Economic Crisis: Impact to Hospitals

The financial markets are spinning. The world economy is faltering. The U.S. government is making a $700 billion or more bailout to avert a worldwide disaster. In this time of global financial crises, all hospitals and healthcare organization face an alarming financial scenario. Factors that accompanied the financial crises are decreasing revenues, increasing costs, and high consumer expectations (McNichol & Lav, 2008).

Many Americans has been laid off or facing mortgage foreclosures. With job loss comes loss of health insurance, thus hospitals are now caring for more uninsured patients. On the other hand, reimbursement has decreased for many patient conditions (Boyd, 2008).

According to Parry & Humprey (2009), the economic turmoil caused hospitals and healthcare systems to lose millions of their investment dollars, affecting their financial safety net. Losing the organization’s safety net present a complex challenge for Chief Executive Officers (CEOs), physicians, nurse executives, administrators, financial advisors and department managers who must not only lead in today’s climate, but also position their organizations for tomorrow’s financial confusion (Parry & Humprey, 2009).

The economic crunch has several effects to hospitals. First, the capital crisis is making it difficult and expensive for hospitals to finance facility and technology needs. Currently, there is an increased cost of borrowing and decrease access to financing. To be specific, nowadays there is an increased interest expense for variable rate bonds, increased collateral requirements, and inability to issue bonds. In addition, the hospital is also having trouble refinancing auction rate debt and inability to renew credit, coupled with acceleration of debt and inability to withdraw funds held by financial institutions. As a result, many hospitals are reconsidering or postponing investments in facilities and equipment (American Hospital Association, 2008).

Second, according to American Hospital Association (2008), many hospitals are seeing the impact of the economic downturn on the number and mix of patients seeking care. There are lower admissions and number of elective procedures have drop significantly. Hospitals are seeing significant decrease in inpatient and ambulatory surgeries, as well as emergency room visits. Employees who have been laid off became uninsured. For this reason, they are putting on hold their health problems and postpone or defer elective procedures.

Third, rising unemployment caused an increased uncompensated care. For every one percent increase in unemployment leads to a loss of employer sponsored coverage for an estimated 2.5 million employees and dependents. The majority of hospitals are seeing an increased in the proportion of patients unable to pay for care, and the need for subsidized care is increasing. With patients unable to pay, more physicians are seeking financial health from hospitals (American Hospital Association, 2008).

Fourth, financial health is worsening as patients seek less care and investment gains turn to losses. Many hospitals making or considering cutbacks by cutting administrative costs, reducing staff, reducing services, divesting assets, and considering merger (American Hospital Association, 2008).

Fifth, according to Smith, Rudowitz, O’Malley, & Marks (2008), stresses on state and federal budgets raise worries about cuts to Medicaid and Medicare provider payments. The Medicaid programs support half of patient care provided but the program is severely underfunded. Consider that Medicaid expenditures that have the largest portion of many state budgets have increase during this economic crisis even as the state tax revenues drop (Smith, et.al, 2008).
Sixth, as the economy weakens, hospitals are shifting insurance costs in the form of higher deductibles or higher co-pays for employees. This is very ironic considering that hospital provides care to patients. However, with the increasing cost of insurance premiums, the hospitals need to find cost-cutting measures to survive (Marmont & Bell, 2009).

The economic environment, exacerbated by the credit crisis, has put the healthcare industry in puzzling waters. The industry's quick response to this challenge is encouraging, but tough times lie ahead. Hospitals that address changing patient demands and shifting reimbursement cycles will be better positioned to mitigate the economic downturn (Hartman, Martin, McDonnell, & Catlin, 2009).

The Joint Commission (2008) in response to economic turmoil issued a report that directs hospitals to respond in new ways as escalating health care costs are hitting record highs and the conditions and care needs of hospitalized patients are growing more complex. The report is the work of an expert panel comprising hospital executives and clinical leaders, as well as experts in technology, health care economics, hospital design and patient safety.

The report recommends action in five core areas. The first core area focuses on economic viability. For hospitals to be economically viable, they must align performance and payment systems to meet quality and efficiency-related goals. Hospitals must use process improvement tools to increase efficiency, reduce costs, and pursue coverage options to ensure patient access to affordable health care services. It is also important to address how general acute hospitals and specialty hospitals can both fulfill the social mission for health care delivery (The Joint Commission, 2008).

The second core area is technology adoption. Information technology plays a major role in improving health care quality and safety, and can help to support the migration of hospital-based care into the community and even the home. The technological transformation of health care also invites the redefinition of the hospital (The Joint Commission, 2008).

To address technology in the future, hospitals should make the business case and sustainable funding to support the widespread adoption of health information technology, and redesign business and care processes in tandem with health information technology adoption. The hospital must also use digital technology to support patient-centered hospital care and extend that care beyond the hospital walls and hiring reliable authorities that will assess the technology and technology investment guidance. Moreover, the technology must be laborsaving and integrative across the hospitals (The Joint Commission, 2008).

The third core area is patient-centered care. The patient has the greatest stake in their care. Thus, patient needs to be respected as an equal partner in their care to promote quality and safety. Family members or others to whom the patient is emotionally tied are also part of the health care partnership (The Joint Commission, 2008).

According to the Joint Commission (2008), achieving patient-centered care should be driven by adopting of patient-centered care values that is a priority for improving patient safety and patient and staff satisfaction. Hospitals must also incorporate patient-centered care principles into the activities of hospital oversight bodies and transparency initiatives and address barriers to patient and family engagement. Moreover, hospitals must eliminate disparities in the quality of care for minorities, the poor, the aged and the mentally ill as well as improving the quality of care for the chronically ill through coordinated, multi-disciplinary care.

The fourth core area is staffing. Work force shortages have persistently plagued hospitals over the last several years. To address the fact that demand for certain health care professionals outstrips supply and to meet the needs of patients, the hospitals must establish fair migration and compensation policies for countries facing shortages of health care workers and expand health professional education and training capacity to accommodate the growing demand for health care workers.

Hospitals must also create workplace cultures that can attract and retain health care workers by develop professional knowledge and skills necessary in a more complex health care environment (The Joint Commission, 2008).

The fifth core area is hospital design. Hospital must improve safety with evidence-based design principles such as single rooms, decentralized nursing stations and noise-reducing materials. It is also important to address high-level priorities, such as infection control and emergency preparedness, in hospital design and construction. Inclusion of clinicians and other staff, patients and families in the design process to improve staff work flow and patient safety, and create patient-centered environments are vital processes to observe to promote safety (The Joint Commission, 2008).

The core areas were the result of the analysis of how socio-economic trends, technology, the physical environment of care, patient-centered care values and ongoing staffing challenges will influence the hospital of the future (The Joint Commission, 2008). The Joint Commission urges hospitals and public policymakers to use the principles embedded in their report to achieve that aim.

For the nurse leaders, they should play a pivotal role in implementing innovative strategies to enhance revenue for the organization. Strategies may include cutting supply costs, decreasing patient length of stay and limit or abolish overtime hours for the staff. According to Buerhaus (2008), in these economic downturn nurse leaders must restructure health care delivery on individual floors and spearhead innovations. The restructuring of the delivery system in the floor may be carried out by consolidating supplies to allow nurses to spend more time in the bedside, thereby increasing patient satisfaction scores and anticipating staffing mix in response to patient acuity.

When times are tough, nurse leaders and managers must avoid unilateral thinking. Nurse leaders must act with authenticity and determination to seek out voices and opinions contrary to prevailing thought. The nurse leader must go beyond the traditional to the nontraditional, to people, places, and resources that are not familiar to get a better grasp of the situation on hand. In addition, nurse leaders must be decisive in term of budget allocation, forecasting, and cost reduction (Boyd, 2008).

Finally, nurse leaders must stand ready in these tough times to educate patients and
their families about the uncertainty and unexpected financial cost associated with acute and chronic disease and the importance of staying healthy. In this tough economic time in health care, CEOs, physicians, nurse executives, administrators, financial advisors and department managers must understand and apply the principles of human and fiscal resources to stay afloat.

References:
American Hospital Association (2008). Rapid Response Survey. The Economic Crisis: Impact on Hospitals. Trendwatch. Retrieved from http://www.ihatoday.org/econcrisisreport.pdf

Boyd, D. (2008). State Tax Revenue Now Flat, for the First Time Since 2002 Recession: After Weak Third Quarter, Further Declines Likely Lie Ahead. The Nelson A. Rockefeller Institute of Government. Retrieved from http://www.rockinst.org/newsroom/news_releases/2008/2008-11-06state_tax_revenues_across_u.s._are_flat_for_first_time_since_2002_recession_new_rockefeller_institute_flash_report_shows.aspx

Buerhaus, P., Auerbach, D., Staiger, D. (2008). Recent trends in the registered nurse labor market in the US: Short-run swings on top of long-term trends. Nursing Economic$, 25(2), 59-66. Retrieved from http://www.medscape.com/viewarticle/556417_1

Hartman, M., Martin, A., McDonnell, P., & Catlin, A. (2009). National health spending in 2007: Slower spending contributes to lowest rate of overall growth since 1998. Health Affairs, 28(1), 246-261. doi: 10.1377/hlthaff.28.1.246

Marmot, M. & Bell, R. (2009). How will the financial crisis affect health? Business Management Journal, 338, 858-60. doi:10.1136/bmj.b1314

McNichol, E. & Lav, I (2008). State Budget Troubles Worsen. Center on Budget Policy and Priorities. Retrieved from http://www.cbpp.org/archiveSite/9-8-08sfp.pdf

Parry J. & Humphreys G. (2009). Health amid a financial crisis: A complex diagnosis. Bulletin of World Health Organization, 87, 4-5. Retrieved from http://www.who.int/bulletin/volumes/87/1/09-010109/en/index.html

Smith, V., Rudowitz, R., O’Malley, M., & Marks, C. (2008). Headed for a Crunch: An Update on Medicaid Spending, Coverage and Policy Heading into an Economic Downturn. Kaiser Commission on Medicaid and the Uninsured. Retrieved from http://www.kff.org/medicaid/upload/7815.pdf

The Joint Commission (2008). Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future. Retrieved from http://www.jointcommission.org/NR/rdonlyres/1C9A7079-7A29-4658-B80D-A7DF8771309B/0/Hosptal_Future.pdf

Improving Nurse Satisfaction and Retention

The nursing shortage in America is a pressing problem that needs to address. Healthcare organizations are employing creative strategies to promote nurse satisfaction to retain their best nurses. The following are some suggestions to promote nurse satisfaction and retention:

1.Employees Benefits, Fair Compensation and Salary Adjustment based on market value
Pay and benefits issues often have to be first and foremost when employees consider whether they can remain in the organization. Additionally, when employees are unhappy about compensation, they often complain more about other issues, especially if they do not believe it is possible to correct the problems without leaving the
organization.

Managers need to ensure that pay systems have internal equity between jobs by paying them in accordance with their importance to the organization based upon job evaluation, establishing equity in pay between employees by proper distribution of rewards, and maintaining equity in pay between organizations by proper budget allocations.

2.Build on social strengths:
-Creation of calendar of social activities that include celebration such as:
Cultural diversity month – bring in food from different culture
Thanksgiving party
Christmas party for the unit
Breakfast with employees’ children and family in December
Valentines socials in February
Organize health and fitness activities (jogging, aerobics and dance class etc.)
Annual Team building retreat
-The major outcomes of team building retreats are
a.Staging ongoing activities that create, nourish, and nurture a positive morale
b.Professional development
c.Employees sharing a positive social experience
d.Staff satisfaction, rewards, and recognition initiating a celebration/morale committee developing a mission statement for specific unit/area and core beliefs goal setting

3.Enhance employee recognition to show employees that they are valued.
-Birthday and work anniversaries celebration
-Bulletin board recognizing employees with exemplary performance, thank-you card and commendations from patients and families

4.Promote work-life balance programs and policies
-It will help individuals balance their work and non-work lives, such as flexible work arrangements (self-scheduling), provision of childcare benefits, and others

5.One time cash incentive (1-2%) for passing certification exams and a plaque listing employees’ names and achievements placed in a prominent place where co-employees can see

6.Grievance processing system
-The system should enable employees to bring problems and questions to the attention of managers without fear of retribution.
-Such a process can be very helpful for managers to determine issues that could lead to undesired turnover if they are not resolved.
-Employees may be less likely to leave if they feel their problems can be addressed equitably in-house.
-To improve employee perceptions of equity in the process, the organization may want to consider alternative dispute resolution with an arbitrator selected to decide the issue if the employee and management cannot reach a mutually satisfactory outcome.

7.Promote shared governance
Shared Governance is an organizational structure in which clinical nurses have a voice in determining nursing practice, standards and quality of care.

The advantages of shared governance are twofold:
•It empowers nurses to use their clinical knowledge and expertise to develop, direct and sustain our own professional practice.
•It allows nurses to network with colleagues and to collaborate among units and departments.

Retention programs that focus on employee participation and involvement in decision-making processes are the ones most likely to experience long-term success. The common denominator for staff retention is to find ways to improve job fulfillment and staff satisfaction.

How Long does it Take for a Biopsy of the Vulva to Heal?

Vulvar biopsy is performed when a woman experiences persistent vulvar itching, pain, or a suspicious lesion. Biopsy of vulvar lesion is necessary for histology analysis, to differentiate benign from cancerous (neoplastic) lesions and it may be curative if the entire lesion is removed for biopsy. Vulvar biopsy is relatively minor and it is done under local anesthetic. Initially women may feel a wasp or bee sting or sharp pain during the injection of anesthetic to the vulvar area, then some burning. This usually lasts more than a few seconds.

Most practitioners use a Keyes-type punch biopsy instrument to obtain a specimen of at least 3mm, but a Kevorkian or Kraus biopsy forceps could also be used. In the case of a single lesion to be completely excised, a scalpel is used. Bleeding in small biopsy sites of less than 5mm is stabilized by applying pressure. Silver nitrate is also applied to biopsy site to prevent infection and promote healing. However, vulvar biopsy with larger lesions should be reapproximated with suture. After the procedure, the patient should be taught about sitz baths to keep the area clean and use of oral over-the-counter analgesics.

Complete healing could take 2-3 weeks. A follow-up appointment with your doctor should be scheduled within two weeks to check biopsy site healing and review pathology and culture results.

Reference:
Heller, D & Wallach, R. (2007).Vulvar Disease: A Clinicopathological Approach. CRC Press

Nurses and Technology

Technology is on the rise! Globalization in healthcare is the current trend. Information highway accessibility is a convenience that nurses need to explore and exploit.

For decades now, technology has been a part in the life of the nurses in patient care. Collision of healthcare and technology has created an industry that now drives both the cost and the standard of healthcare. While nurses are utilizing technologies such as intravenous therapy, ventilators, glucometers, chest tubes, telemetry packs and monitors, arterial lines, microchips driven IV pumps and many others, most documentation and communication in many hospitals have remained tied to pen and paper, face-to-face or phone-to-phone encounters.

Computer technology revolutionized patient care. The routine, dull nursing care transformed into a challenging high-technology patient care. Many hospitals accross the nation is adapting computerization in their facility. However, this new technology raised several concerns in the nursing profession. Several questions have been raised, questions such as: Does technology detract from the humanistic side of patient care? Does it diminish quality patient care? Does it minimize the value of the nurse’s skills? Looking into all these concerns led me to several points about the advantages of utilizing the new technology.

In my personal opinion, the use of computers and information systems have helped nurses perform their jobs better and more efficiently. Nurses can readily access patient records or check patient’s medications and laboratory results while at bedside. Technology can also improve job satisfaction, reduce errors, and give nurses more time for direct patient care. Furthermore, technology help nurses take information and turn it into insight to make life-saving decisions at patient’s bedside.

However, many nurses are still cynical with the use of computers especially for nurses who are not computer savvy. Most nurses would think that using computers would drive them to spend more time and effort to complete their documentation. Technology should not get in the way of patient care. It should help nurses perform a better if not the best patient-centered care. It is therefore the role of the hospital administration to choose a system that would allow the nurses to do what they usually do and not to reinvent their job because of the new technology in the facility. The nurse educators must also train the staff about the ins and outs of the new technology to make them comfortable and confident in using the technology.

I believe, with the right attitude, openness to change, integration to IT environment through skills training and support from a competent nurse educators and unit administrators, nurses will have a better chance to learn new technology that will help them deliver holistic care to their patients.

What do you think???

Nurses with Disability?

The term suited for nursing means to me when an individual has the physical and psychological capacity to take care of sick persons. It is the nurse educator's moral and social responsibility to examine the capacity of a nursing student to become a registered nurse or a nurse who become disabled to stay in the profession.This is stipulated in ANA Code of Ethics for Nurses, which states that, “The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintain integrity of the profession and its practice, and for shaping social policy.” However, the defining line of who is suited and not suited to enter and stay in the nursing profession is still a subject of debates, deliberations, and controversies in the academia and in the clinical practice.

Accepting students with disability in the nursing profession and allowing nurses who become disabled to stay in the profession are controversial issues because of its legal implications. Rehabilitation Act of 1973, Section 504 states that, “No otherwise qualified handicapped individual in the United States…shall solely by reason of handicap be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” Moreover, the American disabilities Act of 1990, “…prohibits discrimination on the basis of disability by entities providing public and private preschool, elementary, secondary and postsecondary education. It also prohibits discrimination on the basis of disability in employment, public accommodations, commercial facilities, transportation and communication.”

It is my personal belief the persons with disabilities may be given a fair chance to enter the profession and practice nursing. The institutions on the other hand, must provide disabled students and nurses physical, psychological, and social support, based on their individual needs.As nurses, we always consider the safety for our patients. This is so, because it is part of our ethical practice to adhere to the universal moral principles. Nevertheless, consider also those disabled individuals who want to enter the profession and those disabled nurses who want to stay in the profession. Let us not leave these individuals who have the hearts and minds in the nursing profession provided they can skillfully practice safe nursing care.

Chloroform for Sleep

Chloroform is a clear, colorless, and mobile liquid with a pleasant, sweet odor. It has a chemical formula of CHCl(3). Chloroform is synonymous to trichloromethane, trichloroform, freon 20, COBEHN spray-cleaner solvent, formyl trichloride, methane trichloride, methenyl trichloride, methyl trichloride. Chloroform is commonly used as solvent in pharmaceutical industries. It can also be used to bond pieces of acrylic glass (Perspex and Plexiglas), producing dyes,pesticides, coolants, grain fumigants and dry cleaning spot remover.

The National Institute for Occupational Safety and Health (NIOSH) has established a recommended short-term exposure limit to chloroform for 60-minute. The time exposure limit is related to its toxic effect in the central nervous system and potential cancer-producing (carcinogenic) effect. Thus if you are wondering if you can use chloroform for sleep due to its central nervous system depression effect, the safe answer is NO.

Inhalation of chloroform causes signs and symptoms of central nervous system depression. Initially, the person may experience feeling of warmth of the face and body, then irritation of the mucus membranes, eyes, and skin. Eventually there is excitation, loss of reflexes, sensation, and consciousness.

Constant exposure to chloroform will cause psychiatric and neurological symptoms such as paralysis, depression, hallucinations, and moodiness. It will also cause cardiac and respiratory failure. Moreover, patients who have chronic exposure to chloroform may also have neurological and gastrointestinal signs and symptoms that resemble chronic alcoholism.

Therefore, if you have trouble going to sleep and staying asleep it is very important to consult your doctor for an appropriate pharmacologic and non-pharmacologic intervention to promote sleep such as sleeping pills and relaxation techniques.

Resource:
http://www.osha.gov/SLTC/healthguidelines/chloroform/recognition.html

BRAT Diet for Nausea, Vomiting, and Diarrhea

As you start recovering from diarrhea, stomach upset (dyspepsia), and stomach infection (gastroenteritis), BRAT diet is the recommendation. BRAT diet is an acronym for:

B-ananas, R- ice, A- pplesauce, T-oast.

These bland, low-fiber foods are easy to digest and well tolerated by most people with stomach illness. BRAT diet foods are low in fiber, protein, and fat. Adults and children need to drink plenty of fluids too while they are sick to prevent dehydration. Water is good, but adding broth, a sports drink, or a rehydration solution such as Pedialyte can help replace lost electrolytes.

While you are transitioning back to a normal diet, you must avoid the following foods:
- Milk and dairy products
- Fried, greasy, or spicy foods
- Rich desserts
- Raw fruits and vegetables such as corn on the cob, onions, beets, raisins, figs, and cherries
- Citrus fruits (oranges, pineapples, grapefruits) and juices
- Alcohol and caffeinated drinks

Resources:
http://www.webmd.com/digestive-disorders/digestive-diseases-nausea-vomiting
http://www.webmd.com/digestive-disorders/brat-diet

Nocturnal Leg Cramps Causes

Nocturnal leg cramps occurs commonly as we age and during pregnancy. The reason for muscle cramps is not very well known yet but they are very common. Some people experience muscle cramps on a weekly or daily basis. Leg cramps affect the muscles in the calf or along the sole of the foot. The cramp usually goes away within a few minutes.

Tight muscles and inactivity usually cause muscle cramps during the night. You can help relieve the pain by grasping your toes, pulling toward you, stretching your calf muscles but the best preventative treatment is regular stretching and exercise. If you suffer from regular nocturnal leg cramps, you should stretch your calves and affected areas as part of your bedtime ritual.

You can do runner's stretch that involves leaning against the wall and stepping forward, leaving the back foot flat on the floor. You can also do stair stretch by standing on the edge of a step and dropping your heels while holding on to the banister. For both stretches, you must hold the stretch for at least 30 seconds.

Pharmacologic treatment
Quinine is one of the few treatments shown to help reduce nocturnal cramps. The way in which quinine helps to reduce frequency and severity of cramps is not known either and there have been studies to try to assess the efficacy of the drug. Quinine is found in low concentrations in tonic water (one-tenth of prescription dose). Drinking eight to 16 ounces at night can be a simple remedy.

Other treatments that may be helpful but have not been studied extensively include the use of muscle relaxant, orphenadrine (Norflex), anti-seizure medicine - gabapentin (Neurontin), blood pressure medicine - verapamil, and Vitamin B complex.

Resources:
http://www.healthcaresouth.com/pages/askthedoctor/Nocturnallegcramps.htm
http://www.3dchem.com/molecules.asp?ID=102

Heart Patient Diet

How much fat?
Try to reduce your total fat intake to 30 percent of your calories. Saturated fats should comprise less than 7% of your daily calories. Saturated fats raise blood cholesterol levels. These fats are solid at room temperature and include butter, shortening, hydrogenated oils, stick margarine, bacon lard, and palm oil. Saturated fats are found primarily in animal products including beef, lamb, pork, poultry skin, cream, whole milk, and egg yolks.

Meat, Poultry, and Fish
Limit fish, meat, and poultry to 6 ounces or less (90% lean) per day.

Red Meat
Limit meat to 3-4 times per week. Choose leaner cuts of meat like sirloin or round. Choose meats that are at least 90% lean. Make sure to trim away visible fat before cooking. This step can reduce overall fat content by 50%.

Poultry
Remove the skin from poultry before or after cooking. Choose white meat. Dark meat is higher in fat.

Fish
The American Heart Association encourages everyone to consume fish at least twice per week. Fatty fish contain Omega-3 fatty acids. This includes salmon, mackerel, albacore tuna, sardines, and lake trout. Omega-3 fatty acids protect against heart disease by lowering blood triglycerides (fats) and reducing blood clotting. Omega-3 fatty acids help lower the risk for heart attacks and sudden cardiac arrest due to an irregular heartbeat.

Tips for Reducing the Salt in your Diet
1. Hide the saltshaker
Remove the saltshaker from the table. Replace with a salt-free substitute like Mrs. Dashã, Papa Dash, Kroger Zesty Blends or your own mixture of favorite spices. But check with your physician before taking a salt substitute (e.g. No Salt, "Lite" Salt) because some substitutes contain potassium and should only be used after talking with your physician.

2. Avoid canned or boxed foods
Sodium is often used as a preservative in canned and boxed foods. Avoid canned meats, soups, canned vegetables, condiments, frozen convenience foods, and TV dinners. Try to use fresh or frozen vegetables and make foods from "scratch."

3. Read labels carefully to find "hidden" sodium.
Many foods that do not taste salty are actually quite high in sodium. Most "hidden" sodium comes from commercially prepared or packaged foods.

4. Learn to prepare meals with less salt
Avoid high sodium condiments like soy sauce, mustard, ketchup & barbecue sauce. Season with herbs, spices, herbed vinegar, herb rubs and fruit juices.Create your own sodium-free substitutes

Resources:
http://www.diabetes.org
http://americanheart.org
http://mayoclinic.com
http://www.dmhcares.org/patient/nutrition/cardiacdietbw.asp

Accountability in Nursing

Healthcare organizations are continually challenged to be excellent and successful. It is a pressing concern for healthcare organizations and the need for effective organizing is imperative. (Ramanujam & Rousseau, 2006). The pressure is unrelenting to the leaders and staff to ensure safe and effective patient care. Achieving safe and effective care is not solely directed to clinical care but also to organizational culture. For this reason, most healthcare organizations are gearing towards examining their culture that promotes patient’s safety (Haydar, Cox, Stafford, Rodriguez, & Ballard, 2009).

The differences in culture within the organization originates from the unique healthcare environment that is interplayed by pressures resulting from increased productivity demands, cost containment requirements, embedded hierarchies, and fear of litigation. These pressures are complicated further by changes or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team (Singer, Falwell, Gaba, Meterko, Hartmann, 2009). These existing pressures create challenges among healthcare professionals to communicate effectively and to build trust among team members. It is ironic how these pressures constantly affect the healthcare team when safety and quality of patient care is dependent on teamwork, accountability, communication, and collaborative work environment (Gerardi, 2005).

Building accountability in the workplace is a collaborative effort. It requires a clear definition of accountability that everyone can agree on and adherence to some basic principles of high performance management and team effort (Zeller & Fontanarosa, 2009). Effective leadership is the key to accountable employees. The nurse leader must know and communicate the strategic direction and core values of the organization to enable the employees understand where the organization is going and what it stands for. A nurse leader must also work with employees as an individual, providing direction and input as well as feedback. (Freeman, McWilliam, MacKinnon, DeLuca, & Rappolt, 2009).

In addition to effective leadership is employees’ engagement. According to Ellis and Sorensen (2007), an engaged employee is the one who knows what to do at work and wants to do the work, which means the employee has the right knowledge as well as the attitude and willingness to do the work. Engaged employees have high levels of energy and are enthusiastic about their work and fully immersed in their work (Ellis & Sorensen, 2007).

Employee engagement is a new model of social contract between companies and their people. It means actively involving its own people in decision-making and change management (Pech, 2009). Each employee needs to understand and believe in the mission statement of the organization and actively work towards its achievement. One should have the freedom to express and develop his ideas at work. Employees who are flexible, committed, and highly motivated have a strong sense of purpose about their work.

Healthcare organization should find ways to adapt their practice to suit different employees’ needs and keep them engage. Providing role clarity, job variety, shared challenges and strategies from time to time, encouraging two-way communication, promoting an open and caring environment, communicating openly and clearly about expectations from the employees, and celebrating individual, team and organizational successes on a sustained basis are strategies that would keep the employees engaged (Welbourne, 2007).

Now that everyone is engaged, it is the role of the nurse leader to monitor the progress of shaping an accountable culture. The nurse leader must evaluate strengths and weaknesses of each employee and its direct effect to the team, identify causes of performance below plan, and allow employees to formulate possible solutions to the identified causes of poor performance. It is also vital to communicate the nurse leader’s direct observation of the employees’ performance.

Accountability in nursing is a means of establishing that employees are aware of their responsibility to maintain safety. It must begin to the highest levels of the organization, and extend down to the teams and individuals. It is a means to secure that the team knows the shared responsibility of safety, both of the patient and one another.



References
Ellis, C. & Sorenson, A. (2007). Assessing employee engagement: The key to improving productivity. Perspectives, 15(1), 45-55.

Freeman, A., McWilliam, C., MacKinnon, J., DeLuca, S., & Rappolt, S. (2009). Health professionals' enactment of their accountability obligations: Doing the best they can. Social Science & Medicine, 69(7), 1063.

Gerardi, D. (2005). The culture of healthcare: How professional and organizational cultures impact conflict management. Georgia Law Review, 21(4), 857-890.

Haydar, Z., Cox, M., Stafford, P., Rodriguez, V., & Ballard, D. (2009). Accelerating best care at Baylor Dallas. Baylor University Medical Center Proceedings, 22(4), 311-315.

Pech, J. (2009). Delegating and devolving power: A case study of engaged employees. Journal of Business Strategy, 30(1), 27-32.

Ramanujam, R. & Rousseau, D. (2006). The challenges are organizational not just clinical. Journal of Organizational Behavior, 27, 811-827.

Schraeder, M., Tears, R., Jordan, M. (2005). Organizational culture in public sector organizations: Promoting change through training and leading by example. Leadership & Organization Development Journal, 26(6), 492-502.

Singer, S., Falwell, A., Gaba, D., Meterko, M., Rosen, A., & Hartmann, C. (2009). Identifying organizational cultures that promote patient safety. Health Care Management Review, 34(4), 300-311.

Welbourne, T. (2007). Employee engagement: Beyond the fad and into the executive suit. Executive Forum, Leader to Leader, 21(5) 45- 51.

Zeller, J. & Fontanarosa, P. (2009). Shared accountability, appropriateness, and quality of surgical care. JAMA: Journal of the American Medical Association, 302(14), 1590-1591.

Nocturnal Chest Pain

There are many different causes of chest pain requiring medical intervention, some of which can be life threatening. Nocturnal chest pain is one type of chest pain. Possible causes of nocturnal chest pain can be attributed to cardiac, gastric and musculoskeletal causes.

Cardiac Cause
Prinzmetal’s angina or variant angina is a form of chest pain, pressure, or tightness caused by spasms in the arteries that supply blood to the heart. It is a form of unstable angina, meaning that it occurs at rest, often without a predictable pattern. Episodes of chest pain caused by Prinzmetal's angina usually occur in clusters, with periods of frequent episodes lasting for a few months followed by weeks or months with no chest pain episodes. The pain usually occurs between midnight and approximately 8:00 AM. Prinzmetal's angina may have no identifiable trigger, or may be brought on by hyperventilation, exposure to cold or extreme emotional stress.

Generally, nocturnal (nonexertional) chest pain is not common in patients with cardiac disease, but in cases of coronary vasospasm or Prinzmetal angina, symptoms often occur at night and can clearly mimic reflux esophagitis.

Gastric Cause
Nocturnal reflux can be one of the reasons for nocturnal chest pain. At night, the acid dwells longer in the esophagus increasing the likelihood that proximal migration of acid will spill over into the aerodigestive tract and the pharyngeal area. Thus, even a single episode of nocturnal reflux results in significant esophageal acid exposure, and cumulative exposures may lead to esophageal and extra-esophageal manifestations and complications that may sometimes cause chest pain.

Musculoskeletal Cause
Posture-related nocturnal chest pain. They describe chest pain while the patient is sleeping in one position and not another and how patients must arise from bed to relieve their pain. Most commonly, patients also have neck pain and headaches. These patients' conditions are often misdiagnosed as being true angina.

Through structured assessment and nursing intervention, it is possible to identify those at high risk and ensure rapid treatment is provided to patients most likely to benefit from reperfusion treatment. Patients with noncardiac chest pain often will be treated with anti-reflux therapy, such as a proton pump inhibitor (PPI), and are referred to a gastroenterologist for further evaluation. Additionally, postural related nocturnal chest pain may be given analgesics to manage the pain.

References:
http://www.cmecorner.com/macmcm/acg/acg2002_04.htm
Orford JL, Selwyn AP. Coronary artery vasospasm. www.emedicine.com. November 8, 2005. Available at: http://www.emedicine.com/med/topic447.htm, 2007.
Rovai D., Bianchi M., Baratto M., et al. (1997). Organic coronary stenosis in Prinzmetal's variant angina. Journal of Cardiology, 30(6), 299-305.
Tough, J. (2004). Assessment and treatment of chest pain. Nursing Standard, 18(37), 45-55.
Walpin, L. (1980).Physical Therapeutics for Pain and Posture Control. JAMA,243(6), 515.

How to Become a Nurse

Education
Individuals who want to pursue a career in nursing must choose among the three major educational paths to become a registered nurse that is:

1.Bachelor’s of science degree in nursing (BSN)
-This program is offered by colleges and universities usually take about four years to complete

2.Associate degree in nursing (ADN)
-ADN programs offered by community and junior colleges, takes about two to three years to complete

3.Diploma from an approved nursing program
-This is administered in hospitals, takes three years to complete.

Many RNs with an ADN or diploma work toward a BSN by completing an RN-to-BSN program or accelerated master’s degree in nursing (MSN) programs by combining 1 year of an accelerated BSN program with 2 years of graduate study.

Accelerated BSN programs also are available for individuals who have a bachelor’s or higher degree in another field and who are interested in moving into nursing. Accelerated BSN programs last 12 to 18 months and provide the fastest route to a BSN for individuals who already hold a degree. MSN programs also are available for individuals who hold a bachelor’s or higher degree in another field.

Some career paths are open only to nurses with a bachelor’s or master’s degree. A bachelor’s degree often is necessary for administrative positions and is a prerequisite for admission to graduate nursing programs in research, consulting, and teaching, and all four advanced practice nursing specialties—clinical nurse specialists, nurse anesthetists, nurse-midwives, and nurse practitioners. All four advanced practice nursing specialties require at least a master’s degree.

All nursing education programs include classroom instruction and supervised clinical experience in hospitals and other health care facilities. Students take courses in anatomy, physiology, microbiology, chemistry, nutrition, psychology and other behavioral sciences, and nursing. Coursework also includes the liberal arts for ADN and BSN students.

Supervised clinical experience is provided in hospital departments such as pediatrics, psychiatry, maternity, and surgery. A growing number of programs include clinical experience in nursing care facilities, public health departments, home health agencies, and ambulatory clinics.

Licensure and certification
In all States, the District of Columbia, and U.S. territories, students must graduate from an approved nursing program and pass a national licensing examination, known as the Nursing Council Licensure Examination for Registered Nurses (NCLEX-RN) to obtain a nursing license. Nurses may be licensed in more than one State, either by examination or by the endorsement of a license issued by another State. The Nurse Licensure Compact Agreement allows a nurse who is licensed and permanently resides in one of the member States to practice in the other member States without obtaining additional licensure. All States require periodic renewal of licenses, which may require continuing education.

Certification is common, and sometimes required, for the four advanced practice nursing specialties—clinical nurse specialists, nurse anesthetists, nurse-midwives, and nurse practitioners. Upon completion of their educational programs, most advanced practice nurses become nationally certified in their area of specialty. Certification also is available in specialty areas for all nurses. In some States, certification in a specialty is required in order to practice that specialty.

Foreign-educated and foreign-born nurses wishing to work in the United States must obtain a work visa. To obtain the visa, nurses must undergo a federal screening program to ensure that their education and licensure are comparable to that of a U.S. educated nurse, that they have proficiency in written and spoken English, and that they have passed either the Commission on Graduates of Foreign Nursing Schools (CGFNS) Qualifying Examination or the NCLEX-RN. CGFNS administers the VisaScreen Program. (The Commission is an immigration-neutral, nonprofit organization that is recognized internationally as an authority on credentials evaluation in the health care field.)

Nurses educated in Australia, Canada (except Quebec), Ireland, New Zealand, and the United Kingdom, or foreign-born nurses who were educated in the United States, are exempt from the language proficiency testing. In addition to these national requirements, foreign-born nurses must obtain state licensure in order to practice in the United States. Each State has its own requirements for licensure.

Other qualifications
Nurses should be caring, sympathetic, responsible, and detail oriented. They must be able to direct or supervise others, correctly assess patients’ conditions, and determine when consultation is required. They need emotional stability to cope with human suffering, emergencies, and other stresses.

Advancement
Some RNs start their careers as licensed practical nurses or nursing aides, and then go back to school to receive their RN degree. Most RNs begin as staff nurses in hospitals, and with experience and good performance often move to other settings or are promoted to more responsible positions.

In management, nurses can advance from assistant unit manger or head nurse to more senior-level administrative roles of assistant director, director, vice president, or chief nurse. Increasingly, management-level nursing positions require a graduate or an advanced degree in nursing or health services administration. Administrative positions require leadership, communication and negotiation skills, and good judgment.

Some nurses move into the business side of health care. Their nursing expertise and experience on a health care team equip them to manage ambulatory, acute, home-based, and chronic care. Employers—including hospitals, insurance companies, pharmaceutical manufacturers, and managed care organizations, among others—need RNs for health planning and development, marketing, consulting, policy development, and quality assurance. Other nurses work as college and university faculty or conduct research.

Reference:
http://www.bls.gov

What is a Good Hemoglobin and Hematocrit Number?

Hemoglobin
Hemoglobin (Hb or Hgb) is a protein substance in red blood cells. It is composed of iron, which is an oxygen carrier.

Normal Values:
Adult: Male: 13.5 – 18 g/dl; 8.4 – 11.2 mmol/l (SI units); Female: 12 – 15 g/dl; 7.45 – 9.31 mmol/l (SI units)
Child: Newborn: 14-24 g/dl. Infant: 10 -17 g/dl. Child: 11-16 g/dl

Clinical Problems:

Decreased level: anemias, cancers, kidney diseases, excess IV fluids, Hodgkin’s disease

Increase level: Dehydration/hemoconcentration; polycythemia; high altitudes; chronic obstructive lung disease; CHF; severe burns

Hematocrit
The hematocrit (Hct) is the volume of packed red blood cells (RBCs) in 100 ml of blood, expressed as percentage. It is the portion of RBCs to plasma.Hematocrit is approximately three times the hemoglobin value if the hemoglobin is within normal level

Normal Values:
Adult: Male: 40% - 50%, 0.40 – 0.54 (SI units); Female: 36% - 46%, 0.36 – 0.46 (SI units); panic value: less than 15% and greater than 60%
Child: Newborn: 44% - 65%; child: 1-3 years: 29% - 40%; 4-10 years: 31% - 43%

Clinical Problems

Decreased level: Acute blood loss, anemias, leukemias, Hodgkin’s disease, lymphosarcoma, multiple myeloma, chronic renal failure, cirrhosis of the liver, malnutrition, Vitamin B and C defeciencies, pregnancy, systemic lupus erythematosus(SLE), rheumatoid arthritis, peptic ulcer, bone marrow failure.

Increased level: Dehydration/hypovolemia, severe diarrhea, polycythemia vera, diabetic acidosis, pulmonary emphysema (later stage), transient cerebral ischemia (TIA), eclampsia, trauma, surgery, burns.

Reference:
Kee, J. (2009). Prentice Hall Handbook of Laboratory & Diagnostic Tests. 6th ed. Pearson Prentice Hall: New Jersey

Nurse Adventures

Going to sleep at 12 midnight and waking up at quarter after 4 in the morning is the usual occurrence after my bouts of two to three straight nights duty. Having difficulty going to sleep and staying asleep are some of the events that I am going through right now. It's not that I'm having problems to think of that keeps me awake, it's just that my biological clock is so screwed up.

Graveyard duty is fun (for me though). I get to see the change in mentation of my demented patients. Sun down syndrome is the usual scenario during my night duty. However other routines includes preparing the patient to bed, assisting them with their activities of daily living (ADL), cleaning them up - changing their diapers soaked with urine and/or sometimes (most of the time) with feces for the very sick and debilitated patients, turning patients to sides regularly, suctioning copious respiratory secretions, giving night pills and injections and hanging those essential antibiotics and other IV medicines, getting admissions from the emergency department are some of the usual activities that happens during the night shift aside of course from watching those heart rhythms in the telemetry monitors for the whole night.

Night duty can be rough or smooth depending on how you see things. There are many surprises for the whole 12-hour shift. I have to prepare myself and consider every difficulties, pressures, and emergencies as challenges. I always consider those things as an exciting learning experiences - positive thinking that's where my paradigm usually is. I am only human and of course there are instances that get into my nerves but I do not drown myself in it. There are other patients that need me. What keeps me in focus when I feel things is not going right is that I stop and gather myself together then start anew.

Nurses have these strange multiple personalities as we take care of sick persons, we can't be the same person always when we deal with different patients but of course not to the point of being schizophrenic (right?). We deal with them according to their personalities and needs. Most of the time we set aside our own problems and feelings just to take good care of these people. Truly, nurses are compassionate and selfless people.

Taking care of the sick is an opportunity to touch lives. I may not transform them to be a better person but at least I imparted myself to them. Working for me is not always about money, it is also about giving myself and finding meaning in what I am doing.

Going back to my circadian rhythm - I'm not complaining, I'm just trying to share my thoughts with you about what I do and what I enjoyed doing. This is my nurse adventure. I hope you have yours too.

Human Insurance Portability and Accountability Act (HIPAA) on Electronic Records

The section of HIPAA relating to electronic healthcare transaction can be found in Title II, Subtitle F - The administrative simplification provisions of HIPPA. The HIPAA rules issued under the administrative simplification provisions are those pertaining to standards for electronic transmission of healthcare data.

The entities covered by administrative simplification provisions are public or private agencies namely healthcare clearinghouse and health care providers. HIPPA did not define records but define health information instead. Health information is a very broad term that covers any information oral or recorded in any form or medium created by health care agencies and providers. Health information also encompasses the past, present and future physical and mental information about the patient.
Section 1173 under Title II, Subtitle F enables the standard of electronic exchange for financial and administrative transactions. Financial and administrative transactions includes health claims, health claims attachments, enrollment and disenrollment in health plan, eligibility for a health plan, health care payment and remittance advice, health plan premium payments, first report of injury, health claim status, and referral certification and authorization.

HIPAA also calls for a standard in the way health information is transferred and the use of standard codes to identify each disease, illness and other health problems. The purpose of the standard formats and codes is to make communications easier and more cost-effective.

Section 1173 mandated further that clearinghouses and healthcare providers must maintain an appropriate administrative, technical, physical safeguard of health information. HIPAA also directed the above-mentioned entities to ensure the integrity and confidentiality of the health information.

In my personal view, no specific technology is mandated by HIPAA, and it appears to be technology neutral without losing its purpose of protecting health information generated from the patients.


References:
http://aspe.hhs.gov/admnsimp/pl104191.htm#261
http://www.hhs.gov/ocr/hipaa/
http://www.hipaa.org/
https://www.highmark.com/hmk2/about/hipaa/hipaa-detail.shtml
http://www.privacyrights.org/fs/fs8a-hipaa.htm

Health Promotion in Nursing

Health promotion is critical in the nursing profession. In nursing promoting health is discovering the internal motivation of the patient for them to achieve optimal health. Nurses teach patients the importance of daily exercise, proper nutrition, lifestyle modification, and adhering to their daily-prescribed medications. However, health promotion is a complex notion that is open to multiple interpretations by individual patients.

Several factors need to be considered by nurses when imparting health promotion strategies to patients.
1.Acknowledge that individual’s health is not only a personal responsibility because it is largely influenced by physical, social, cultural, and economic environments in which we live and work.
2.Consider that health education is an essential component of health promotion.
3.Know that health promotion are planned activities for the patients and patients needs to be motivated to follow through these plans
4.Consider individual behavior and lifestyle, social and individual determinants, health services, and genetic predispositions as an important factors in planning for health promotion

Nurses who constantly encourages patients to take responsibility of their own health without considering the social and environmental circumstances that contributed for them to become ill is essentially defective. According to the World Health Organization, health promotion is an integral concept for those individuals who acknowledge changing their lifestyle and conditions of living in order to promote health. It is imperative therefore, that nurses approach health promotion using a holistic view of the patient.

The Importance of Chemistry to Nursing

Chemistry is a science that focuses on the composition and properties between a variety of substances and different forms of matter and their interaction with each other. Chemistry is also a physical science that analyzes various atoms, molecules, crystals and other aggregates of matter.

On the other hand, nursing is an art and science. It interplays with other disciplines outside nursing such as social, behavioral, and physical sciences. Nursing, as a profession is unique because it is focus on health promotion, health maintenance, and health problems of individuals and families (Funnel, 2008).

Dissecting the definition of chemistry and nursing will help us realize that indeed the two are interrelated. Take notice that as defined, chemistry focuses on physical science and nursing as a profession derive their practice from physical sciences.
Chemistry in nursing is very important because it will guide the nurses in understanding the medications that he/she is administering to his/her patients.

Having an understanding of chemistry will enable the nurse why medications with the same generic names or within the same classification do not work the same. For example, cephalosporin is one antibiotic classification. Cephalosporins are group of antibiotics that treat a variety of bacterial infections in the human body. However, each drug within the group kills specific bacteria. It is therefore vital for nurses to have the knowledge why specific antibiotics are prescribed by the physician to his/her patient.

Chemistry will also guide the nurse understand the present condition of the patient. Understanding the importance of Sodium (Na), Potassium (K), Chloride (Cl), Bicarbonate (HCO3), Carbon dioxide (CO2), Oxygen (O) and other electrolytes in the body will guide the nurse to identify if his/her patient is experiencing electrolyte imbalance. The nurse must be adept in understanding the concept of fluid and electrolyte imbalance in the human body because patients might be experiencing metabolic and respiratory acidosis or alkalosis while under your care because if you do not have the knowledge about these things,the patient might die under your care.

It is vital for nurses to have the skills to take care of their patient emotionally but it is also important to have the necessary knowledge to interpret data regarding patient condition to treat the physical symptoms accurately.

References:
http://dictionary.reference.com/browse/Chemistry
Funnell, R. (2008).Tabbner's nursing care: theory and practice, 5th edition. Churchill Livingstone: Australia