group (n = 192) patients consisted of Christian born-again individuals who willingly offered prayers from a distance for these individuals whom they had never met, although they were given their names. A second group (n = 201) from the same CCU acted as the control group, and these individuals were not assigned to others to pray for them. Results indicated that patients who were prayed for had significantly less congestive heart failure, used fewer diuretics, had fewer cardiopulmonary arrests and less pneumonia, used fewer antibiotics, and were less intubated than those who did not receive intercessory praying from the born-again Christians” (para. 19). With this in mind prayer as an intervention with patients, fits the broader spectrum of spiritual care (Winslow & Winslow, 2003, para. 4).
One nursing strategy is to assess a patient’s desire for prayer or spiritual care. Assessing the patient’s need is essential for providing true holistic care. Every patient whether they are religious, spiritual, or, agnostic has needs for spiritual or emotional support. “Nurses must conduct a spiritual assessment to be involved in a caring-healing relationship that transcends all other dimensions of the physical world” (DiJoseph & Cavendish, 2005, para. 27). By allowing the patient the opportunity to reveal their beliefs or values, nurses can “understand the patient, meet spiritual needs, and provide appropriate support” (DiJoseph & Cavendish, 2005, para. 27). Using assessment skills to determine the patient’s need for spiritual care is a way to get to know the patient’s understanding and value of prayer. The nurse may try this statement to assess the patient’s desire for prayer as a coping mechanism, ‘It has been shown that prayer is a common way for people to cope with illness and life in general. Does this apply to you?’ Some other questions that may help in the assessment are, “Do you consider yourself spiritual or religious? [...] How might health care providers address any needs in this area?” (Winslow & Winslow, 2003, para. 14). If the patient answers affirmatively about prayer and the desire to receive support from the nurse, these following questions may also be helpful. “How important is prayer to you now?” or “How helpful is prayer for you now?”(Taylor, 2003, Table 1). Spiritual care may be as easy as the "gift of presence" through listening to you patient.
Another nursing strategy to help meet the spiritual needs of a patient is to implement guidelines for prayer in patient care. Suggested are some questions/ guidelines that may be appropriate. When should nurses pray with their patients? “The need for prayer during illness, even for people who do not consider themselves to be particularly religious” (Wallace, S., n.d. para. 5) is much higher and more common than many nurses probably know. Prayer with your patient is a personal choice and should not be taken lightly, but if the patient wants prayer, the nurse needs to address that need. Determining if prayer is an appropriate intervention is the first step to figuring out when to pray with a patient. If the patient suggests that, it is appropriate, asking them if they would like you to pray or for to just be present in silence with them, may be the best course of action. According to Taylor, how will a nurse know whether to pray or even discuss spiritual care with a client is a question that many nurses have asked (2003). First, permission from the patient is crucial before any prayers by the nurse should be said or thought. If the patient grants permission, the best thing to do is follow the patient’s cues as to how to proceed. When the patient specifically asks the nurse to pray for them, the next step would be to find out how they pray and what their beliefs are. An adequate assessment of a patient’s spiritual strength, needs, resources, and preferences will often include some knowledge of his or her religious tradition (Winslow & Winslow, 2003, para. 16). The nurse should focus on the patient’s spiritual needs and not their own. If the nurse does not have the same beliefs, then they should inform the patient that they are available to listen and be present while the patient prays but does not feel qualified to properly pray for them. When this happens, utilizing the hospital’s pastoral resources is an option.
Pastoral services are a good nursing strategy when the nurse is unable to provide for the patient’s religious needs. Whether it is when a nurse does not feel comfortable, they are lacking the knowledge base required for praying with the patient, or if the nurse just does not have the time necessary to address the patient’s spiritual needs, pastoral care is available. Pastoral support services may not be the exact religion or belief system that the patient follows, but they are trained in providing spiritual care. They can provide a more personal and in depth manner of care than the nurse may be able to. If the particular religions supported by the hospital are not sufficient, then they have resources outside of the hospital that can be used. Pastoral care should be able to address the patient’s needs when the nursing staff cannot, whether personally or through other religious avenues.
Praying is one of many ways to be effective in spiritual nursing care. Establishing guidelines for spiritual care and/or prayer is necessary if nurses are going to be able to provide this very important component of holistic nursing care. Assessing the patient’s need for prayer is another key element in providing good care. In the event that a nurse is not knowledgeable, uncomfortable or to busy to provide personal spiritual care and prayer, than hospital pastoral services are available. A nurse should never neglect or ignore a patient’s spiritual needs.


a. Intervention 1 (Assessment of patient’s desire for prayer or spiritual care)
i. Disadvantage 1 (Too many assessments too little time)
Assessments are the registered nurses job and priority. These assessments include respiratory, cardiovascular, skin, gastrointestinal, neurological, and psych/psycho-social to name a few. With all these assessments necessary to maintain proper care of the patient and keep them alive it would seem that assessing spiritual needs might not be prudent to the nurse, although it is definitely taught that spiritual well-being is part of holistic care. Nursing is a very fast paced stressful field of work, and nurses often have more than four patients to care for at any given time and the ongoing needs of the patients should come first. Some patient care events such as assessment, giving medications, and blood sugar checks are time specific and cannot be put off or ignored, while other patient care events can be juggled around to fit the time constraints of the nurse. Prioritization of these events enables the nurse to accomplish the job within the shift, yet emergencies can and do happen. (Navuluri, 2001) With all these patient care events, it is no wonder that spiritual care often takes the back burner in priorities.
ii. Disadvantage 2 (Delivery may discourage patient from verbalizing desire)
According to a national survey in 2004 of over 200 Americans, over one-third prays for good health. Among those who said they pray for specific health problems 69% stated that the prayer was helpful. Researchers say that people who are ill may turn to prayer as a means of coping, but on average 1 in 10 actually verbalize the desire to their nurse.(McCaffrey, et al. 2004) This may be due to the approach or delivery that the nurse uses to assess the patients desire. The delivery or route taken in order to acquire an assessment for the desire of prayer can vary greatly. If the nurse is friendly forthcoming and honestly believes in the assessment then the likelihood is that the patient will cooperate and verbalize the desire to pray if it is there. If on the other hand the nurse is short and seems distracted during the assessment results will more often than not be that the patient will keep their desires to themselves.
b. Intervention 2 (Implementing guidelines for prayer and spiritual care)
i. Disadvantage 1 (Noncompliance)
Implementing guidelines in nursing for prayer is a good idea, but there is a potential problem. While there are many guidelines in nursing, there has never been a specific set of universal guidelines for prayer. This may be due to lack of resources or interest in the subject. Without nurses, pursuing the development of these guidelines there is a huge potential for facilities to not put forth the effort to implement guidelines. With this in mind, it is not too far fetched to think that if guidelines were established but the nurses were not aggressive about implementing them then noncompliance would follow. Guidelines have been established for many different aspects of nursing and some of these are not followed as well as expected. If these guidelines are not being followed then who can expect that prayer guidelines would be, especially since prayer in nursing is not being used to its full potential as it is. Nurses may feel that they have not really used prayer so far in their care of patients so why should they start now even with guidelines.
ii. Disadvantage 2(establishing guidelines that apply to all patients)
Once the idea of guidelines has been established, we then face the problem of creating guidelines that will fit all aspects of prayer and spiritual care. This would be a very time consuming process, especially considering the many different beliefs in this world today. If the guidelines seem to cater more towards one belief than another does, it could cause serious problems with the religions or cultures of those that are not the majority. While this is understandable, it would also be almost impossible to incorporate all cultures, religions, and beliefs into one set of guidelines. This in itself can be a barrier in the implementation of prayer guidelines and then when you add in the reactions from the patients if guidelines were actually implemented but the patient’s beliefs did not fit the mold. Which would cause further issues with establishing guidelines for nurses and prayer?
References
DiJoseph, Josephine, & Cavendish, Roberta. (July-August 2005) Expanding the dialogue on prayer relevant to holistic care. (CONTINUING EDUCATION). In Holistic Nursing Practice, 19, p147(9).Retrieved April 16, 2007, from Expanded Academic ASAP via Thomson Gale
Maier-Lorentz, Madeline M. (July-Sept 2004) The importance of prayer for mind/body healing. In Nursing Forum, 39, p23 (10). Retrieved April 19, 2007, from Expanded Academic ASAP via Thomson Gale
Navuluri, R.B. (2001). Our time management in patient care. Retrieved October 20, 2007, from http://www.graduateresearch.com/NovuTime.htm
Taylor, E.J. (2003). Prayer’s clinical issues and implications. Holistic Nursing Practice, 17 (4), 179-188. Retrieved September 28, 2005, Expanded Academic ASAP database
Wallace, S. (n.d.). Should you pray with your patients?. Retrieved October 29, 2005, from http://nasw.org/users/suewallace/pages/pray_with_patients.html
Winslow, G.R. & Winslow, B.W. (2003). Examining the ethics of praying with patients. Holistic Nursing Practice, 17 (4), 170-178. Retrieved September 28, 2005, from Expanded Academic ASAP database

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Controversy of Hand Washing vrs Alcohol Based Hand Rubs

I thought they were really singing me Happy Birthday.....
The Controversy of Hand Washing vrs Alcohol Based Hand Rubs
How did the hospital staff know that is was almost my birthday? Of course it was on my chart, but I thought they would be more interested in my medical history more than my personal history.
I heard that familiar song being sung over and over with each nurse that came into my room. It wasn't until I said thank you for the 20th time before the nurse told me it was because they use that old familiar tune for the timing of hand washing.
This made me think about my Mother asking me over and over again...”Did you wash your hands?” Who would have known that this training would help me in my future nursing career? There are many agencies with guidelines, the CDC may be the best known, on just how to wash you hands and why. My question was, “Is alcohol based hand rubs better or more efficient than soap and water?” We all know that washing has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (ie...MRSA: methicillin resistant staphylococcus aureus) and reduce overall infection rates. Alcohol-based hand rubs take less time to use than traditional hand washing, but is one better than the other? Research (2*) shows that in an eight hour shift, an estimated one hour of time will be saved by using an alcohol-based hand rub.
Are hand rubs more effective than washing your hands with running water and soap? According to the Middlesex-London Health Care Unit (2*), the answer is “no”. Traditional hand washing with water and soap is just as effective if done properly.
While hot water may more effectively clean your hands, this is primarily due to its increased capability as a solvent, and not due to hot water actually killing germs. Hot water is more effective at removing dirt, oils and/or chemicals, but contrary to popular belief, it does not kill microorganisms. A temperature that is comfortable for hand washing is about 113 degrees F and it would take more than double that temperature, about 212 degree F, to effectively kill germs. The addition of antiseptic chemical to soap does have a killing action to a hand washing agent. (4*)
The proper washing of hands with water in a medical setting generally consists of use with generous amounts of the antiseptic soap, rubbing each part of ones hands systematically for 15-20 seconds...(3*)which happens to be that old familiar song talked about earlier. Hands should be rubbed together with digits interlocking. If there is debris under fingernails, a bristle brush is used. Finally, rinse well and wipe dry with a paper towel. Lastly turn off water with a dry paper towel. (2*)
Non water based hand hygiene agents, also known as alcohol based hand rubs, antiseptic hand rubs, or hand sanitizers, are based on isopropyl alcohol or ethanol formulated together with a humectant such as glycerin into a gel, liquid, or foam for ease of use and to decrease the drying effect of the alcohol. Their increasing use is based on their ease of use, rapid killing activity against microorganisms, and lower tendency to induce irritant contact dermatitis as compared to soap and water hand washing. Despite their effectiveness, the non water agents do not clean hands of organic material, they simply disinfect them. However, disinfection does prevent transmission of infectious microorganisms.(4*)
Hand sanitizers containing a minumum of 60-95% alcohol are very efficient germ killers. It kills bacteria, multi-drug resisitant bacteria (MRSA & VRE), tuberculosis, and viruses (including HIV<>
Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use, it is reasonable to expect have occasional true allergic reactions to such products. (2*)
In conclusion, Alcohol rubs and combination hand sanitizers are effective at killing germs on your hands, but not effective at removing dirt. Conversely, soap and water are very effective at cleaning dirty or soiled hands, but are not good at killing germs (as discussed above).
References:
1* “Why Do I Really Need to Wash My Hands?”; Mary L. Gavin, MD from Children's Hospital, 13123 E. 16th Ave; Aurora, CO http://www.thechildrenshospital.org/wellness/info/kids/10624.aspx
2* “Hand Hygiene Fact Sheet”; United States Department of Health and Human Services: Center for Disease Control and Prevention Hospital URL:http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm
3* “Alcohol Based Hand Rubs; Questions and Answers”; Local Public Health Program at the Middlesex-London Health Unit, 2007 http://healthunit.com/article.aspx?ID=12684
4* “Hand Washing” from Wikipedia.org; http://en.wikipedia.org/wiki/Hand_washing
A. Interventions #1 Truth about actually killing HIV virus with alcohol based hand rub
Disadvantage #1: There is not enough evidence in the articles researched to confirm this claim of alcohol being absolutely responsible to kill the AIDS virus through proper hand sanitizing techniques. The reference sited as its source: Hand Hygiene for Healthcare Workers. LearnWell Resources, Inc, a California nonprofit public benefit 501(c)(3) corporation. Retrieved on 2007-04-27,
Disadvantage #2 Even though microorganisms are killed on your hands after washing or alcohol base hand rub, there are still other areas in the room that can be picked up after gloving and transferred to patients wound sites or to their body. ( 1*)
B. Intervention #2 Hand washing must be done every time a nurse, Dr., other personnel staff or visitors enter the room.
Disadvantage #1: Due to the hurry staff or visitors are in, the assurance that hand washing or alcohol based hand rub is used every time is questionable and therefore puts the patient in greater risk for infections or contamination. (CDC.gov on their Fact Sheet on Hand Washing)
Disadvantage #2: Constant hand washing or use of alcohol based hand rub dries skin and may cause allergic reactions to occur on personnel while caring for patients. (Wikipedia web site under “Hand Washing”)

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Best Practices for Nurses in Maintaining Safe Medication Administration by Practicing the "5 rights" of Medication Administration.

A medical mistake made at a Methodist hospital in Indianapolis was reported again in California at the Cedars Sinai Medical Center. In the California pediatric unit, the three infants got an adult dose of Heparin, a blood thinner.

That's 10,000 units instead of the infant dose of ten. “It's the same mistake that led to the death of three young patients in the NICU at Methodist hospital last year (Tiernon, 2007)”
Ongoing research shows that medication errors are happening frequently and that adverse drug events, or injuries due to drugs, occur more often than necessary. According to Kaufman (2006), at least 1.5 million Americans are sickened, injured or killed each year by errors in prescribing, dispensing and taking medications (para.1). Mistakes in giving drugs are so prevalent in hospitals that, on average, a patient will be subjected to a medication error each day as he or she occupies a hospital bed (Kaufman, 2006, para.2). Medication administration errors are not only harmful and widespread but also very costly. "The extra expense of treating drug-related injuries occurring in hospitals alone was estimated conservatively to be 3.5 billion a year” (Kaufman, 2006, para.4). The errors indicate a breakdown in the system. Nurses should carefully practice the “5 rights” of medication administration in order to provide safe medication administration. The “5 rights” of medication administration are: Right patient, right route, right time, right drug, and right dose.

Meadows (2003) noted that the National Coordinating Council on Medication Error Reporting and Prevention defines a medication error as “any preventable event which may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health-care professional, patient, or consumer" (para.4).According to Stoppler (2006), a study by the Food and Drug Administration evaluated reports of fatal medication errors from 1993-1998, “the most common error involving medications was related to administration of an improper dose of medicine, accounting to 41% of fatal medication errors. Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Almost half of the fatal medication errors occurred in people over the age of 60. Older people may be at greatest risk for medication errors because they often take multiple prescription medications.”In addition, many medication names look or sound like other medication names, which may lead to potentially harmful errors. Examples of medications that look and sound alike include: Amaryl and Reminyl, Clonidine and Klonopin, Depakote and Depakote ER, Famitidine and Furosemide, Xanax and Tenex. "An 8-year old died, it was suspected, after receiving methadone instead of methylphenidate, a drug used to treat attention deficit disorders.A 19-year-old man showed signs of potentially fatal complications after he was given clozapine instead of olanzapine two drugs used to treat schizophrenia. And a 50-year-old woman was hospitalized after taking flomax, used to treat symptoms of an enlarged prostate, instead ofvolmax, used to treat bronchospasm. In each of these cases reported to the Food and Drug Administration, the names of the dispensed drugs looked or sounded like those that were prescribed” (Rados, 2005).
To provide safe medication administration, the nurse should carefully practice the “5 rights” of medication administration. First, the nurse should ensure that the medication is given to the right client by checking the client’s identification bracelet and having the client state his or her name. The nurse should never go by room and bed number alone. “Some clients answer to any name or are unable to respond, so their identification should be verified each time a medication is administered. The nurse should verify the client by checking the identification bracelet. Some facilities put the client’s photo on his or her health record. The nurse should distinguish between two clients with the same last name” (Kee & Hayes, p.24)."Children are not totally reliable in giving correct names on request. Infants are unable to give their names, a toddler or preschooler may admit to any name, and school age children may deny their identification in an attempt to avoid the medication. Children sometimes exchange beds during play. Parents may be present to identify their child, but the only safe method for identifying children is to check their hospital identification band with the labeled medication or medication card" (Wong & Perry, 2002,p.1156). According to Kee & Hayes, in settings such as schools, physician’s office, and outpatient departments where clients do not wear identification bands, it is the nurse’s responsibility to identify accurately the individual when administering medications.
Second, the nurse should ensure that the medication is administered via the prescribed route. “The common routes of absorption are oral (by mouth), sublingual (under the tongue), inhalation (aerosol spray), suppository, (rectal, vaginal), buccal (between gum and cheek), via feeing tube, instillation (in nose, eye, ear), topical (applied to skin), intramuscular (IM), subcutaneous (SC), intradermal, and intravenous (IV)” (Kee & Haye, 2006, p.26).The oral route is preferred for administration of medication to clients whenever possible because of the ease of administration of oral medications. However, whichever route is prescribed, the nurse needs to make sure that the route is accessible. For example, if a medication is to be given by mouth, can the patient swallow? If not, can the medication be crushed? Third, the nurse should administer the medication at the time the prescribed dose should be administered. “Daily drug dosages are given at specified times during the day, such as twice a day, three times a day, four times a day or every 6 hours, so that the plasma level of the drug is maintained” (Kee & Hayes, 2003, p.26). Drugs with a long half-life are given once a day whereas drugs with a short half-life are given several times a day at specified intervals. In addition, drugs that are prescribed in association with meals need to be given with meals.In addition, the nurse should administer the right drug. This means the client receives the drug that was prescribed. To do this effectively, the nurse should check the medication order against the medication. If the order is illegible or some components of the order are missing, such as signatures, the nurse should contact the health care provider.
Furthermore, the nurse should administer the right dose prescribed for a particular client. The nurse should check the order and the medication label and look up any medication which he or she is not familiar with. The nurse should calculate each dose accurately, and ensure that each dose is within the recommended dose for the particular drug. Mayor (2004) states that “training and assessment of competence in pediatric drug therapy- including calculations of doses and infusion rates should be introduced to reduce the risk of drug errors in children.”
In conclusion, medication errors are surprisingly common and costly to the nation. They can lead to prolonged hospital stay, unnecessary diagnostic tests, unnecessary treatments, and death. Nurses can help to decrease the prevalence of medication errors by carefully practicing the “5 rights” of medication administration. Nurses can maintain patient safety by administering the right medication, in the right dosage, to the right client, by the right route, and at the right time.

References:
Kaufman, M. (2006, July 21). Medication Errors Harming Millions. The Washington Post. p. A08. Retrieved February 19, 2007 from http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.
Kee, L.J., & Hayes, R.E. (2003). Pharmacology. A Nursing Process Approach (4th Ed.). Philadelphia, PA: W.B.Saunders Company.
Mayor, S. (2004). Report Calls for Strategies to Reduce Medication Errors.British Medical Journal 328:248 .7434.248-b . Retrived May 20, 2007 from http://www.bmj.com/cgi/content/full/328/7434/248-b
Meadows, M. (2003).Strategies to reduce medication errors. FDA Consumer Magazine. Retrieved, February 14, 2007 from http://www.fda.gov/fdac/features/2003/303. Rados, C. (2005). Drug Name Confusion: Preventing Medication Errors. Retrieved, May 20,2007 from .http://www.medicinet.com/script.
Stoppler, C.M. (2006). The Most Common Medication Errors. Retrieved, May 20, 2007 from http://www.medicinenet.com/script/main.
Tiernon M.A (2007). Families upset over new Heparin overdose cases. Retrieved, December 3, 2007 from http://www.msnbc.msn.com/id/21920910.
Wong, D., Perry,S. & Hockenberry, M.J. (2002). Maternal Child Nursing Care. (2nd Ed.) St. Loius, MO. Mosby-Year Book, Inc.

A: Intervention # 1: Incomplete and illegible orders

Disadvantage # 1: Sometimes physicians write incomplete orders with either the drug, dose, route, and frequency missing from the order. All of these components must be present for a physician order to be considered complete. It is not a good practice to accept orders when the dosage is written as "1 tablet." "A complete order includes specific numerical dosages. For example, Acetaminophen 2 tablets po prn should now be written as Acetaminophen 650 mg. po prn. It is also no longer safe practice to administer vague orders such as "Laxative of choice." Drugs ordered need to be specific and the dose explicit (Cook, 2007)."

Disadvantage # 2: At times physicians write illegibly making it difficult for the nurses to read and transcribe orders correctly. Some facilities such as The Massachusetts Hospital Coalition recommends physicians use computers to directly order medications. "However, such costly systems may take years to implement.Cefoxitan and Cefotetan may look alike when hand written but confusing one drug for the other results in the patient receiving the wrong medication (Cook, 2007)."

B: Intervention # 2: Knowledge deficit

Disadvantage # 1: "Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication." However, not every family, nursing facility or clinic have drug guides. The package insert that comes with every medication is also a good resource but yet due to language barrier, inability to read and comprehend medical terminology, some patients or nurses may not be in a position to give the right dose, of the right drug, at the right time. Pharmacists are knowledgeable resources and can answer many questions regarding medication but this may not be the case for over-the-counter medications (Hauswirth, 2002).

Disadvantage # 2: At times nurses have minimal or no knowlege of calculations leading to the right dosages. "Calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams (Hauswrith, 2002).

References:

Cook C. Michelle (2007). Nurses' Six Rights for Safe Medication Administration. Retrieved November, 7 2007 from http://www.massnurses.org/nurse_practice/sixrights.htm Katherine Hauswirth (2002). Administration of medication. Gale Encyclopedia of Nursing and Allied Health, 2002. Retrieved November 7, 2007 from http://www.healthline.com/galecontent/administration-of-medication

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Preventing Child Abuse and Neglect

Child abuse and neglect (CAN) is a serious problem that results in devastating and long lasting damage to the individual affected, and to the community at large. Abuse and neglect in childhood can destroy self-esteem, self-concept, relationships, and the ability to trust (Valente, 2005).

Because nurses are on the frontline of assessment, they must be trained to recognize child abuse and neglect, and they must be trained in the proper response to positive screening results. Nurses must also be educated in methods of support for affected victims, and in ways to prevent abuse and neglect.
Children who are abused and neglected often come to believe that they do not deserve loving treatment. Abuse teaches those who suffer from it that others can not be trusted. Neglect and abuse of children is far from rare: The American Humane Association (2003) cites statistics that indicate that 17% of college students experienced abuse before the age of 18. The effects of abuse and neglect persist throughout the lifetime of the affected child. Society is affected as well, because those whose belief in themselves is shattered may turn to criminal enterprises, are more likely to engage in substance abuse, and are more likely to be sexually promiscuous (Overstolz, 2001).
Nurses are well trained to recognize the indicators of physical disease. Screening for problems with hearing and vision is a common nurse's role in primary schools. Because nurses routinely conduct screenings and assessments, they are ideally placed to also screen for the indicators of CAN. However, even nurses who have been practicing for many years may often believe that they have had little or no experience with abused or neglected children. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007). Studies have shown that nurses are interested in learning to screen for CAN, and that they feel confident in their ability to effectively do so (Waibel-Duncan, 2006). Once the nurse has identified a child who is at risk for or experiencing CAN, he or she needs to respond properly. Education of nurses in the identification of CAN must therefore include training in the appropriate response to positive screens. This response may include notification of legal authorities or supportive interventions for the family, depending on the severity of the indicators observed and the parties involved. Just as protocols are developed to achieve high standards of physical care, so too should nurses act to develop protocols for response to danger signs in the dynamics of the families that they care for.
Nurses develop therapeutic relationships in order to support those suffering physical and psychological disease. It is vital that nurses also be trained in the specifics of properly supporting victims of CAN. Recovery from CAN is often a life-long process. Recovery is facilitated when those afflicted receive appropriate and caring support and guidance. Well meaning but poorly trained attempts to help victims can actually slow recovery, as when the affected child is advised to "just put it out of (his or her) mind" or "just get over it." This illustrates the importance of education in the proper methods for supporting and facilitating victim's recovery. Nurses may encounter CAN victims in the hospital, or may discover that they have identified a child at risk for or suffering CAN during school screenings or at a doctor's office visit. In these situations, nurses can begin the process of recovery of CAN victims by taking steps to build the affected child's self esteem. Ensuring that the child has a safe environment where his or her needs are met in a loving manner is a major priority. Nurses may also work with CAN victims in mental health units. Abused children often believe they are damaged, unlovable, and worthless (Valente, 2005). Nurses must constantly reinforce the idea that an affected child is worthwhile, lovable, valuable and deserving of loving care. It is crucial that nurses allow those suffering from CAN to speak openly about their experiences, and that when a victim reports abuse, they must be believed (American Humane Association, 2003).
Supporting recovery of victims is very important, but few would dispute that it is far better to prevent a situation that causes serious harm to a child from happening in the first place. This is especially true in CAN. No means of therapy exists that is superior to avoiding the experience of abuse trauma or neglect entirely. There are many ways to reduce the chance that children will suffer abuse or neglect. Preventative measures include the following: At schools, health fairs, or clinics, nurses can provide age appropriate educational materials on CAN to children. Children can be trained in problem solving techniques, taught to identify troublesome occurrences, and conditioned to believe in themselves. Parents can be educated in finding safe child care arrangements. The public at large can be taught that a child abuser is most often some one who is known to the child. For too long, efforts at avoiding CAN have centered on alerting children to "stranger danger," when in fact the danger most often comes from relatives or acquaintances (American Humane Association, 2003).
Child abuse and neglect is a significant and pervasive problem which causes devastating and long lasting damage to those affected. In their roles as patient advocates, nurses can make a real difference in the lives of children, through training in CAN recognition, and in the appropriate response to positive CAN screening results. Nurses can effectively support the recovery of those who are damaged by CAN, and can take meaningful action to stem the tide of CAN. As compassionate professionals who dedicate their lives to serving their patients, nurses are ideally suited to make the world of childhood brighter and safer for all children.
There are potential disadvantages to these interventions:
a- "Because nurses are on the forefront of assessment, they must be trained to recognize child abuse and neglect, and trained in the proper response to positive screening results".
i- Disadvantage 1: Inadequate Insurance. The cost of training nurses is already high. Health care receivers ultimately shoulder the burden of the education of heath care providers, either through insurance payments, or through direct payment for services. Every item that is added to a nursing school curriculum adds costs to that program, in terms of time and money. Insurance is already unaffordable for many people. Adding to the costs of healthcare would put insurance out of the reach of even more people. A survey of 1,712 college students revealed a 17% rate of occurrence of sexual abuse before age 18 (Epstein & Bottoms, 1998). Ending abuse for 17% of the population would involve a huge increase in insurance rates.
ii- Disadvantage 2: Discrimination. The poor have long had a saying: "Justice means 'just us'", meaning that fairness is only available to those who are prosperous and mainstream. Disenfranchised minorities would be vulnerable to any attempt to screen for abuse as they lack the money and power to appeal an inaccurate finding. According to Douglas Besharov in The Future of Children (1994), “Potential reporters are not expected to determine the truth of a child’s statements. As a general rule, therefore, all doubts should be resolved in favor of making a report.” This implies that every time a child made a statement indicating potential abuse, the parents of that child would inevitably face a removal process, and the costs of an appeal. Poor and minorities by definition do not have excess funding and power, therefore their children would be removed at rates much greater than prosperous members of mainstream culture.
b- "Nurses must be educated in methods of support for affected victims and in ways to prevent child abuse and neglect".
i- Disadvantage 1: Knowledge Deficit. Most nurses would not know where to begin in repairing the shattered psyche of an abused child. A knowledge deficit exists in the nursing community at large regarding what child abuse is and how to respond to it. To remedy this problem, programs are being developed to educate nurses in identification of the at-risk or victimized child (Young, Jackson, 2007), however these programs are still in development. ii- Disadvantage ii: Religion. Preventing child and abuse means that some of the power over decisions about a child is taken away from parents and given to government. Religions vary in their views on the roles of child and parent, however most religions advocate for submission of the child to the will of the parent. The Bible tells the story of Abraham, who was preparing to sacrifice the life of his son to God (Genesis 22:1-12 ). This action would not be condoned by a society that educates its nurses in preventing abuse, however that occurrence is a cornerstone of the Christian faith. The religious right believes that there is one ultimate authority for all things, and that authority is God. It would be expected that they would oppose the transfer of power from God to the government.
Child abuse and neglect is a complex problem. Finding solutions to this problem requires evaluation of the benefits and the drawbacks of potential interventions.

References
Besharov, D. J. (1994). Responding to child sexual abuse: The need for a balanced approach. In R .E. Behrman (Ed.), The future of children (Vols. 3 and 4) (pp. 135-155). Los Altos, CA: The Center for the Future of Children, The David and Lucile Packard Foundation.
Epstein, M., & Bottoms, B. (1998). Memories of childhood sexual abuse: A survey of young adults. Child Abuse & Neglect, 22(12), 1217-1238.
Genesis 22:1-12 , (1952). Holy Bible. Dallas, Texas: The Melton Book Company.
Young, C, & Jackson, E (2007). Innovative Learning Opportunity. Journal of Nursing Education, 46, Retrieved May 1, 2007, from http://proquest.umi.com/pqdweb? index=0&did= 1245472821&SrchMode=1&sid=2&Fmt=6&VInst= PROD&VType= PQD&RQ T=309&VName=PQD&TS=1180685630&clientId=3236.

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Nurse's Role in Palliative Care

Research indicates that professional education and knowledge on end-of-life or palliative care has been limited or nonexistent in both nursing and medicine (LaPorte-Matzo & Sherman, 2001; Foley, 2005). Competent and compassionate end-of-life care is a responsibility of all health care professionals. Nurses consume the health care profession, and thus, have a tremendous potential to effect change in the care of the dying and their families.

(LaPorte, Matzo & Sherman, 2001). Armed with an understanding of the goals of palliative treatment,
nurses can play a leading role in palliative care by creating and implementing a plan of care.
The World Health Organization published its first definition of “palliative care” in 1986
and a revised version in 2002 (Foley, 2005). The revised definition the WHO provides states:
“Palliative care is an approach which improves quality of life of patientsand their families facing life-threatening illness, through the preventionand relief of suffering by means of early identification and impeccableassessment and treatment of pain and other problems, physical,psychosocial, and spiritual.”
By definition, palliative care now addresses the continuum of a patient’s illness and
preventing suffering rather than simply treating it (Foley, 2005). Caring for the whole person is
a key concept in palliative care (Seery, 2004). An easy way for nurses to accomplish this is by
considering the domains of holistic care, that is, the physical, psychological, social, and spiritual
needs of a patient.
Dying patients asked to rank their basic needs have said that they wished to be free of
pain, anxiety and shortness of breath; to be kept clean; and to be touched (Seery, 2004). For
many patients, the diagnosis of a chronic or terminal disease means the immediate end of a
“good life.” This is why palliative care today seeks to integrate curing with caring, to improve
quality of life and support the patient’s view of a “good death.” ( Rushton, Spencer & Johanson,
2004). The goals of palliative treatment are concrete: relief from suffering, treatment of pain
and other distressing symptoms, psychological and spiritual care, a support system to help the
individual live as actively as possible, and a support system to sustain the individual’s family
(Kuebler, Davis, & Moore, 2005).
Comfort measures should be included in the physical component of care which involve
frequent repositioning and padding of bony prominences (Seery, 2004). Attention should also
be taken to skin care to prevent the development of pressure ulcers. Additional physical
symptoms include nausea and fatigue. Nurses should focus care of the tired patient on
promoting adequate, restful, and restorative sleep when possible (Kuebler, Davis, & Moore,
2005). This can be done by preventing or reducing the factors that are disturbing the patient’s
sleep or that have the potential to do so and by providing bedtime routines, comfort measures
and a setting that accommodates sleep.
Palliative care can relieve most, but not all of terminal suffering for the patient. While
most experts agree that 95% of pain can be relieved by treatment that is acceptable to the
patient, the fact still remains that 5% of the palliative care population must cope with
unrelieved pain (Quill, 2001). The goals of palliative treatment become less concrete for these
patients. Nurses must acknowledge the fear for patients and families regarding unrelieved
pain. Also, it becomes paramount for the nurse to understand the therapeutic and institutional
barriers to effective pain management. The palliative care nurse may need to rely on non-
pharmacological alternatives to complement pain management (LaPorte, Matzo & Sherman,
2001).
Nurses can face an ethical dilemma when treating patient suffering. The most
commonly cited reason for requesting physician-assisted death is not pain, but rather
increasing weakness, debility, fatigue and dependence (Quill, 2001). Some end-of-life patients
experience terminal delirium and lose the capacity to make decisions for themselves toward
the end (Quill). This can lead to patient agitation and the decision to sedate such a patient who
can now no longer consent to such treatment. The palliative care nurse needs a plan for
handling such tough symptoms especially if they threaten the patient’s integrity during the
dying process. Inevitably, nurses may struggle with morally and ethically compromising
decisions such as these.
When addressing psychological, social and spiritual needs of the patient, an effective
way to determine his or her needs is to ask open-ended questions designed to elicit thoughts,
feelings, hopes and values. Utilizing therapeutic communication and empathy tends to not only
help the patient feel better, but also improves the patient and family’s perception of care
during the last days (Seery, 2004). Thus, care planning with the palliative patient should include
more than discussion of treatment preferences. Nurses should also address patient values,
beliefs, and goals. Patient values are the foundation for treatment preferences and medical
decision making (Kuebler, Davis, & Moore, 2005). Nurses can assess values and goals by asking
open-ended questions such as: What is most important to you as you think about the future
(Kuebler, Davis, & Moore, 2005)?
Nurses must also be aware that they bring their own spiritual and cultural beliefs and
values, as well as their own personal and professional experiences regarding death and dying to
palliative care nursing (LaPorte, Matzo & Sherman, 2001). Without this awareness and coming
to terms with it beforehand, the potential for biased care exists. This is why some professionals
have argued against using the method of open-ended questions during palliative care (Quill,
2001).
As nurses make every effort to ensure the psychological and spiritual component of
palliative care and help to create valuable support systems, they place themselves at risk of
becoming emotionally and physically drained (Laporte, Matzo, & Sherman, 2001). Nurses often
spend many hours in the supportive role and can suffer from caregiver strain. Efforts should be
made by the palliative care nurse to seek their own emotional outlets and plan care
accordingly.
Nursing’s history reveals compassionate care for the dying and that care exists beyond
cure. Presently, nurses must take the lead in integrating palliative care into the daily practice of
every nurse, making it a core competency for all nurses who care for people with actual or
potentially life-limiting illnesses (Rushton, Spencer & Johanson, 2004). In summary, nurses are
responsible for educating themselves on the goals of palliative treatment. With this
accomplished, nurses can most effectively create and implementa plan of care, thus becoming
the best advocate for the palliative care patient and their families.

REFERENCES
Foley, K. M. (2005). The past and future of palliative care. The Hastings Center Report,
35, (6), 42-. Retrieved February 20, 2006 from ProQuest database.
Johanson, W; Rushton, C. H.; & Spencer, K. L. (2004). Bringing end-of-life care out of the
shadows. Nursing Management, 35, (3), 34-. Retrieved February 20, 2006 from Infotrac
database.
Kuebler, K.K.; Davis, M.P.; & Moore, C.D. (2005). Palliative Practices: An Interdisciplinary
Approach. (63-396). Elsevier Mosby, Philadelphia, PA.

LaPorte-Matzo, M., Sherman, D. W. (2001). Palliative Care Nursing: Quality Care to the
End of Life. (xvii – 278). Springer Publishing Company, New York, NY.

Quill, T. (2001). Caring for Patients at the End of Life: Facing an Uncertain Future
Together. (115-154). Oxford, University Press.
Seery, D. H. (2003). Shifting gears: from cure to comfort: hundreds of thousands of
patients die in ICU’s each year, but few receive palliative care. Nurses play a central role in
transitioning from aggressive treatment to comfort care. RN, 67, (11), 52-. Retrieved February
20, 2006 from ProQuest database.

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Pressure ulcers Know How to Stop the Pain

To the untrained eye, a pressure ulcer may appear to be an open scab; although a pressure ulcer is more serious. According to Black and Hawks (2005), a pressure ulcer is, “any lesion on the skin caused by unrelieved pressure and resulting in damage to the underlying tissue” (p. 1403).

People who most commonly get pressure ulcers are those that are immobile or paralyzed. The reason for this is because sitting or laying down for extended periods of time increases pressure points by collapsing blood vessels and restricting the flow of blood to these areas. This may eventually lead to the death of the cells in these areas. By studying the causes of pressure ulcers and knowing the proper treatment procedures, nurses should be able to reduce the number of pressure ulcer cases in high risk groups.
Educating patients and nurses is one of the most important strategies to prevent and reduce pressure ulcer occurrences. Continuing education programs should be periodically conducted for nurses to reinforce and update their training. This will help to make sure the patient teaching that the nurses are doing is accurate and reliable. Pressure ulcers can affect anyone who is either paralyzed or immobile for an extended period of time, although these types of ulcers are most commonly seen in elderly people. Pressure ulcers develop when soft tissues are compressed between a bony prominence and a firm surface for a long period of time. Elderly people have the highest occurrences due to their limited mobility in conjunction with their thinner fragile skin. Given that this group has the greatest risk for pressure ulcers evaluating what causes them to appear and how to prevent them is the next step.
There is a scale that can be used in order to determine risk for pressure ulcers called a Braden or Norton tool. This tool gives a numerical score to six different areas in order to better determine risk factors for skin breakdown. According to Frantz (2004), “a patient in any setting with a score of eighteen or below should be considered at risk” (p. 5).Using this tool while doing daily skin checks could dramatically influence the number and severity of cases seen. Risk assessments should be completed on admission and 48 hours later. One cause, which could affect how fast a pressure ulcer is detected, is the lack of pain perception related to a loss of sensation. The Mayo Clinic staff state that , “in some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, wrinkled clothing or sheets, a chair whose tilt is slightly off- even perspiration, which can soften skin making it more vulnerable to injury”(2007, para. 3). This is usually due to spinal cord injuries or disease. Smoking, malnutrition, incontinence, and medical conditions such as diabetes or cardiovascular disease can also affect the chances of getting pressure ulcers.
Once the patient is admitted with pressure ulcers the focus needs to shift to treatment and to prevent them from getting worse. One way to reduce the ulcers is to change the patient’s support surfaces, such as switching to an air mattress or water mattress, in order to limit the number of pressure points and increase movement. Another very important part of the treatment plan is turning the patients. The outdated recommendation for moving a patient to help with relieving pressure used to be every two hours. The new recommendation is dependent on the patient and their illness. When caring for a client who already has a pressure ulcer it is essential to know the different stages involved in order to give the proper treatment depending on the stage.
Stage 1- Skin has redness that does not turn white with pressure. It may hurt, itch or fell warm and spongy. If pressure is relieved quickly stage 1 will go away shortly after.
Stage 2- The top layer of the skin and the skin just below it are damaged. The ulcer can look like a shallow blister or abrasion. The surrounding tissue may have a red or purple discoloration.
Stage 3- This stage can have damage down to the muscle by causing damage or necrosis of the subcutaneous tissue.
Stage 4- A deep crater with extensive destruction or damage to muscle, bone or supporting structures. It is very difficult to heal and can lead to deadly infections.
It is crucial to identify pressure ulcers as early as possible to increase the chance of saving the skin from any further damage.
The skin can be protected using several methods; movement is the most effective for patients that are in bed. Movement at least every two hours is very important because it relieves pressure on the blood vessels and allows unrestricted blood to flow to those areas. Frantz (2004) states, “when patients are sitting in chairs and are unable to reposition themselves, their weight should be shifted every fifteen minutes to relieve pressure on the ischial tuberosities” (p. 7). Another method is to inspect the skin at least once a day, looking for warm reddened areas mostly around bony prominences, for example: the hips, heels, shoulders and back of the head. As detailed by the figure below from, Aging in the Know (2007).
Using pillows can help to avoid reddened areas or areas of increased pressure. Using a systematic schedule for turning and repositioning will help to ensure repositioning is being done consistently and in the right time frame. When repositioning a patient, lifting devices such as a trapeze or lifting sheet are helpful to make turning and repositioning easier. An important thing to remember is to be careful not to cause shearing or breaking of dry cracked skin. Dry cracked skin can be avoided by washing with warm water and a mild cleaning agent and treated with moisturizers to minimize irritation and dryness. It is also imperative to protect the skin from excess dampness, caused by sweat, wound drainage, and urinary or fecal incontinence.
Knowing the causes of pressure ulcers and who is at the greatest risk will make it easier for nurses to reduce the number of cases in high risk groups. As stated by, Courtney, Ruppman, and Cooper (2006), ”nearly 60,000 U.S. hospital patients are estimated to die each year from complications due to hospital acquired pressure ulcers” (p. 36). That is a very high number for a condition that is so preventable with daily skin checks and regular repositioning.
a. Intervention 1 Education and Prevention
i. Disadvantage 1 Anxiety and Interpretation of the material.
The material may be misinterpreted because English may not be the patient’s primary language which may cause the important issues and points to not be communicated properly. The patient may also not understand everything the nurse is saying due to an increased anxiety level from being in the hospital. According to (Quinn, 2007, p. 451). Some disadvantages are that the patient may feel under the spotlight. They may also miss the support of other patients. Along with the fact the patient may feel embarrassed they are not learning the information quickly and the teaching is going to fast.
ii. Disadvantage 2 Nurses misconception of the patient and patient’s reluctance.
The nurse may be taking for granted that the patient understands everything the nurse is saying due to the patient’s not wanting to ask questions. The nurse also knows the information much more than the patient and it comes easy to them so the nurse may skip over something they feel is not as crucial to cover. The nurse may go too fast thinking the patient can keep up also which may make the patient more apprehensive to asking questions. Because of this the patient may feel rushed and unimportant.
b. Intervention 2 Treatments
i. Disadvantage 1 Support surfaces
Disadvantages to having an air mattress can be that it may be punctured. Without proper inflation the bed is easier to puncture which is not beneficial to the patient. A water mattress may also be used but some disadvantages to this are that it must have a heater for the water to keep the patient’s body temperature at a comfortable level. Maintenance of a water mattress is difficult because the water has to be conditioned to prevent bacteria from growing. Procedures may also be more complicated when trying to perform them on a water mattress, such as a thoracentesis. Getting out of bed or changing a patient’s dressings may be more difficult for the patient as well. There are other support surfaces available to patients all having their own disadvantages. According to (Popescu and Salcido, 2006, section 8). The other available options are gel, foam, low air loss, dynamic overlays and air fluidized. Nurses should include this as part of the risk assessment that is performed when patients arrive at their facility to ensure patients are getting the proper support surfaces.
ii. Disadvantage 2 Dressings and Nutrition
Dressings are a very important part of the treatment process. Although dressings are not effective unless the wound is kept moist while the skin around it is dry. If the wound is not cleaned and the dressing not changed daily the wound will not heal. The disadvantage to this is the fact the patient may not be able to change the dressing on the wound by without assistance. Nutrition also plays a vital role in wound healing because if proper nutrition is not maintained the wound will heal slower. When discussing nutrition the nurse must make sure the patient does not have any GI dysfunction or can not swallow without aspirating. As stated in Black and Hawks (2005). Nutritionally compromised clients need to have a plan for nutritional support or supplementation implemented. Implementing a plan could be difficult for older patients that have definite food preferences and expectations. If adequate nutrition is not met alternative methods are put into action such as enteral or parenteral feedings.






References

American Geriatric Society, (2005). Pressure sores (bed sores). In Aging in the Know (ch 30). Retrieved January 31, 2007, from
http://www.healthinaging.org/aging intheknow/chapters_ch_trial.asp?ch=30
Black, J.M., & Hawks, J.H. (2005). Pressure Sores. Medical Surgical Nursing Clinical Management for Positive Outcomes, 7, 1403-1411.
Courtney, B.A., Ruppman, J.B., & Cooper, H.M. (2006). Initiative cuts pressure ulcer incidence in half. Nursing Management, 37, 36-45.
Frantz, R.A., (2004). Prevention of Pressure Ulcers. Journal of Gerontological Nursing For Nursing Care of Older Adults. 30, 4-9
Mayo Clinic Staff, (2007). Bed sores. Retrieved January 31, 2007, from http://mayoclinic.com/health/bedsores/DS00570
The Medical Journal of Australia, (2004). Preventing Pressure Ulcers. Retrieved October 28, 2007, from http://www.mja.com.au/public/issues/180_07_050404/sta10029_fm.html
NSW Department of Health, (2003). Prevention of Pressure Ulcers Rehabilitation and Residential Settings. Retrieved October 20, 2007, from http://www.health.nsw.gov.au/quality/pdf/pressure_ulcers_rehab.pdf
Propescu, A., Salcido, R. (2006) Pressure Ulcers and Wound Care Retrieved October 15, 2007, from http://www.emedicine.com/pmr/topic179.htm
Quinn, F. (ND). The Principles and Practice of Nurse Education. Retrieved October 15, 2007, from http://books.google.com/books?id=r0bqU8lgSXgC&pg=RA1-PA451&lpg=RA1-PA451&dq=patient+teaching+disadvantages&source=web&ots=5jGbU94u21&sig=OjBf02Rpm6fI1h54EPkxkd-5oDE#PRA1-PA451,M1

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The Role of the Nurse in Incorporating Spirituality within the Healthcare Field

Thesis: Nurses, as caretakers, are in the position to offer spiritual health care through education in recognizing spiritual distress w/in their patients, developing or utilizing an preexisting spiritual assessment tool to measure the level of spirituality in each client and providing unique interventions to attend to their spiritual needs.

Patients that now come into health care facilities seeking care are inflicted with many multiple acute or chronic diseases that are not curable but, perhaps, manageable. Despite how manageable these diseases are, they are debilitating to the patient physically and psychologically. Many clients spend the majority of their time in rehabilitative care, slowly progressing to some level of self-sufficiency. Although long term care facilities have advanced to a more humane caring environment than before, it can be a lonely, depressing, isolating experience for clients previously independent or involved. This is a time that clients are endowed with plenty of time to think about their lives in retrospect and their lives to be. Many develop/enhance their spirituality as means of coping and emotional support. Methods of spiritual engagement, such as prayer, have been associated with benefits to physical health. Nurses, as caretakers and a client’s most frequent visitor, are in the position to offer spiritual health care by allowing themselves to be educated in recognizing spiritual distress w/in their patients, develop or utilize an preexisting spiritual assessment tool to measure the level of spirituality in each client and provide unique interventions to attend to their spiritual needs.

Many patients in hospitals do not perceive their nurses at spiritual caretakers. According to a study in the New York Metropolitan area of hospitalized adults, the participants in the study perceived that nurses were not having enough time to provide spiritual care because of short staffing and heavy work loads, were not comfortable discussing another's spirituality, and were not well prepared to provide spiritual care (Cavendish, Konecny, Naradovy, Luise, Kraynya, June & et al., 2006). They believed the nurses were kind and caring but didn’t attend to their spiritual care. However, many nurses feel that spirituality can promote the health of their patients but do not engage confidently in the responsibility of assessing and implementing spirituality into the care plan. In a nationwide study, Piles (1990) found that although 96% of nurses believed spiritual care is a component of holistic care, almost two thirds of them felt inadequate to perform spiritual interventions. Between 75-90% (of 299 nurses providing care in one of the largest hospitals in the southwest) believed spirituality could reduce bodily pain, provide an experience of God’s forgiveness and assurance of eternal life, produce physical healing through the powers of the mind, and half patients discover the deeper meaning of their illness. (Grant, 2004).

One nursing strategy is for nurses in training and nurses in the field to be educated to recognize manifestations of spirituality. The focus of this strategy mostly targets nursing education programs to prepare students to identify spiritual distress and provide spiritual care. Since 2004, the National Council of State Boards of Nursing have been moving towards this goal by requiring students (RNs and LPNs)( in their most recent test plan) to be knowledgeable of religious and spiritual influences of health (as cited by Lantz, 2007, ¶ 29). The education provided should include teaching of different etiologies of spiritual distress (acute, chronic, and terminal illness, and near-death experience), the variety of concepts in spiritual health, assessment of, interventions, and applying appropriate nursing diagnoses. Nurses can also gain knowledge by examining their own spirituality. Friedemann, Mouch, and Racey (2002) believed it is important that nurses experience a self-exploration through reading, religious involvement, or activities such as meditation to understand their own beliefs and values (as cited in Potter & Perry, 2005, p. 549) . The critical thinking knowledge and skills learned from examining one’s own biases and spiritual concept as well as recognizing others will help the nurse to enhance the client’s spiritual well-being and health.

Because spirituality is a very subjective concept, nurses in health care facilities should develop different assessment strategies in defining the client’s spiritual well-being. According to Lantz (2007), JCAHO enforces the standard through a requirement that every patient be assessed for spiritual needs on admission and resultant spiritual care interventions be provided by a team of caregivers (¶ 31). One approach is the JAREL spiritual well-being scale which provides nurses with a simple tool comprised of three key dimensions (faith/belief, life/self-responsibility, and life-satisfaction/self-actualization) for assessing a client’s health (Potter & Perry, 2005, p. 551). Another assessment is called the two step approach suggested by Catterall and others (1998). Identification of the client’s religious beliefs, preferences, affiliations, and practices are documented in the initial assessment. The second step includes an ongoing in-depth assessment of the client spiritual well-being over the course of their stay. During the assessment, the nurse becomes more acquainted to the client’s behaviors and emotions enough to identify if the client is at risk for spiritual distress. Both assessments provide nurses with excellent strategies to gather subjective and objective data from their clients.

After gathering information about the client’s faith, religion, rituals, and beliefs, reviewing the client’s view of life, life satisfaction, and meaning, and developing appropriate nursing diagnoses, the nurse can provide effective collaborative management and/or nursing management. Many health care facilities have chaplains on staff to provide spiritual counseling and provide information about community support resources for the patient. Nursing management includes providing different coping methods for care receivers and offering “support to the patient’s religion by encouraging prayer and church attendance, readings, music, and other religious activities” (Baila, Biordi, Coeling, Nalepka, & Theis, 2003, ¶ ). According to Gorman, Raines, & Sultan, 2002), some nursing interventions include seeking assistance of or referrals to hospital chaplain or other resources, promoting the use of prayer and scripture when appropriate if within the patient’s belief systems, allowing patient to ventilate thoughts and feelings, allow family to participate in religious rituals, and being open to the patient’s expression of spiritual concern (p. 326). The use of support systems, diet therapies, supporting rituals, prayer, meditation, and supporting grief work can be incorporated into the plan of care.

Because many clients faced with multiple diagnosis and end-stage diseases spend the majority of their remaining time in health care facilities without receiving satisfactory spiritual support, it is the nurse’s responsibility to be educated in providing spiritual care and implementing care plans that support the client’s spiritual needs appropriately in order to reverse this problem. By recognizing their own aptitude and knowledge of spirituality, nurses can become aware of the client’s spiritual climate. By following a devised spiritual assessment tool for every admitting client, nurses will gather subjective and objective data for measurement or to diagnose a patient in danger of spiritual distress or ineffective coping methods. Afterwards, can nurses implement a nursing care plan unique to the client and apply appropriate nursing interventions such as prayer, chaplain assistance, and meditation. The client’s perception of the attempts of spiritual support made by the nurse would change for the better after these interventions, allowing comfortable and receptive communication between the patient and nurse about spiritual concerns and, in return, enable quality spiritual care to be implemented.

1. Intervention 1: One nursing strategy is for nurses in training and nurses in the field to be educated to recognize manifestations of spirituality. The focus of this strategy mostly targets nursing education programs to prepare students to identify spiritual distress and provide spiritual care

a. Disadvantage 1. Proper educator training of spirituality remains a problem that impedes the student’s spiritual education. Greenstreet (1999) postulated that nurse educators do not teach this content well and have a poor record in preparing nursing students for the delivery of spiritual care (as cited by Lantz, 2007, ¶37). As cited by Lantz (2007), Clark (2005) “acknowledged problems with traditional nursing education based on Western medical methods and suggested a shift to a partnership model that includes holistic and intuitive approaches to nursing” (¶5). According to Meyer (2003), less than 6% of classroom topics and less than 10% of clinical discussions were related to spirituality (as cited by Bennett, Manfrin-Ledet, Mitchell, 2006, ¶7). These problems are manifested in nursing students whom are ill prepared to handle spiritual crises during clinicals and many nurses, today, that do not take the time and energy to conduct a thorough spiritual assessment of their patients. As cited by McEwen (2004), Highfield et al. (2000) found that only “approximately half of the nurses reported receiving formal education in spiritual care through academic work and/or continuing education and that a majority of the nurses stated they were inadequately prepared to provide spiritual care” (¶8). In addition, research remains inadequate and nursing textbooks lack much information to provide nursing educators guidelines to proper delivery of spiritual content. McSherry and Ross (2002) agreed that there is indeed little “research about the assessment of client spirituality and delivery of spiritual care” (as cited by Lantz, 2007, ¶39).

b. Disadvantage 2: Besides nursing educators not being properly equipped and trained for proper teaching of spirituality in nursing care, legal complications, alone, set limitations upon the educator’s depth of teaching. According to Lebold and Douglas (1998), "although nursing is widely known as a caring profession, little is known about how to teach and enhance caring practices" (as cited by Lantz, 2007, ¶18). Besides adequate training, nursing educators in publicly funded colleges are face with legal roadblocks to their curriculum and undefined intricacies relating to separation of church and state. Lantz (2007) states that nursing education textbooks such as Bilings and Halstead test Teaching in Nursing: A Guide for Faculty, did not address the legal implications of teaching spiritual care content (¶ 7). According to Lantz (2007), “inability to engage in prayer, avoidance of religious discussions between students and faculty, cautious display of religious symbols, and sensitivity to the use of the Bible and other religious literature in public education” makes it very “difficult for nurse educators in publicly funded institutions of higher education to teach spirituality principles and spiritual care intervention” (¶ 26).

2. Intervention 2: Because spirituality is a very subjective concept, nurses in health care facilities should develop different assessment strategies in defining the client’s spiritual well-being.

a. Disadvantage 1: Assessments that are created by healthcare facilities are often conducted towards the population of patients in oncology, hospice, with AIDS, and/or with compromised mental health. Patients in other health settings are given little consideration regarding their spiritual health. This occurs because many current spirituality assessments are cumbersome, irrelevant, and time consuming in situations in which physiological care takes priority. According to Bennett, Manfrin-Ledet, and Mitchell (2006), “spirituality is often the last in a long series of assessments for patients” (¶14). If the nurse continues to perceives it as being low priority, the result will be little or no focus upon developing and implementing spiritual care plans, In a study conducted by Narayanasamy in 1993, it was found that the majority of nurses viewed spirituality as a religious matter and rarely offered spiritual care (as cited in McEwen, 2004, ¶7). According to Wakefield, Gerdner, and Tripp-Reimer (2002), there appears to be "collective amnesia of scientists regarding the significance of spiritual issues and religion for health" (as cited by McEwen, 2004, ¶4). Even if health care policies require spiritual assessment with admittance, will there be proper implementation of nursing interventions to alleviate spiritual distress and support the patient’s spirituality?

b. Disadvantage 2: Spiritual assessments, currently, appear to be more focused on information related to specific religious backgrounds and practices. Biases from the nurse with controversial religions may unintentionally instill their own values in assessing and providing care. O’Reilly (2004) states that “in a society characterized by religious pluralism, preconceived notions of clients' religious affiliations or spiritual beliefs must be set aside, and assessment must be guided by cues provided by clients” ¶14). Anandarajah and Hight (2001) proposed that “health care providers assess their own spiritual beliefs, values, and biases before initiating spiritual assessment with clients, in order to remain client centered and nonjudgmental” (as cited by O’Reilly, 2004, ¶ 13). Assessments created for identifying spiritual and religious elements of each patient should include spiritual and religious components that can be easily defined by nurses. As cited by Mohr (2006), Richards and Bergin (1997) differentiate religious interventions as “more structured, denominational, external, cognitive, ritualistic, and public, whereas spiritual interventions are more ecumenical, cross-cultural, internal, affective, transcendent, and experiential” (¶ 32).

References

Baila, M., Biordi, D. L, Coeling, H., Nalepka, C., & Theis, S. (2003). Spirituality in caregiving and care receiving. Holistic Nursing Practice, p48(8). Retrieved November 4, 2006 from Expanded Academic ASAP database.

Bennett, M.J., Manfrin-Ledet L., Mitchell, D.L. (2006). Spiritual Development of Nursing Students: Developing Competence to Provide Spiritual Care to Patients at the End of Life. Journal of Nursing Education, 45(9), 365-70. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 1121916271).

Cavendish, R., Konecny, L., Naradovy, L., Luise, B., Kraynyak, C., June, O., et al. (2006). Patients' perceptions of spirituality and the nurse as a spiritual care provider. Holistic Health. Retrieved October 21, 2006, from Expanded Academic ASAP via Thomson Gale.

Lantz, C. M, (2007). Teaching spiritual care in public institution: Legal implications, standards of practice, and ethical obligations. Journal of Nursing Education, 46(1). Retrieved February 18, 2007, from Expanded Academic ASAP database.

McEwen, M. (2004). Analysis of Spirituality Content in Nursing Textbooks. Journal of Nursing Education, 43(1), 20-30. Retrieved November 2, 2007, from Platinum Full Text Periodicals database. (Document ID: 523561021).

Mohr, W.K. (2006). Spiritual Issues in Psychiatric Care. Perspectives in Psychiatric Care, 42(3), 174-83. Retrieved November 2, 2007, from Research Library database. (Document ID: 1157381211).

O'Reilly, M.L. (2004). Spirituality and Mental Health Clients. Journal of Psychosocial Nursing & Mental Health Services, 42(7), 44-53. Retrieved November 2, 2007, from Research Library database. (Document ID: 670735571).

Perry, A. G., & Potter, P. A. (2005). Fundamentals of nursing (6th ed). St Louis, Missouri: Mosby.

Gorman, L. M., Raines, M. L., Sultan, D. F. (2002) Psychosocial Nursing for general patient care (2nd Ed). Philadelphia, PA: F.A. Davis Company.

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Impacting Childhood Obesity

Obesity has become the largest health problem in the world surpassing AIDS and malnutrition. The World Health Organization (WHO) designated obesity as a global epidemic affecting adults and children (WHO, 2007).

The incidence of obese children continues to rise in all ages and ethnic groups, equally affecting both sexes, leading to an increased urgency for health care providers to identify and treat children who are obese or are at risk of becoming obese. In order to combat this problem nurses need to identify these children and use a holistic approach in treating and preventing childhood obesity by promoting family involvement in nutrition, positive lifestyle changes and client education regarding physical education.
Currently obesity is defined as having a body mass index (BMI) greater than 30 and a BMI over 25 is considered overweight: BMI equals kg/[height (m)]² (CDC, 2007). “In the United States, the most recent estimates of obesity prevalence are based on data from the 1999-2000 National Health and Nutrition Examination Survey 20.6% of 2- to 5-year-old children in the United States were overweight. In older children, this prevalence was even higher, with 30.3% of 6- to 11-year-old children and 30.4% of adolescents (12-19 years of age) being overweight” (Velasquez-Mieyer, Perez-Faustinelli, Cowan, 2005). Being overweight in childhood also leads to an increased risk of becoming an obese adult. Children and adolescents who have a BMI greater than the 95th percentile have a 62-98% chance of becoming obese adults (Guo SS, Wu W, Chumlea WC, Roche AF, 2002). Childhood and adult obesity lead to increased incidences of type-2 diabetes and cardiovascular disease (Drohan, 2002). Furthermore, over 50% of overweight children suffer from hypertension (Velasquez-Mieyer et. al., 2005). Genetics and parental influence also have a strong influence in determining a child’s predisposition to obesity: As stated by Velasquez-Mieyer , 2005 “biological relatives exhibit similarities in maintenance of body weight, and that heredity contributes between five and 40 percent of the risk for obesity”.
Early detection of overweight and obese children is essential in order for nurses to make a positive impact on the obesity epidemic. Routine assessments include obtaining the child’s height and weight is all that is needed to calculate BMI (kg/m²) and determine if the child is overweight. Identification can be performed during routine clinical visits, at health fairs, or during school health screening. Assessing the child’s parents is also very helpful in identifying a child who is at risk of becoming obese. “If one parent is obese the child is 4-5 times more likely to become obese” (Guo, 2002). This number increased to 13 times in children under 5 years of age if both parents are obese (Velasquez-Mieyer et al., 2005). Nurses need to recognize the importance of identifying overweight children and plan interventions as early as possible. “Interventions should be started when the child reaches the 75th percentile, not the 95th for their age. At this point the child has an adult equivalent BMI of 30” (obese), thus compounding complications and requiring a greater level of intervention. (Hoolihan L, 2005). Interventions should include education regarding health risks and nutrition, as well as promoting physical activity.
Once a child is identified as being overweight and at risk of becoming obese, education regarding obesity is of utmost importance. A nurse should take every opportunity possible to educate children and their parents. This could be during clinical visits, at school, or during health fairs. Education should include nutrition, physical activity, and the multiple health risks associated with obesity including diabetes, cardiovascular disease, and hypertension. Educating the child and particularly the parents can make a substantial impact on a child’s nutritional intake and lifelong habits. Parental influence is a strong determinant in a child’s behavior and nutritional habits. If parents consume high fat, high sugar diet without meeting daily requirements for fruit and vegetable intake, their children will likely follow this example (Hoolihan, 2005). Nutritional education should focus on foods that contain necessary nutrient requirements. A wide range of foods should be listed for sources of each nutrient as well as appropriate serving size. A nurse may also provide the family with a copy of the United States Food and Drug Administration’s food pyramid which lists serving recommendations of each food group and portion sizes. Informing parents of a healthy weight is an important step of education. Many people do not perceive their children as being overweight due to being “accustomed to seeing overweight youth”. “In fact, in certain ethnic and racial groups, overweight is increasingly accepted, almost expected.” (Hoolihan, 2005). Along with nutrition children must also maintain an active lifestyle to treat and prevent obesity.
Physical activity is an important step in preventing obesity. The amount of physical activity varies greatly among children and adolescents; however there is a direct correlation between the amount of regular physical activity and a child’s weight (United States Department of Health and Human Services, 2005). Watching television, video games and computer usage are activities that require an insignificant amount of physical activity. Estimates suggest that the average child in the United States spends 25% of their waking hours watching television (USDHHS, 2005), and “even more hours are spent watching television if the set is in the child's room” (Holcomb, 2004). Often children are consuming high calorie snacks while engaging in sedentary behaviors, further increasing the correlation between lack of physical activity and obesity. A recent examination of the Department of Education’s Early Childhood Longitudinal Survey (ECLS-K) found that a one-hour increase in physical education per week resulted in a 0.31 point drop (approximately 1.8%) in body mass index among overweight and at-risk first grade girls. There was a smaller decrease for boys (USDHHS, 2005). Nurses should stress the importance of physical activity and recommend various activities while educating patients regarding obesity. Examples of activities to recommend include a daily walk with the family, a YMCA membership, enrolling in school or county sponsored organized sports, or at last resort an interactive video game that requires dancing or other intense physical movement. A brief explanation of the benefits of being physically fit will also enhance a patient’s willingness to engage in physical activities. This should include physical changes such as weight loss, improved muscle tone and endurance, body image and self esteem, as well as how it benefits the metabolic and cardiac systems. Again promoting physical activity with the child’s family would help strengthen the family’s commitment to treat and prevent obesity.
Early identification, nutritional education and promoting physical activity are essential components of treating and preventing childhood obesity. Nurses often spend more time with clients than other heath care providers during clinical visits and health promotion activities, or illness prevention functions. Therefore, nurses have multiple opportunities to initiate and facilitate identification, education and physical activity that will have a positive impact on childhood obesity.
References:
Drohan, S.H. (2002) Managing early childhood obesity in the primary care setting: A behavior modification approach. Pediatric Nursing, 28, 599-611. Retrieved October 27, 2006, from ProQuest database. (277433901).
Guo SS, Wu W, Chumlea WC, Roche AF (2002) Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition. 76:653-658.
Holcomb S.S., (2004). Obesity in children and adolescents: Guidelines for prevention and management. Nurse Practitioner. 29(8), 9-13. Retrieved October 26, 2006, from ProQuest database (683132191).
Hoolihan, L. (2005) The role of education and tailored intervention in preventing and treating overweight. Nutrition Today 40.5: 224(10). Retrieved Feb 16, 2007, from Expanded Academic ASAP. A138397561
World Health Organization (WHO). (2006). Overweight and obesity. Fact sheet N-311. Retrived January 9, 2007, from: http://www.who.int/mediacentre/factsheets/fs311/en/index.html
United States Department of Health & Human Services. (2005). Childhood Obesity. Washington, DC. Retrieved January 9, 2007, from: http://aspe.hhs.gov/health/reports/child_obesity/
Velasquez-Mieyer, P., Perez-Faustinelli, S., & Cowan, P. A. (2005). Identifying children at risk for obesity, type 2 diabetes, and Cardiovascular Disease. Diabetes spectrum. 18(4), 213-221. Retrieved January 20, 2007 from ProQuest database (933878111).


Type rest of the post here
Impacting Childhood Obesity.
Early detection and identifying overweight and obese children.
Insufficient Parental knowledge regarding obesity and Body Mass Index.
Basic assessment of height and weight and calculating a BMI are part of every complete physical assessment. While this information provides valuable data for health care providers, parents are often unaware of what BMI indicates. A lack of information and teaching leads parents to disregard the significance and negative health consequences of a BMI above 25. Health care providers may not emphasize the importance of an elevated BMI assuming the parents are aware that their child is overweight and they understand the importance of such information. Culture may also effect the how a parent views their child’s weight and BMI, obesity is not stigmatized in some cultures as it is in others (Davis). This leads to increased boundaries regarding patient education and receptiveness to teaching.
Legal considerations preventing widespread Health screening and reporting for Children.
A majority of public grade schools institute annual health screening programs. From state to state a these programs are required to assess immunization compliance (50 states), vision (36 states), hearing (35 states), scoliosis (27 states), and dental (9 states). However few schools obtain BMI information, according to Center for Disease Control report (2006) only 11 states have policies that require height and weight to be obtained during health screening. Furthermore only 60% of schools sent information home regarding each component of the health screening, but less than 30% offered any health education to families (CDC, 2006). Broad Federal Government legislation covering school health screening is currently lacking. States are allowed choose what screening is performed and what information and teaching is offered to families. State to state legislation mandating minimum health screening also fails identify overweight children. To compound the problem only 3 states require schools to have at least 1 full time nurse (CDC, 2006). This leads to a lack of professional health assessment capability as well as planning and recording information from health screening activities.
2. Boundaries to successful interventions through education.
1. Socioeconomic status may prevent may prevent families from obtaining appropriate nutrition required to treat and prevent obesity.
Education aimed at providing nutritional information for overweight and obese children often emphasizes low fat foods, fresh fruit and vegetables, low fat dairy products and an avoidance of highly processed foods. Many processed and prepared foods are inexpensive, high in fat content, calories, and poor in nutrients. With an overwhelming availability of poor cheap food choices it is difficult for families to follow a nutritional diet. Fresh foods require preparation time and cost significantly more than pre-packaged and processed foods. Ounce for ounce potato chips cost less than apples, as does prepared fried chicken (loaded with saturated fats and oil) vs. fresh skinless chicken breast (98% fat free). The cost alone will prevent many families from obtaining nutritious foods. Convenience also plays a major role in nutritional decisions. Over 61 of all two parent families with children under 18 have two incomes, this leads to increased time away from home and less time for obtaining and preparing nutritional foods. Forty two percent of food dollars are spent on food consumed outside of the home.(Savage).
2. Poor feasibility in changing parental eating habits.
Obese children have learned to eat what their parents provide and aquire tastes and preferences similar to their parents beginning at birth. Educating a parent regarding proper food choices and encouraging them to follow the recommendations will not have a beneficial effect on the child’s weight if the parents do not concurrently change how and what they eat. Combating childhood obesity is compounded three fold by educating and promoting change in the child, the parent, and the entire family. To further complicate this 31% of children are cared for during mealtime by a caretaker or grandparent and 41% are enrolled in an organized day care center (Savage). This limits the parents influence on nutrition and relies on someone else to follow proper nutrition guidelines.

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Best Practices in the Management and Treatment of Irritable Bowel Syndrome

THESIS: Best practices in the management and treatment of Irritable Bowel Syndrome includes treatment combinations tailored to each individual and their proven efficacy.

INTRODUCTION
Irritable bowel syndrome (IBS) is a common gastrointestinal condition characterized by abdominal pain, discomfort, and altered bowel patterns. The pathophysiology of IBS is not explicit. Approximately 10 to 15 percent of the U.S. population is affected by IBS, and women are more likely to have symptoms than are men (Hadley & Gaarder, 2005, p. 2501). No one pharmacological treatment is effective for all symptoms of IBS, and not all clients are in need of drug treatments. The absence of acquired facts regarding the cause and origin of the ambiguous symptoms of IBS impedes research for a cure and effective management.
DIAGNOSIS
The diagnosis of IBS cannot be made by laboratory tests. A focused assessment and patient history should be conducted, noting the intensity of symptoms and their impact on quality of life. Diagnosis is based on clinical signs and symptoms that include abdominal pain, bloating, constipation, and diarrhea (Hadley& Gaarder, 2005, p. 2501). The diagnostic criteria in Table 1 were developed to assist in the diagnosis of IBS.
"The diseases that need to be considered when evaluating gastrointestinal complaints include Irritable Bowel Disease (IBD), which is a condition of inflammation of the intestinal tract, celiac sprue, gallbladder inflammation, infection, including parasites, dietary intolerances, and colon cancer, among others” (Meisler, 2001, p.224).

TABLE 1
Diagnostic Criteria for IBS
Abdominal discomfort or pain, for at least 12 weeks (which need not be consecutive) in the preceding 12 months, with two or more of the following features:
Relief with defecation
Onset associated with a change in stool frequency
Onset associated with a change in form or appearance of stool
These additional symptoms cumulatively support the diagnosis of IBS:
Abnormal stool form (loose and watery or lumpy and hard)
Abnormal stool passage (urgency, frequency, feeling of incomplete evacuation)
Passage of mucus (white material)
Bloating or sensation of abdominal distention
IBS= irritable bowel syndrome
Note: The diagnostic criteria for IBS is adapted from “Treatment of Irritable Bowel Syndrome” [Electronic Version], by S.K. Hadley & S. Gaarder, 2005, American Family Physician, 72(12), pp.2501-2506.

TREATMENT
Management of IBS should begin by initiating a therapeutic provider-client relationship.
Education regarding the nature of the illness and long-term prognosis should be addressed, as well as any concerns the client has. The diagnosis is common and there is no special risk of serious complications may comfort many (Thompson, 2002, p. 1398).
Initial suggestions are related to modification of the client's diet that may reduce symptoms. Frequent exercise, allotting sufficient time to eat and defecate, and consuming a balanced diet can be addressed. "Reported dietary triggers of IBS include caffeine, citrus, corn, dairy lactose, wheat, and wheat gluten, with lactose and caffeine being associated with diarrhea-­predominant IBS" (Hadley & Gaarder, 2005, p. 2502).
Increasing fiber in the diet has been recommended as a treatment for IBS, because of its action on the stool. Fiber enhances the stool's water-holding properties, provides lubrication, aids to bulk the stool, and enhances the binding of agents such as bile (Hadley & Gaarder, 2005, p. 2503). Because fiber is inexpensive and easily accessible, it may be a good starting point, especially for those who experience constipation-predominant IBS. There are a variety of fibers available, including synthetic fibers and natural fibers. The synthetic fibers are more soluble, but may generate gas discomfort. Psyllium seed and linseed are bulking agents with lubrication properties and both contain mucilages that contribute to this (Hadley & Gaarder, 2005, p. 2503).
Sweeteners, such as sorbitol and fructose are added to gum, jams, and soda, for example, and are laxatives that may be upsetting to the bowels. Some medications may provoke IBS, such as opiates, calcium channel blockers, and non-steroidal anti-inflammatory drugs, which may cause constipation. While some antacids, antibiotics, and occult laxatives may induce diarrhea (Thompson, 2002, p. 1399).
Eating stimulates the gut to move and secrete, and an exaggerated gastrocolic response experienced by those with IBS can lead them to believe foods in their diet are the cause. The impact of this response may be relieved by avoiding meals high in fat content (Thompson, 2002, p. 1399). It may be useful for the client to keep a food diary containing foods eaten, bowel habits, and exercise, and their response to those activities.

No drug treatment is efficacious for all symptoms of IBS, and many clients do not need any drugs at all. Drugs should be prescribed based on the predominant symptom, constipation or diarrhea (Thompson, 2002, p. 1395).
Antispasmodics (anticholinergics) temporarily block nerve impulses to the gut, thereby reducing smooth muscle contractions. Dicyclomine (Bentyl) and hyoscyamine (Levsin) act to relax smooth muscle 1. These drugs can offer relief from the cramping of constipation. If used habitually, they may induce constipation (O'Hare, 2001, p. 132).
Loperamide is an opioid agonist and works by inhibiting intestinal secretions and increasing fluid and electrolyte absorption due to increased intestinal transit time (Talley, 2003, p. 364). Loperamide does not cross the blood-brain barrier, therefore side effects are minimal (Hadley & Gaarder, 2005, p. 2503).
5-HT3 receptor antagonists slow colonic transit, relaxes the descending colon, and results in decreased perception of volume in diarrhea-predominant irritable bowel syndrome (Talley, 2003, p. 365). Alosetron (Lotronex), an IBS-specific medication, is available again after being pulled from the market following cases of ischemic colitis and five deaths. It is available for women only with severe diarrhea-predominant symptoms, but with strict prescribing guidelines. Alosetron should only be prescribed after other conventional treatments have failed (Hadley & Gaarder, 2005, p. 2505).
5-HT4 receptor agonists, such as tegaserod (Zelnorm) stimulate the release of neurotransmitters and increases colonic motility. Zelnorm is safe for up to 12 weeks of use, but long-term safety has not been proven. Zelnorm improves general symptoms of IBS in women, although it is minimally advantageous (Hadley & Gaarder, 2005, p. 2505).
Antibiotics may be prescribed for refractory diarrhea due to a bacterial infection, for short-­term use. Long-term use of antibiotics can increase diarrhea by changing the normal flora in the bowel (Hadley & Gaarder, 2005, p. 2505).
Peppermint acts as an antispasmodic and may improve digestion. It also acts by anesthetizing, decreasing nausea, and relaxing smooth muscle. It is inadvisable in clients with gastroesophageal reflux disease (Hadley & Gaarder, 2005, p. 2505).
CONCLUSION
The treatment and management of Irritable bowel syndrome has proven to be difficult due to the lack of understanding about the pathophysiology. IBS presents differently in each client, and treatment should be comprehensive and approached by the provider and client. While many treatment options exist, each client should be treated individually and holistically.

Intervention 1: Patient Education
An important component in treating patients with Irritable Bowel Syndrome is the provision of patient information, including an explanation of the syndrome and reassurance.
Disadvantage 1: Knowledge Deficit
Irritable bowel syndrome remains undiagnosed in many individuals mainly because of failure to seek medical attention for symptoms and lack of recognition of the syndrome (Spinelli, 2007). Manifestations of IBS include constipation, diarrhea, and abdominal pain, which may be interpreted as a "stomach flu" or food allergy. Fear of cancer and malignant disorders may keep the individual from seeking medical care (Mearin, 2006). This may result from an ineffective patient-physician relationship that lacks communication and trust. Therefore, a confident diagnosis and avoidance of repeated or unnecessary tests is important.
Disadvantage 2: Lack of Resources
Irritable bowel syndrome is a disease of unclear, complex pathophysiology (Spinelli, 2007) and research shows healthcare professionals still have limited knowledge of the disorder
(Boyd-Carson, 2004). Providers in busy outpatient practices may have difficulty providing detailed information, advice and support about the disorder, the precipitating factors and treatment options. Studies demonstrate that less than thirty percent of IBS patients under the care of a primary care physician are referred to a specialist (Faresjo et aI, 2006).
Intervention 2: Dietary Modifications
Dietary modifications are frequently recommended as a first step in the management of Irritable bowel syndrome. Although no specific diet can be recommended to all patients with IBS, many will report an improvement in symptoms with the identification and avoidance of specific trigger foods and the inclusion of dietary fiber (Boyd-Carson, 2004).

Disadvantage 1: Exacerbation of Symptoms
Fiber must be introduced gradually, as an increase in fiber initially may worsen symptoms such as bloating and pain ((Boyd-Carson, 2004). Fiber therapy may aggravate symptoms by decreasing pain threshold secondary to distention and by inducing colon distention through the formation of gas from bacterial fermentation (Mearin, 2006).
Disadvantage 2: Altered Nutrition
Limitations on dietary habits may further impair the patient's quality of life (Mearin, 2006). Avoidance of nutrients that induce symptoms may require supplementation, such as calcium supplements (Boyd-Carson, 2004). Insufficient intake of nutrients can have an effect on the metabolic system, as evidenced by weight loss, poor muscle tone, muscle weakness and abnormal lab studies (iron deficiency, electrolyte imbalances).

REFERENCES
Boyd-Carson, W. (2004). Irritable bowel syndrome: assessment and management. Nursing Standard, 18(52), 47-52. Retrieved October 29, 2007, from Academic Search Premier Database.
Hadley, S.K., S., Gaarder. (2005). Treatment of Irritable Bowel Syndrome. American Family
Physician, 72(12), 2501-2506. Retrieved July19, 2007, from Academic Search Premier
Database.
Faresjo, A., Grodzinsky, E., Foldevi, M., Johansson, S., Wallanders, M.A. (2006). Patients with Irritable bowel syndrome in primary care appear not to be heavy healthcare utilizers. Alimentary Pharmacology & Therapeutics, 23,807-815. Retrieved October 29, 2007, from Academic Search Premier Database.
Mearin, F. (2006). Pharmacological Treatment of the Irritable Bowel Syndrome and Other Functional Bowel Disorders. Digestion, 73(suppl1), 28-37. Retrieved October 29, 2007, from Academic Search Premier Database.
Meisler, J.G. (2001). The Experts Discuss Irritable Bowel Syndrome.
Journal of Women's Health & Gender-Based Medicine, 10(3), 223-228. Retrieved July 19, 2007, from Academic Search Premier Database.
O'Hare, L. (2001). The Irritable Bowel Syndrome. New York:
McGraw-HilI.
Spinelli, A. (2007). Irritable Bowel Syndrome. Clinical Drug Investment, 27(1), 15-33. Retrieved October 29, 2007, from Academic Search Premier Database.
Talley, N.J. (2003). Evaluation of Drug Treatment in Irritable Bowel Syndrome. British Journal of Clinical Pharmacology, 56(4), 362­-369. Retrieved July 19, 2007, from Academic Search Premier Database.
Thompson, W.G. (2002). Review Article: The Treatment of Irritable Bowel Syndrome. Alimentary Pharmacology &Therapeutics, 16, 1395-1406.

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Best Practices in Nursing: Elderly Wellness and Restraint Alternatives

The use of restraints in health care settings has been a long debated topic. Restraints are used in every arena of patient care, including acute care settings, long-term care, pediatrics, and especially geriatrics. Although the use of restraints is ordered by a physician, nurses are often the caregivers who apply the restraints and care for the patient, while the restraints are in place.

Nurses have an ethical and professional responsibility to their patients during their care. Often their own beliefs relating to restraints will shape their decision making and actions regarding their patient’s care. Further education on the use of restraints and possible alternatives to their use has proven to influence nurses in their care practices. By minimizing the use of physical restraints, overall patient wellness has improved in elderly populations and their care settings.
Physical restraints have been defined as limiting a person’s freedom of movement by specific devices such as wheelchairs, safety vests, a room with closed doors and bed rails (Hantikainen, 1998, p. 331). The Health Care Financing Administration further defines a physical restraint as “any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient’s body that he or she cannot easily remove that restricts freedom of movement or normal access to one’s body” (Janelli, Stamps, & Delles, 2006, p. 163). Medications such as tranquilizers and sedatives are used as chemical restraints, which will treat behavioral symptoms by altering their mental state (NCCNHR, para. 1). Physical restraints are the most often used.
In 1987, Congress passed the Nursing Home Reform Act. The Act was prompted by prior studies that found nursing home residents to be abused and neglected. This act aims to provide quality care which in turn will lead residents to live at their optimal physical and mental state. To ensure these rights, the Act contains a Resident’s Bill of Rights, which specifically states residents have the right from freedom of physical restraints. States have a certification process which monitors homes and holds them to the standards set forth by this act. If standards are met, the homes will receive government funding (Klauber & Wright, 2001, para. 1-7)
In response to neglect, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also has a set of standards for restraint use. JCAHO is one of the primary organizations that aim to constantly provide quality care while safely protecting the patient. JCAHO is asking hospitals to implement interventions to decrease patient restraint use. Also, if restraints are warranted under their standards, they are requesting an increase in patient monitoring (Janelli et al., 2006, p. 163).
The utilization of restraints in the elderly population often receives the most attention, as they require extensive care for a wide variety of conditions and diseases. Due to their reduced independent capacity to care for and protect themselves, elderly choose to move into long-term care settings. The responsibilities of the patient’s health and security have now shifted to their nurses, whom have become their primary caregivers (Hantikainen, 1998, p. 343). Nurses care for the elderly in nursing homes for lengthy periods and also in acute care settings, when their medical needs exceed what the nursing home can provide.
In order to protect the elderly from potential harm to themselves, numerous types of restraints are used. Myers et al. (2001) states types of restraints used during their study were numerous, and the most common restraints used in the past year were jacket restraints, wrist/hand restraints, belt restraints, and secured table (30-31). Bed rails, wheelchairs, and waist restraints were other frequently used devices (Hantikainen, 1998, p. 332, & Liukkonen & Laitinen, 1994, p.1084).
The reasons these restraints were used on patients were widespread. Myers et al. (2001) stated patients were restrained in acute care settings primarily for preventing falls, limiting wandering, controlling disruptive behavior and to avoid interfering with medical devices (p. 29). In long-term care settings, often the reduced physical and cognitive state of residents is the reason for restraint. This must be done in order to protect the resident, to allow the nurse to complete basic care, and for time management of all nursing duties (Liukkonen & Laitinen, 1994, p.1083).
Outcomes of restraint use are rarely positive. While the nurse is capable of accomplishing more tasks, this is often at the detriment of the patient. The National Citizens’ Coalition for Nursing Home Reform [NCCNHR], (2007) cited that restrained individuals experience physical changes that include, decreased circulation, skin breakdown, ulcer formation, incontinence, constipation, muscle atrophy, weakened bones, increased risk of urinary tract infections and pneumonia (para. 5) Risk for falls and death by strangulation are also possible physical risks (Myers, 29). Of equal importance, the quality of the patient’s life is diminished by being physically restrained. The patient will experience depression, sleep disturbances, increased anxiety, and loss of independence and will become socially withdrawn from their environment (NCCNHR, 2007, para. 5)
Nursing response on the ethics of restraints is ambiguous. While Myers et al. (2001) cited nurses had a slightly positive attitude toward the elderly on all three scales of measurement, they indicated restraint use was acceptable in circumstances in which they were protecting their patients from harm and preventing injury (p. 31-32). Liukkonen & Laitinen (1994) also points out that physical restraints create a perpetual ethical dilemma for nurses. Restraints directly interfere with the nursing objective of patient autonomy. While trying to support their independence, nurses find the effect of restraints as “dehumanizing” to the patient and themselves (p. 1082). Hantikainen (1998) reported that nurses felt “ambiguity, frustration, sadness, powerlessness, strain and dissatisfaction” related to restraint use (p. 341). Liukkonen & Laitinen (1994) noted that the nursing staff in each research group was “considering the use of restraint as a difficult ethical problem which needed to be brought into open discussion on the wards.” While restraints were still applied to patients, their use is often questioned, leaving the use of alternatives more prevalent (p. 1085).
Janelli et al. (2006) stated 77% of the nurses in their study indicated they would attempt to use alternative measures before applying restraints to a patient (p. 165). Alternatives most attempted by the nurses were one-on-one observation, sedation, diversional activities and bed/chair alarms (p. 166). Both Hantikainen (1998) and Liukkonen & Laitinen (1994) stated the staff in their studies most frequently tried to comprehend patient behavior, used therapeutic touch and listening, and complied with resident’s requests that deviated from their daily schedule as substitutes for restraint use (p. 338 & p. 1082).
In their literature review, Evans, Wood, & Lambert (2002) found
a common restraint minimization technique to be staff teaching in conjunction with expert clinical consultation (p. 616). Different studies, conducted in acute and long-term settings, proved a decrease in restraint of patients using nursing education in conjunction with “multiple restraint-minimization activities” (pg. 619). Education topics included resident’s rights, risk and results of physical restraint, myths of restraint use, law based on restraint use, behaviors that are predictors of restraint and alternatives to restraint (p. 621). Evans et al. (2002) identified the best results occurred with gradual change that involved an interdisciplinary approach (p. 622).
When education and consultation are implemented in long-term care, overall results were successful. Residents restrained dropped from 41% to 4.05% when education was introduced (p. 619). Restraint use in long-term care was reduced without a rise in resident falls and major injury (p. 619). Nursing attitudes after alternative measures were not reported in any study. Additional studies must be conducted to explore nurses’ attitudes toward the implementation of restraint alternatives. As the debate over restraints continues, more research and education is needed to improve nursing practice.


Intervention 1 - Knowledge Deficit
i. Disadvantage 1 – Emphasis on Prior Experience
In several studies, when nurses were questioned on the use of restraints, nurses found restraint use to be an integral part of patient care. Many nurses did not feel restraints were a violation of patient rights, rather a means of patient safety. Nurses admitted that they often restrained residents of their long-term care facility for unclear reasons and without physicians’ orders. Restraints were used more often as routine practice rather than a reaction to a specific situation. Over one half of these nurses had more than six years of nursing experience (Hantikainen, 1998, p. 331-6). Concern for patient protection and safety was the prevailing primary reason nurses used restraints on their patients. (Liukkonen & Laitinen, 1994, p. 1084, Hantikainen, 1998, p.338). In a study by Myers, Nikoletti, & Hill (2001), nurses with an average of fifteen years experience were in agreement that restraints were used to protect patients from falls and injuries from interfering with therapeutic devices (p. 32).
ii. Disadvantage 2 – Lack of Training
As care facilities differ in their focus of care, staff for each type of facility varies. Acute care settings generally require nursing staff with more professional licensure (RNs, LPNs, and CNAs), many long-term care facilities have more unlicensed assistive personnel (Hantikainen, 1998, p.334). Uncertified staff are often uneducated in specific aspects of care, like restraint use. Without proper teaching, correct implementation of patient restraint use cannot be expected, even for licensed personnel. Liukkonen & Laitinen (1994) stated that more than 60% of nurses in one study stated they had received no instruction at all on the use of physical restraint while working in a geriatric ward (p. 1085). Furthermore, Evans, Wood, & Lambert (2002) found little evidence of the minimization of restraint use after an educational program was implemented. Over a year after restraint intervention and alternatives had been taught in an acute care setting, restraint use was over fifty percent, which was twenty percent higher than the pre-intervention level (p. 618).
Intervention 2 - Discrimination
Disadvantage 1 – Dislike for the elderly
Negative feeling regarding the elderly has been a theory as to the widespread use of restraints in this aged population. A study that examined the relationship between attitudes toward the elderly and attitudes toward restraint use did find a significant relationship between these negative attitudes toward older people and positive attitudes toward restraint use. (Myers, Nikoletti, & Hill, 2001, p. 29-30). This correlation may explain why up to eighty-five percent of elderly nursing home residents have been restrained at least once while living in the facility (Hantikainen, 1998, p. 331).
Disadvantage 2 – Dislike for the Mentally Ill
Caring for patients with mental illness results in may challenges, in addition to a nurse’s regular duties. With mentally ill patients, nurses face problems with “verbal and non-verbal communication, nutrition, physical functioning, safety, perceptual and motor difficulty, memory loss, and social isolation, “all in addition to other disease processes. With the addition of these factors to the nurses’ duties, some nurses grow to dislike their patients and treat them with less respect. Decreased understanding of demented patient’s behavior may contribute to nurses’ negative reactions in difficult care situations. (Liukkonen, 1994, p. 1086).


References

Evans, D., Wood, J., & Lambert, L. (2002). A review of physical restraint
Minimization in the acute and residential care settings. Journal of Advanced Nursing, 40(6), 616-625. Retrieved July 5, 2007 from
Academic Search Premier Database.
Hantikainen, V. (1998). Physical restraint: a descriptive study in Swiss
nursing homes. Nursing Ethics, 5(4), 330-346. Retrieved July 12, 2007 from Academic Search Premier Database.
Janelli, L. M., Stamps, D., & Delles, L. (2006). Physical restraint: a
nursing perspective. MEDSURG Nursing, 15(3), 163-167. Retrieved July 12, 2007 from Academic Search Premier Database.
Klauber, M. & Wright, B. (2001, February). The 1987 Nursing Home
Reform Act. AARP. Retrieved August 7, 2007 from
http://www.aarp.org/research/longtermcare/nursinghomes/aresearch
-import-686-FS83.html
Liukkonen, A. & Laitinen, P. (1994). Reasons for uses of physical restraint
and alternatives to them in geriatric nursing: a questionnaire study among nursing staff. Journal of Advanced Nursing, 19, 1082-1087. Retrieved July 12, 2007 from Academic Search Premier Database.
Myers, H., Nikoletti, S., & Hill, A. (2001). Nurses’ use of restraints and
their attitudes toward restraint use and the elderly in an acute care setting. Nursing and Health Sciences, 3, 29-34. Retrieved July 15, 2007 from Academic Search Premier Database.
National Citizens’ Coalition for Nursing Home Reform. (2007). Fact sheets: restraint use. Retrieved August 7, 2007 from
http://www.nccnhr.org/public/50_156_451.cfm

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Addressing the Shortage of Nurses: From a Nursing Perspective

A posting by Nathan Ho about the the nursing shortage and what nurses can do to combat it.
Nursing has always had a shortage, but with the upcoming generation of Baby Boomers (those born from 1946 to 1964) reaching the social security age of 65, the need for additional healthcare workers increases.
Whether Baby Boomers find themselves in hospitals or long term care centers, registered nurses will need to be there to ensure proper care.

However, many factors such as a deficit of teaching faculty, a negative work environment, and the fact that women now have broader career options, have placed a severe shortage on the amount of current nurses. The nursing shortage leads to a decreased quality of care in patients which is further perpetuated by an increase of those needing care, the Baby Boomers. This dilemma is best solved through nurses forming committees to find and address concerns they may have, advertising the benefits of nursing through job fairs or school visits, and encouraging retiring nurses to become faculty.
Born right after World War II.and around the Vietnam War, thanks to soldiers returning to their wives, Baby Boomers created a sharp increase in the population. As this large age group matures, requires more care as they grow older, and lives longer due to advanced medicine, a problem arises. By 2020 there will be at least 400,000 less nurses than in 2006, right when Baby Boomers are around their seventies or eighties (Hassmiller, 2006). The Service Employees International Union Nurse Alliance reports that nurses already work eight and a half weeks of overtime a year (as cited in Hassmiler, 2006) and a study done by Curtin and Rogers reports that, “Taking care of too many patients and working overtime…are associated with errors and poorer quality of care” (as cited in Hassmiler, 2006, para.8). As the Baby Boomers age and begin to seek more health care, the ratio between patient and nurse will only increase, further increasing the stress of nurses still in the field and decreasing quality of care.
According to a 2002 and 2004 United States national nursing survey reviewed by Buerhaus, Donelan, Ulrich, Norman, and Dittus (2006), four of the top reasons for the nursing shortage were inadequate benefits and salary, more career options for women, objectionable hours, and a negative work environment. Though the 2004 survey showed an increased satisfaction in these areas compared to the 2002 survey, both surveys stated the change most desired was an improved working environment. The surveys reported that nurses who felt they had a very good or excellent relationship with their fellow nurses had increased from 53% in 2002 to 72% in 2004. However, few Registered Nurses reported having very good or excellent relationships with the physicians or hospital managers. While individual hospitals can survey nurses to determine how they feel about their work environment a more aggressive action would be for nurses to come together and form committees to agree on what needs to be changed at work and how it should be done. It has been suggested by Buerhaus et al (2006) that the government establish an independent board within the Department of the Health and Human Services which would be responsible for essentially “grading” the quality of care hospitals provide. If there is a quantifiable quality of care difference between facilities which incorporate the nursing committee’s ideas and facilities that do not, then in the future the status of nurse’s opinions would increase.
According to Buerhaus et al (2006), 83% of nurses in both the 2002 and 2004 surveys reported being either somewhat, moderately, or very satisfied with their profession and 70% of nurses would recommend nursing to qualified students. If this is the case, nurses should take the time to voice how they feel about their career to the public. Exposing the community to nurses through free blood pressure readings, presentations at local schools, or a booth at job fairs would increase public interest in nursing. In addition, having male nurses present during these exposures could open interest to a whole new group of people to nursing, the males. Though the amount of male nurses has increased from 57,000 in 1983 to 164,000 in 2002, men made up only 5.9% of the nurses in 2003 (Cantrell, 2004). A lot of room for potential growth exists for this population, especially since Auerbach, Buerhaus, and Staiger state that “recently published projections indicate large, demographically driven shortages [are] developing in the next decade” (as cited in Buerhaus, Donelan, Ulrich, Norman, DesRoches, Dittus, & Wfcthan, 2007, para. 4).
Exposure of nursing to the public however is not enough to quell the shortage. Nursing school enrollment has gone from a 3.7% increase in 2001 to a 13% increase four years later, yet in 2005 over 147,000 qualified applicants were rejected from nursing schools due to a lack of faculty to teach them (Larson, 2006). In addition there has been a 72% percent growth in faculty who desire to teach only part time. Coupled with the fact that the influx of about 180,000 new RN’s between 2002 to 2004 were over the age of 50 and that almost a third of them plan to retire within three years, recruiting seems to have little benefit (Buerhaus et al, 2006). However, what if the retiring nurses were to become faculty? Even if they desired to teach part time, enough part time faculty members could make up for the lack of full time members. Retiring nurses could enjoy a less demanding schedule with a chance to impart the wisdom they gathered throughout their nursing career. If they require further education before being able to teach, the government is currently debating on two programs to assist potential faculty in financing their education, the Nurse Faculty Education Act and the Nurse Education, Expansion and Development Act which might prove convincing for those interested in returning to school to increase their education but are deterred by the cost (Larson 2006).
Though the burden of more patients looms ever closer to nurses, strategies exist to help cope with this challenge. By forming committees committed to alleviating any concerns nurses may have about their work environment, the number one desired change by nurses may be addressed and improve work morale. This in turn helps keep nurses from leaving the field. Exposing the community to nurses through public health fairs, free blood pressure tests, or simply by word of mouth is also an excellent way to attract new nurses. Finally, nurses who have had enough of the business environment of health care, but would still like to be involved in helping people, have the chance to spread their knowledge and experience by becoming teachers. Government programs even exist to assist in financing nurses who need further education. The journey ahead may be difficult, but nurses are by no means without the power to do something about it.
a. Intervention 1- Retiring Registered Nurses further their Education and become Teachers
i. Disadvantage 1- Difficulties with Distant Education
In order to maximize productivity of time, RN’s with a desire to continue their education while still working have the opportunity to do so via distant learning (otherwise known as fully online classes). Though benefits of online classes include elimination of distance between student and classrooms and a more flexible schedule, a study of students done by Sit, Chung, Chow and Wong revealed some learning hindrances to be “inadequate opportunity to study with others, lack of confidence, difficulty applying concepts taught, and inadequate opportunities for discussion with faculty and to establish peer support” (as cited in Murphy, 2007, para. 16). Murphy (2007) states that technical expertise is important when taking an online class which might be difficult for retiring nurses with little computer experience. Also, a survey done by Atack and Rankin which evaluated RN’s who took online classes at home and at work showed general dissatisfaction when classes were performed at the workplace (as cited in Murphy, 2007).
ii. Disadvantage 2- Funding
Though scholarships and programs exist to help finance RN’s with desires to continue their education, there are not a whole lot of them. According to Livsey, Campbell, and Green, the Nurse Training Act passed in 1964 puts Title VIII in the Public Health Service Act which is responsible for funding nursing education. However, less than 3% of resources from Title VIII were directed towards faculty development and many Title VIII programs expired in 2002 (2007). Due to a lack of sufficient scholarships most RN students who pursue a doctorate are part timers which in turn decrease the graduation rate. Also, to make matters worse, not all nursing doctorates decide to become faculty with a 23% reporting that they will take a practice related position due to the better financial reimbursement (Livsey, Campbell, and Green, 2007). Thus limited capital for continuing nursing education in the hopes of producing teachers is wasted.
b. Intervention 2- Increased Exposure of Public to Nursing
i. Disadvantage 1- High School Student’s Perceptions on Nursing
With students in high school graduating and deciding what career to pursue, exposing them to the nurse’s role is critical to provide an accurate idea of what the vocation entails. Unfortunately though, high school student perception of nursing is somewhat negative and a vast majority has little interest in pursing a career in nursing. A study done by Steven and Walkers showed that of 642 high school students only 7.7% (about 49) considered nursing as a future career. This lack of interest also extends to other cultures as another study done by Tang et al. with 789 non English speaking students from 36 different high schools had a majority state that they did not view nursing as a potential career due to their impressions of it being non influential and poor paying (as cited in Catz, 2007, para 26). This impression was verified by Warda who found that negative impressions of nursing included the facts that nurses were powerless, poorly paid, and worked in poor conditions (as cited in Catz, 2007, para 27). Those working to expose high school students to nursing have a bit of an uphill battle to fight.
Ii. Disadvantage 2- Males in Nursing
While recruitment of men into nursing represents a huge potential work force, the public perception of male nurses has generally been negative. An informal survey of the public by Rallis stated that men disapproved of male nurses and often they were mistaken for doctors (as cited in LaRocco, 2007, para 4). Some male RN’s stated it was difficult to establish themselves in a female work group (LaRocco, 2007). Male RN students recollecting some perceived barriers during nursing school included no mentorship programs for male students, a pressure to prove themselves because people expected women to be nurses, no opportunity to work with male nurses during clinical settings, fear of accusation of sexual inappropriateness when providing intimate care and no guidance provided on the appropriate use of touch (O’lynn, 2007). Males interested in pursuing nursing have the difficulties of social expectations and then barriers present during RN education.
References
Buerhaus, P. I., Donelan, K., Ulrich, B. T., Norman, L., & Dittus, R. (2006). State of the
registered nurse workforce in the United States. Nursing Economics, 24, (1) 6.
Retrieved February 4, 2007, from ProQuest database.
Cantrell, M. (2004, December 13). Male Call. Nurse Week. Retrieved January 7, 2007
from http://www.nurseweek.com/news/Features/04-12/MenInNursing.asp
Doheny, K. (2006). Treating the nursing shortage. Workforce Management, 85, (19) 1.
Retrieved February 4, 2007, from ProQuest database.
Fulcher, R. (2007). Nursing in Crisis. Community College Journal, 77 (5) 38-43.
Retrieved November 2, 2007 from ProQuest database.
Hassmiller, S. B. & Cozine, M., (2006). Essay: Addressing the nurse shortage to improve
the quality of care. Health Affairs, 25, (1) 268. Retrieved February 4, 2007, from
ProQuest database.
Katz, J. (2007). Native American High School Student’s Perception of Nursing. Journal
of Nursing Education, 46 (1) 282-287. Retrieved November 2, 2007 from ProQuest
database.
Larson, L. (2006). Who will teach the nurses we need. Hospital and Health Networks, 80,
(12) 52. Retrieved February 4, 2007, from ProQuest database.
LaRocco, S. (2007). A Grounded Theory Study of Socializing Men into Nursing. Journal of Men’s Studies, 15 (2). Retrieved November 2, 2007 from ProQuest database.
Mead, J. (2006). On the east end, a nursing shortage is felt more deeply. The New York
Times, p 14L1.) Retrieved February 4, 2007, from ProQuest database.
Murphy, J. (2007). Distance Education in Nursing: An Integrated Review of Online
Nursing Students' Experiences with Technology-Delivered Instruction. Journal of
Nursing Education, 46 (6) 252-261. Retrieved November 2, 2007 from ProQuest
Database.
O’lynn, C. (2004). Gender Based Barriers for Male Students in Nursing Education
Programs: Prevalence and Perceived Importance. Journal of Nursing Education, 45
(1) 229-237. Retrieved November 2, 2007 from ProQuest database.

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Nursing Best Practices on Barriers of Preventing Medication Errors

Gladys Ng’ethe
More than 2 years after the first Institute of Medicine (IOM) report, reducing medication errors and enhancing patient safety remain among the most compelling issues in health care. The 1999 IOM report To Err is Human: Building a Safer Health System elevated the level of urgency needed to focus on how medical errors are killing thousands of people in the United States annually, and adding billions of dollars to the cost of health care.
Medication-related errors alone kill 7,000 people or more each year, and the rate of deaths for inpatients has dramatically increased in the past 15 years (Phillips, Christenfeld, & Glynn, 1998). Beyond medication errors themselves, there are also serious and potential adverse drug events (ADEs) that have a significant human and financial cost.
THE RIGHT REPORTING SYSTEMS.
Miscommunication/ Knowledge deficit:
Collaborative communication among healthcare providers is a prerequisite for safe and effective patient care. The Joint Commission suggests that communication is a key contributor to sentinel events and medication errors. Kirkpatrick (2003) stressed people in organizations typically spend over 75% of their time in an interpersonal situation; thus it is no surprise to find that at the root of a large number of directorial problems is poor information exchanges. Nurses are required to read back any verbal of telephone orders given. Noisy transmission (unreliable messages, inconsistency), receiver distortion: selective hearing, ignoring non-verbal cues are contributing factors erroneous messages.
Prescribers should avoid using abbreviations, including those for drug names because they can be misunderstood. Indecipherable handwritten prescriptions, metric vs apothecary systems, look alike- sound alike drug names, drug miscalculations, ambiguous or incomplete orders.
Identifying Vulnerabilities:
You cannot begin to correct a problem or susceptibility until you know that it exists. You cannot fix what you do not know about. Reporting systems appropriately used for self-reported information such as incident reports and many kinds of administrative data sets. Unfortunately, many organizations view the data in reporting systems as a true reflection of what is really happening in their organization according to Patient Safety(2007). This is in no way a reliable assumption. As far as patient safety is concerned, the reporting system should be looked at as a vulnerability detector, not as a measurement of incidence or prevalence. Realizing that clear communication and credibility are crucial to leading change, NCPS established a goal that people would accept: preventing harm to the patient (VA 2002).
SOCIO-ECONOMIC STATUS.
Insurance policies:
The relentless, decades-long rise in the cost of health care has left many Americans struggling to pay their medical bills. Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare. A closer look at the people who admit to having prescription-filling problems shows that they come from all socio-economic strata, but are more likely to report low income or no insurance coverage. This suggests that financial burden rather than personal preference may be the culprit. Cohen (1997) found that elderly persons living below the poverty level were six times more likely to go without a necessary prescription than those with higher incomes.
Lack of unexpendable resources:
Kozer et al propose a few widely advocated potential systems improvements. For example, computerized physician order entry (CPOE) has been shown to be an effective technology for reducing prescribing errors. CPOE clearly has enormous potential for improving patient safety. At the most basic level, CPOE ensures that orders are complete, legible, and in a standardized format. When decision support is incorporated, CPOE can guide drug dosage, frequency, and choice of route or administration, as well as perform checks for drug allergy and drug-drug interactions. Handheld devices have considerable promise in hectic environments such as EDs and clinics, where it may be difficult to access a computer terminal while providing care. Robots have promise in reducing errors in drug dispensing; smart intravenous pumps may reduce administration errors, and bar coding can improve the reliability of the entire medication system.
The availability and quality of supervision is particularly important for preventing and catching mistakes by trainees. Prompt, direct faculty supervision is available in most EDs, and close supervision of trainees is fast becoming the expected standard of care. Real or perceived authority gradients (eg, seniority-based, gender-specific, cultural) are particularly problematic because they inhibit trainees from seeking help and dampen enthusiasm for open dialogue and feedback.
Nursing education must look beyond the finite skill of medication calculation and acknowledge system issues that plague most medication errors. Nursing must be experts in evaluating systems embedded within the medication administration process, and educators need to assume leadership with this daunting task. Risk factors could be proactively addressed and ultimately reduce the factors surrounding with medication errors. Hence, nursing faculty must foster critical thinking in risk reduction factors when administering medications and examine the entire continuum of the medication process with students.

BIBLIOGRAPHY
Phillips, D.P., Christenfeld, IV., Glynn, L.M. (1998). Increase in US medication-error deaths between 1983 and 1993. Lancet, 351, 643-644.
Joint Commission on the Accreditation of Healthcare Organizations. The measurement mandate. Oakbrook Terrace, IL: JCAHO; 1993.
Kirkpatrick, C. (2003) Safety first: The JCAHO introduces new patient goals. Nurses Week, 4(2), 23.
National Center for Patient Safety. 2005. "Safety Assessment Code Matrix." [Online information; retrieved 9/24/07.] http://www.patientsafety.gov /matrix.html.
Veterans Health Administration (VA). 2002. VHA National Patient Safety Improvement Handbook. [Online document created 1/30/02; retrieved 10/23/07.] VHA Handbook 1050.1. http://www.patientsafety.gov/NEWS/Pubs/NCPShb.pdf.
Cohen RA, Bloom B, Simpson G, et al. Access to Health Care. Part 3: Older Adults. National Center for Health Statistics. Vital Health Stat 19(198),1997.
Kozer E, Scolnik D, Macpherson A, et al. Variables associated with medication errors in pediatric emergency medicine. Pediatrics.2002; 110; 737 –742

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Reducing litigation risks related to Obstetrics and Nursing:

Increasing demands society has placed on obstetric nursing, especially through issues of malpractice, has put our nation’s pregnant mothers at risk for a national crisis due to a lack of care to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims.
Some nursing strategies that will help to do this include preventative measures within the workplace to minimize errors in patient care; insisting that there be a designated support person in every woman’s laboring process; and implementing some of the strategies of care in midwifery because midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients.

In numerous counties across the nation pregnant mothers must drive anywhere from 45 to 80 miles for prenatal care (Moninger, 2007). The doctors can no longer afford to deliver babies; they are being charged malpractice insurance premiums into the six figures. Many maternity wards have closed across the nation due to a lack of obstetricians; this even affects the midwives in those areas considering they often have to work in collaboration with obstetricians (Moninger, 2007). Liability insurance for certified nurse midwives has increased as well. Neonatal/obstetric nursing can often be at the forefront of a malpractice suit when an injury to a neonate happens in the hospital’s care (Verklan, 2004). The author, Verklan (2004), goes on to give an example of a perinatal nurse who questioned a physician’s orders in the care of an induced mother, the nurse followed all orders regardless of her questions and the child ended up with severe retardation. Here, the doctor misinterpreted the electronic fetal monitor, and ordered the continuation of Oxytocin. The nurse’s questionable administration of Oxytocin is what placed her at fault and in the courtroom. According to the authors the misinterpretation of the electronic fetal monitor often leads to suit. Another major factor that comes into play in medical malpractice hearings is insufficient documentation (Greenwald & Mondor, 2003). With all of the possibilities for malpractice suit in the obstetric setting, a plan to reduce errors and increase positive outcomes is the only option for obstetric nurses.
OB nurses must decrease risk factors in labor and deliver through a prophylactic approach, starting with transitioning teamwork innovation from other industries into healthcare, resulting in better safety. Implementation of the MedTeams Training Program to enhance overall performance on the Labor & Delivery floor it is a strategy that could decrease the risk of error and the inevitable litigation that accompanies malpractice (Harris, et al, 2006). MedTeams Training is something the registered nurse will have to justify to hospitals management. It addresses management of distractions, changing coping mechanisms, behaviors, and attitudes; improving communication and teamwork; and evaluation of information related to operational dangers. “In a closed case review of civilian emergency department risk management cases, Dynamics Research Corporation suggested that 43% of errors were due to a lack of team behaviors (Harris, et al, 2006).” A retrospect review of closed claim L&D files by two separate pairs of physician-nurse experts suggested that 40% or more of L&D malpractice events could have been prevented by a formal team approach (Harris et al, 2006).
A lack of adequate teamwork between obstetrical nurses is as big a problem as a lack of physical or emotional support for the patient. Having a support person during labor and childbirth has been associated with decreased rates of cesarean births and lengthy labor (Cragin, & Kennedy, 2006). Therefore, suggesting that patients choose a person to be their birth partner as added support through the four stages of the laboring process will lessen the complications that often are associated with malpractice cases. Added support provides a positive presence to the situation which potentially can improve the patients’ labor and delivery.
Certified Nurse Midwives have been found to have better outcomes in delivery even with the inclusion of “risky” patients. According to a study done to examine optimality in women at equally moderate risk, “those cared for by midwives achieved a higher optimality score (less use of technology and equal or better health outcomes) than those cared for by physicians, with equally positive neonatal outcomes (Cragin & Kennedy, 2006).” This would be a wonderful research opportunity for the Registered Labor and Delivery nurse. If implementing some of the strategies of the CNM in hospital care will decrease adverse outcomes in the hospital setting than in turn malpractice litigation will also be decreased. Collaboration between CNM and OB RN will also decrease the stress that the patient feels just by being in the hospital.
Increased adverse outcomes in obstetric nursing have led to increases in malpractice cases, and therefore a lack of care due to doctors and nurse midwives leaving practice. With the demands society has placed on obstetric nursing, especially through issues of litigation, our nation’s pregnant mothers are at risk for a national crisis of not being able to meet the demands of childbirth. Ultimately, OB nurses need to decrease the risk factors that are increasing malpractice claims. In order to do this first RNs will implement team strategies and coordination, which in turn will reduce risk through a decreased work load and open communication. Next, the RNs will suggest a system that designates a person of support to help ob patients through their labor; this will decrease mom’s anxiety resulting in fewer complications during birth. The last strategy the RN will do is through taking on some of the qualities of care that nurse midwives are using, as in less technology, which will also lead to better outcomes for mom’s meaning better outcomes for babies.
A. Intervention 1: implementing some of the strategies of care in midwifery.
i. Disadvantage 1: Knowledge deficit related to midwifery.
Midwifery has been proven to be as effective as or even more effective than hospitals with good outcomes related to childbirth. Yet, the findings are not being recognized by hospitals nor insurance companies making it very hard for certified midwives to practice and for patients to find coverage if they decide to go with a midwife rather than an obstetrician. “Many insurers discourage giving birth at home, a practice usually attended by a midwife, arguing that it is not as safe as going to a hospital” (Perez-pena 2004). For example, “Aetna (a health insurance company) will not contract with some birthing centers because it considers them inadequate for emergencies or too far from hospitals, and it will not cover any home births unless required to by state law . . . Midwives argue that they actually save health insurers money, because their care results in fewer Caesareans and other expensive procedures” (Perez-pena 2004). Without the practice of midwifery taken seriously hospitals and insurance companies continue to utilize too many machines, too many drugs, and end up causing more problems using this whole medicalized, institutionalized way of birth that doctors do (Perez-pena 2004).
ii. Disadvantage 2: Lack of insurance related to midwifery practice.
Patients across the nation are turning to midwifery for childbirth practices often being stopped in their tracks by the insurance companies denying coverage. On another note midwives across the nation are being stopped in their tracks by increased malpractice insurance rates and decreased Medicare coverage sending them out of business. “Certified Nurse Midwives receive only 65% of the physician reimbursement rate for comparable services” (Health Insurance Week 2005). Many patients are being forced to pay larger shares of their bills with a CNM than if they would’ve gone to a doctor (Perez-pena 2004). The obstacles of both patient and midwife in regards to insurance have driven many birthing centers out of business. “The Elizabeth Seton Childbearing Center in Greenwich Village, shut it’s doors, driven out of business by rising medical malpractice insurance premiums . . . when Seton needed a new malpractice policy last summer, the best quote it could find was a 400% premium increase” (Perez-pena 2004). “ Midwives face fast-rising malpractice insurance premiums, and new limitations imposed on their practices by many hospitals and health insurance companies” (Perez-pena 2004).
B. Intervention 2: Transitioning teamwork innovation from other industries into healthcare.
i. Disadvantage 1: Knowledge deficit related to strategies for teamwork.
Strategies for teamwork innovation are not being looked at seriously. Hospitals are not realizing the benefits of spending money on such quality assurance programs to decrease the risk of malpractice and lower malpractice rates in the long run. “The MedTeams training program, a nationally funded research project, provided the framework for team training in several labor and delivery units in the United States. Many challenges were confronted when team training was implemented” (Harris; et al 2006). The article goes on the state, “little has been written about how to implement teamwork initiatives to ensure success” (Harris, et al 2006). However, formal teamwork training was almost nonexistent in obstetric care settings until the development of the MedTeams training program leaders (managers, directors, clinical nurse specialists, chiefs of obstetrics and anesthesiology) attended several days of training. Staff did not attend. As a result, they perceived that their input did not matter and that the project was simply another change they did not control (Harris, et al 2006). Therefore, the MedTeams training program dedicated to providing a framework for team training in labor and delivery units confronted many challenges.
ii. Disadvantage 2: Malpractice insurance rates shut down OB units.
Malpractice rates are launching our country into national crisis due to a lack of childbirth care. There are numerous OB units and birthing centers that have already been shut down without ever giving teamwork innovation a chance. Teamwork innovation programs, such as Medteams Training or other quality assurance programs are not being implemented prior to shut down, and the power that they hold in decreasing risk will never be known in those locations. “Jeanes Hospital in Philadelphia closed its obstetrics ward in May, it became the 33rd Pennsylvania hospital, and the 14th in the Philadelphia area, to stop delivering babies in the last decade” (Thrall 2007). Only one hospital in Rhode Island has taken steps to prevent this trend, the hospital, with a captive insurance plan, offers discounts of up to 30% for doctors who participate in quality assurance training (Thrall 2007).
References New Stuff:
1. Bush, H. (2007). Perfect storm forces hospitals to shut down obstetrics services. Hospitals & Health Networks, 81(9), 20.
2. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.
3. Health Insurance Week (2005). Obstetrics; Midwives to lobby U.S. congress for Medicare reimbursement equity. http://proquest.umi.com/pdqweb?did=860911461&Fmt=3&clientid=3236&RQT=309&VName=PQD
4. Perez-pena, R. (2004). Use of midwives, a childbirth phenomenon, fades in city. New York Times, B.1.
Reference List Original:

1. Cragin, L., & Kennedy, H. P. (2006). Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(6), 779-785.

2. Greenwald, L. M., & Mondor, M. (2003). Malpractice and the perinatal nurse. Journal of Perinatal & Neonatal Nursing, 17, 101-109. Retrieved January 7, 2007, from Proquest online database.

3. Harris, K. T., Treanor, C. M., & Salisbury, M. L. (2006). Improving patient safety with team coordination: challenges and strategies of implementation. Journal of Obstetrics and Gynecology Neonatal Nursing, 35(4), 557-566.

4. Moninger, J. (2007, January). The doctor drought: skyrocketing insurance premiums are forcing thousands of ob-gyns out of the baby business. And your doctor could be the next to go. Parents, 62-65, 116-117.

5. Verklan, M. T. (2004). Malpractice and the neonatal intensive-care nurse. Journal of Obstetrics and Gynecology Neonatal Nursing, 33(1), 116-123.

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