Friday, April 28, 2006
Act I: The Project
I recently completed a final project in pharmacology. We were assigned in groups and given a MAR (med administration record) listing 10 drug orders. From this list alone we had to figure out the patient's many medical diagnoses, develop a plan of care, and uncover the various mistakes, interactions, and risks associated with the given orders.
It was nightmarish to say the least, but we got it done. Everyone ended up arguing over why the person wasn't on Lasix, and whether we should point out the combination of a "-pril" and a "-tan" as a mistake even though we have seen this combo in the hospital before... well anyway I don't want to get into a bunch of jargon. The list of stuff goes on and on. The point was that it was a freaking hard assignment. The good thing is I really feel like my studies this semester prepared me well.
But there was something Pharmacology didn't prepare me for...
Act II: The Standardized Test
Each semester we are expected to pass a series of ATI Exams before moving on the next level. ATI scores don't affect our grade. They just provide benchmarks to gauge our competency and predict our NCLEX scores. I finished up the Fundamentals exam last week and took the Pharmacology one today. You only have to make a 65% to pass (which may seem low until you consider the fact that the national average is only 63%).
I took a few practice tests to warm up. Scored in the high 70s, so I figured I was safe. Even when I missed a question on the practice test, my second choice was usually right. I waited outside the computer lab with confidence...
...until student after student came out looking dismayed. "Failed it by one question" they'd say. Ack! Apparently the class was right on par with the national average. When I finally logged in and began my own test, I had that sinking feeling of impending doom. I had never even heard the names of several of the medications before. I guessed many, MANY times at the answers. The proctor caught my expression and came over to pat me on the back. "Take your time, Heather! Everything will be okay."
I looked up at her sadly as I hit the score button. "I know I did horribly. I was only certain of about 10 of those answers". She glanced down at the screen and made a noise of delight, and my eyes followed hers. I'd made an 80%. Apparently it was one of the highest scores in the class.
After the initial shock my first reaction was anger. "This is stupid!" I said. "There is no way this is an accurate score of my ability! There is no way this will indicate my success rate on the NCLEX! I guessed on almost everything!"
"Maybe you're a really good guesser then. It's impossible to know the effects of all the drugs. You've learned HOW to think about them this semester, so you can apply it to the others."
"No. That's not good enough." I said. And it's true; we're dealing with people's lives here. I need to know what side effects go with these medications. I know I can't expect to learn it all immediately, but damn it, I don't want to make a "good guess" about toxicity symptoms. I want to have time to learn it now. But there isn't time.
She was unphased. "You know best what you need to study. Do that, and don't worry about it."
So I guess I won't worry about it. Still makes me angry though. That test is flawed. A big mistake.
But not as big a mistake as my last story...
Act III: The Shirt
My friend Meredith and her girlfriend Cris have started making tie-dye. Anytime Meredith gets excited over something cool she HAS to share it with people, so on the last day of clinicals Meredith brought her latest tie-dye shirt for our inspection. She described the process of creating the tiny folds just so in order to make the intricate zig-zag pattern across the front. She spent days on it. It was a cool shirt, as tie-dye shirts go. We were all proud.
We took Instructor Sarcastic (also known as Instructor Incredible) out for lunch on the last day of clinicals. We gave her some gifts and a card to let her know we appreciated her teaching. I made her this little picture and all of us signed it:
(Everyone thought it was cute. I might use something like it for SNA shirts next year. What do you think?)
But anyway, back to the story:
Meredith wanted to show off her tie-dyed shirt, so she held it up for our instructor to see. Instructor Incredible smiled with delight. "Oh! Thank you!" she said.
What a sad misunderstanding! I could see Meredith's face fall as she realized that she wasn't getting her shirt back. Everyone at the table got big eyes and looked over at her. No one knew what to say. Of course, it wasn't exactly the best timing on her part. And she has a way of handing things to people that somehow conveys a finality... but still! Her pride and joy, mistakenly gifted away. I don't think she even got to wear it once. Instructor Incredible, on the other hand was thrilled. She pulled it over her head immediately and praised it and profusely.
Meredith has a really sweet heart, she just smiled and said "You're welcome"... and let it go. There will be others, after all. Later, when I asked her how her day was, she looked at me flatly. "I lost a shirt."
"Look on the bright side," the others intoned. "Maybe this will help your clinical grade a little?"
The lesson of all this kids? Study hard, study hard, and keep smiling.
Good luck on your finals everyone!
Monday, April 24, 2006
This conference focuses on information technology trends and issues facing the nursing professional and provides a comprehensive examination of nursing informatics theories, systems analysis and the impact of human factors. As the use of computers in healthcare becomes increasingly critical, it is essential to provide nurses with skills and knowledge in information management. Please click here for the brochure/registration http://www.ania.org .(scroll down home page for brochure) For more information, please contact Linda Privette at Linda.Privette@stjoe.org or 714/771-8000, ext. 2698.
Monday, April 17, 2006
Nursing Evidence-based Projects
1. Assessment of community based smoking/tobacco cessation training program for healthcare professionals
Investigators: Tim Chen, PharmD; Pamela Matten R.N., O.C.N.; Siu-fun Wong, PharmD
Purpose: To determine the effectiveness of a community based tobacco cessation training program for healthcare professionals.
Methods: Rx for Change: Clinician-Assisted Tobacco Cessation is a 7-8 hr tobacco cessation training program designed for use in pharmacy schools. Using the basis of Rx for Change, a 3-hour modified multidisciplinary program, incorporating 2-hour lecture-based module (behavioral counseling and pharmacotherapy) and 1-hour interactive session with role-playing, will be held 3 times per year. Initial program participants will be inpatient nurses. Due to the nature of the nurses’ patient contact, the program will emphasize on first 4 of the 5A’s (Ask, Advise, Assess, Assist, Arrange). Outcomes research evaluating the effectiveness of the training program will be conducted using pre, post, and follow-up surveys at 3, 6, and 12 month.
2. Time and motion study to evaluate the costs of cardioversion for atrial fibrillation
Investigators: Suzanne A. Feigofsky, MD; Donald J. Mahon, MD; Warren D. Johnston, MD; Tyson Cobb, MD; Thomas Kim, MD; Mila Garcia, NP; Beverly Niemeyer, RN
Purpose: The goals of this study are to quantify costs of both direct current cardioversion and pharmacologic cardioversion for treating atrial fibrillation and to evaluate the responsiveness of two new questionnaires to assess the symptoms and health-related quality of life impact of atrial fibrillation.
3. Oral care attitudes in ICU nurses
Investigator: Dana Rutledge, RN, PhD
Purpose: To obtain information about current oral care practice; oral care training; and nurses’ attitudes related to oral care in intensive care unit.
Methods: This comparative pre/post study aims to describe oral care practices, training, and nurses’ attitudes along with VAP rates before and after the implementation of an evidence-based oral care protocol in intensive care units (ICU) at a community hospital. The research sample consists of RNs working the intensive care units (ICU). Nurses will be evaluated for attitudes and knowledge about oral care before and after a change in oral care practices. VAP rates in ICUs 3 months prior to an oral care protocol change and those 3 months after will be compared.
4. Examining the factor that influence males decisions to choose nursing as a career
Investigator: Sabrina Valentine, RN, BSN
Purpose: To explore the factors that influence men to enter nursing as a
5. Knowledge and attitudes assessment toward pain management of registered nurses at St. Joseph Hospital
Investigators: Maureen Mikuleky, RN; Dana Rutledge, RN, PhD; Carmen Belasario, RN; Shivi Dixit, RN, BSN
Purpose: To determine the current knowledge and attitudes of St. Joseph Hospital registered nurses by shift and department. Based upon the unit-based knowledge and attitudes, to develop and implement unit-specific educational interventions, and then, reevaluate unit-based knowledge and attitudes toward pain management.
6. Presenting symptoms for acute coronary syndrome study
Investigators: Beth Winokur, RN, MSN, CEN; Joseph Barrea, RN, BSN; Amy Waunch, RN, MSN, CEN; John Senteno, RN, BSN
Purpose: To describe presenting symptoms of patients with acute coronary syndrome (ACS) admitted to the emergency department, and to describe symptoms by sex and by ethnic groups. Also, to determine if patients with ACS who desire interviews in a language other than English differ in the symptoms reported on 2nd (non-initial) interview done by a person speaking the patient’s language.
7. CalNOC Partners for Quality TRIP to Reduce Hospital Falls
Investigators: Kathleen Penzes, R.N.
(Include in summary – no info in IRB other than policies)
8. Clinical Narratives: Evaluation for Components of Caring
Investigators: Dana Rutledge, PhD, RN
Purpose: To analyze clinical narratives written by nurses at St. Joseph Hospital.
Methods: This descriptive study aims to analyze clinical narratives written by nurses at St. Joseph Hospital in order to determine the following questions.
1. What types of patient care experiences do nurses consider as “a clinical experience that reflects an incident in which they feel their intervention or their relationship with their patient made a difference “?
2. To what extent do the narrative experiences describe specific caring behaviors by nurses (e.g., spending time with the patient, being hopeful for the patient)?
3. To what extent are the five dimensions of Watson’s Theory of Caring reflected in the narratives?
4. Do narratives of nurses who are less experienced (new graduates or orientees) differ in terms of the caring dimensions than are narratives of experienced nurses at St. Joseph Hospital?
5. If a difference is present, does the magnitude of the difference change over time (as the Watson Model is incorporated into care at St. Joseph Hospital)?
9. Emergency Department Pediatric Temperature Study
Investigators:Amy Waunch, MSN, CEN, FNP, Michael Vicioso, RN; Christine Marshall, RN, MSN, Beth Winokur, RN, MS, CEN
Purpose: To compare temple thermometer readings in emergency department patients 17 and younger with oral, rectal, and axillary temperature. A study sub-aim is: Inpatients who have received antipyretics, to evaluate the presence of a “lag” in any temperature measure (oral, rectal, axillary, temporal) compared to the others due to physiologic responses to the antipyretic.
Design: A correlational comparative study is proposed.
Sample: In the SJH ED, 300 pediatric patients 4 – 17 years of age (Group 2) and 300 infants and children less than 4 years (Group 1) will be invited to join the study. In order to gain maximal variability in temperature, children most likely to have fever will be preferentially recruited.
10. Patients on 96hrs Continuous Ventilation in ICU: Improving Interdisciplinary Communication and Ethical Decision Making
Investigators: Carmen Ferrell, RN, MS
Purpose: To determine the effects of early ethics interventions in intensive care patients on the ventilator 96 continuous hours on improved team communication and decision making in accord with patient preferences.
Methods: SJH intensive care units will be part of a St. Joseph Health System project to determine the effects of a chaplain/nurse proactive ethics consultancy for patients who have been on 96 hours of continuous ventilation.
Sample: ICU patients who have been ventilated for 96 hours
Setting: All SJH intensive care units (medical, coronary care unit, cardiovascular ICU)
Design: Pre/post evaluation of chart audits on measures to include demographic data (age, ethnicity, race, religion, admitting diagnosis, discharge diagnosis), cost parameters (ventilator days, ICU days, total LOS), issues and decisions communicated and documented.
Intervention: Proactive ethics consultation will occur during daily ICU rounds and will be led by either a chaplain, or Carmen Ferrell, a nursing director. The consultation will occur following chart review that explores the following 7 questions:
• Has the patient created or expressed any directions with respect to treatment?
• Is the patient currently competent?
• Is the patient, the whole team and the family aware of patient’s current diagnosis, prognosis, treatment objectives and alternatives?
• Do any treating physicians anticipate hurdles to recovery. What are they and what are the indicators of response to treatment.
• Is there any discussion or concerns about the limits of treatment for this patient?
• Are the ethical issues identified and understood in the Ready Reference Grid?
• Are there any unaddressed issues regarding patient care, management, patient preferences, or communication?
During rounds, the consultants will raise issues arising in conversations about issues arising from the above questions. These consultants will facilitate ethics discussion on issues arising from the questions. They will assist in the decision making process and bring to the surface difficult questions. If a difficult care dilemma is not easily resolved, the consultants will follow standard protocols per SJH (e.g., palliative care consult), and if necessary, obtain formal consultation through the ethics consultation (ACES) This is the end of the consultation.
Issues raised, discussion ensuing, and outcomes will be charted in the progress notes of the patient record. The attending physician will document necessary decisions/orders.
The intervention will last for 3 months.
11. Conference – October 13, 2006
“Pain Solutions Evidence-based Approaches to the Care of Persons Experiencing Pain”
Conference committee: Dana Rutledge, Peggy Walsh, Geri Westad, Pati Hagen, Pam Riley, Peggy Delmastro, Meri Van Gordon, Shivi Dixit, April Beachler, Vivian Norman, Nickol Frantzich, Mary Welly, Melissa Ogata, Jill Donaldson (Mission Hospital), Gloria Franklin (St. Jude Medical Center), Karen Savage.
· Discuss the relationship of scientific evidence to clinical recommendations in pain management
· Describe clinical issues and initiatives related to pain management
· Apply evidence in discussions with clinical cases
Wednesday, April 12, 2006
Iowa City, Iowa, September 20-22, 2006 will be the site of the next Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice. This program, developed by Marita G. Titler, PhD, RN, FAAN and Laura Cullen, RN, MA, has a small-group focus, is customized to meet individual needs, and is for nurses in leadership positions who are responsible for promoting EBP within their organizations.
Offered by the Department of Nursing Services and Patient Care at the University of Iowa Hospitals and Clinics since 2002, this Institute repeatedly generates positive comments like, "Great, usable workshop"; "This was the best group I have been involved with for a long time"; "Fabulous!"; "So impressed with the scheduling and program".
For more information or brochure http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/apinstitute.html
Grace Rempel, Clerk
Nursing Research, Quality and Outcomes Management
University of Iowa Hospitals and Clinics
200 Hawkins Drive, T-100 GH
Iowa City, IA 52242-1009
Friday, April 7, 2006
This controversial study should generate some great blogging!!
An Evidence Based Approach to the
Care of the Psychiatric Patient
This 4-hour class will examine psychiatric patient care issues concerning mood disorders, schizophrenia and agitation. Through the use of interactive lecture and case studies, the participant will be introduced to evidence based treatment modalities that are applicable to care issues in BHS, the Emergency Department, and the Critical Care and Medical/Surgical Units. Class content is appropriate for healthcare providers, specifically those with RN, MFT or LCSW Certification and in Spiritual Care.
Upon successful completion of the course, the participants should be able to:
Describe the presentation of patients in the depressed and manic phases of mood disorders.
Outline appropriate in hospital management for schizophrenic patients.
Evaluate treatment plans for patients with a history of aggressive behavior.
Himasiri DeSilva, MD
Vinayak Shanbhag, MD
Michael Wu, MD
Shelly Aguilar, RNC
Jeannine Loucks, RNC
Christine Pierce, RNC
Beth Winokur, RN, MSN, CEN
Linda Winston, MFT, CEAP
May 3, 2006
(8:00 am-12:00 pm)
St. Joseph Hospital, Orange, California
$15 refundable registration fee for SJHS Staff. All others $40.
Provider approved by the California Board of Registered Nursing, Provider Number 00156. Four (4) Contact Hours will be given for this course. Administrator of the CE Program is Patti Aubé, RN, MSN. The California LVN Board will accept credits that have been approved by the California BRN.
This course has been approved by the California Board of Behavioral Examiners PCE Number 1276.
Registration For: Evidence Based Approach to Psychiatric Care – May 3, 2006
All participants should make their checks payable to St. Joseph Hospital Department of Clinical Education, and mail them along with the above registration form to 1100 West Stewart Drive, Orange, California 92868. Refunds will be given if the request is received prior to the start of the course. No refunds will be given after the course has started. A refundable $15 registration is required for all St. Joseph Hospital, CHOC, and St. Joseph Health System employees. Refunds will be given upon completion of the class.
Wednesday, April 5, 2006
Evidence-Based Approaches to the
Care of Persons Experiencing Pain
October 13, 2006
7:30am to 4:30pm
Kathleen Puntillo, RN, DNSc, FAAN
For more information or to receive a brochure, please contact St. Joseph Hospital's
Clinical Education Department at 714/771-8000, ext 7495
or email Cheri.Cancelliere@stjoe.org