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June • 2015
June-July 2015 • Volume 26, Number 6
Nursingmatters www.nursingmattersonline.com
INSIDE: Population is your patient
3
2014 Wisconsin RN Survey Report
7
The Finish Line
PAID
MADISON WI PERMIT NO. 1723
PRST STD US POSTAGE
10
Evidence: The Ultimate Game Changer
T
he nursing profession is comprised of the largest group of clinicians participating in the delivery of healthcare in this country. Numbering more than 3 million, nurses are the largest sector of the health professions. Nursing is practiced in virtually every setting in which healthcare is delivered, from the home, to hospitals, clinics, nursing homes and hospices, to name a number of the most common. Though nursing care has been, or will be, experienced by everyone at some stage of life, it is ironic that the work of the profession is poorly understood by those who are recipients of its services, colleagues in other clinical disciplines and those who administer healthcare organizations. Nursing has not clearly communicated the nature of its work to its publics. It has also been less effective than it must be in assuming ownership of all of the accountabilities that comprise any clinical profession including defining practice, managing quality, assuring competence, generating and validating the knowledge base of the discipline and managing the resources essential to the work. The result has been detrimental to the care of patients across the country in many settings, but nowhere more acutely than in hospitals. Since the early 1980s, the pressure of declining reimbursement to hospitals has resulted in decisions related to nurse staffing that have at times created unworkable and even unsafe, practice environments. The Institute of Medicine Report on the Future of Nursing identifies that high turnover rates among new nurses continues to be a concern. Nurses, disenchanted with practice environments that do not support excellence, and may even pose risks to patient safety, have left those settings. Nurses are knowledge workers. While much of what nurses do in the form of tasks is observable, such as administering medication, teaching a patient, or changing a dressing on a wound, the essence of nursing practice is not. Nurses, in caring for patients, are engaged in a continuous process of interpreting a broad array of objective and subjective information. The information is gathered through a variety of means including observation,
JOAN ELLIS BEGLINGER MSN, RN, MBA, FACHE, FAAN physical examination, conversing with the patient and/or family and review of diagnostic test results. Nurses interpret and assign meaning to the information by drawing on a vast knowledge base from the physical and social sciences, liberal arts, practice wisdom and intuition. They make judgments about the significance of the information and decisions concerning appropriate intervention. Continuous evaluation of practice interventions for desired outcomes rounds out what has come to be known as “nursing process.” Effective nursing practice is dependent upon the nurse’s ability to know the patient’s “story,” including pertinent history, co-morbidities, present illness, culture/beliefs, family support, education and any compounding variables that might impact his/her interpretation of the patient situation. Subtle changes in a patient, which may precede a significant change in condition, can only be noted if the nurse has the opportunity to remain in adequate contact with the patient. Research has demonstrated that the expert nurse can often intuitively detect deterioration in a patient’s condition before there are any objective findings to support that conclusion. Further, studies have shown that an assignment of too great a number of patients to a nurse may result in “failure to rescue”, that is, impending signs of patient deterioration are missed because of inadequate opportunity to observe the patient first hand. Research continues to contribute to the growing, and irrefutable, body
Effective nursing practice is dependent upon the nurse’s ability to know the patient’s “story,” including pertinent history, co-morbidities, present illness, culture/beliefs, family support, education and any compounding variables that might impact his/her interpretation of the patient situation. of evidence that patient outcomes are improved with increased RN staffing, positive practice environments and greater percentages of BSN prepared nurses. The Principles and Elements of a Healthful Practice/Work Environment, developed by the American Organization of Nurse Executives in 2004, supports the presence of adequate numbers of qualified nurses as important to the provision of quality care to meet the patient’s needs. In the absence of research-based evidence to guide us, decisions about “adequate numbers of qualified nurses” have historically been largely opinion-based. As we move forward, these methods must be replaced by decisions based on best available evidence. In 2005, the Wisconsin Organization of Nurse Executives published its first evidence-based position paper on nurse staffing entitled Guiding Principles in Determining Appropriate Nurse Staffing: Standards of Practice for Acute Care in the State of Wisconsin. The Standards were developed to reflect the best available evidence and the process involved eliciting input on the draft document from all Wisconsin Organization of Nurse Executives members, as well as support from the Wisconsin Nurses Association. SEE EVIDENCE, Page 3
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Catch the wind Nursingmatters is published monthly by Capital Newspapers. Editorial and business offices are located at 1901 Fish Hatchery Road, Madison, WI 53713 FAX 608-250-4155 Send change of address information to: Nursingmatters 1901 Fish Hatchery Rd. Madison, WI 53713 Editor .......................................... Kaye Lillesand, MSN 608-222-4774 • kayelillesand@gmail.com Managing Editor .................................. Julie Belschner 608-250-4320 • jbelschner@madison.com Advertising Representative...................Andrew Butzine 608-252-6263 • abutzine@madison.com Recruitment Sales Manager ......................Sheryl Barry 608-252-6379 • sbarry@madison.com Art Director ..........................................Wendy McClure 608-252-6267 • wmcclure@madison.com Publications Division Manager ................. Matt Meyers 608-252-6235 • mmeyers@madison.com Nursingmatters is dedicated to supporting and fostering the growth of professional nursing. Your comments are encouraged and appreciated. Email editorial submissions to klillesand@sbcglobal.net. Call 608-252-6264 for advertising rates. Every precaution is taken to ensure accuracy, but the publisher cannot accept responsibility for the correctness or accuracy of information herein or for any opinion expressed. The publisher will return material submitted when requested; however, we cannot guarantee the safety of artwork, photographs or manuscripts while in transit or while in our possession.
EDITORIAL BOARD Vivien DeBack, RN, Ph.D., Emeritus Nurse Consultant Empowering Change, Greenfield, WI Bonnie Allbaugh, RN, MSN Madison, WI Cathy Andrews, Ph.D., RN Associate Professor (Retired) Edgewood College, Madison, WI Kristin Baird, RN, BSN, MSH President Baird Consulting, Inc., Fort Atkinson, WI Joyce Berning, BSN Mineral Point, WI Mary Greeneway, BSN, RN-BC Clinical Education Coordinator Aurora Medical Center, Manitowoc County Mary LaBelle, RN Staff Nurse Froedtert Memorial Lutheran Hospital Milwaukee, WI Cynthia Wheeler Retired NURSINGmatters Advertising Executive, Madison, WI Deanna Blanchard, MSN Nursing Education Specialist at UW Health Oregon, WI Claire Meisenheimer, RN, Ph.D. Professor, UW-Oshkosh College of Nursing Oshkosh, WI Steve Ohly, ANP Community Health Program Manager St. Lukes Madison Street Outreach Clinic Milwaukee, WI Joyce Smith, RN, CFNP Family Nurse Practitioner Marshfield Clinic, Riverview Center Eau Claire, WI Karen Witt, RN, MSN Associate Professor UW-Eau Claire School of Nursing, Eau Claire, WI © 2015 Capital Newspapers
I grew up on a small inland lake where my father taught me how to sail. I remember there were different rules for different wind conditions. In light winds we kept the sails pretty tight and watched the surface of the water for tiny ripples so we could catch the wind. When there was a strong wind, we let the sails out and climbed out onto the running boards to prevent tipping over. Going downwind with the wind at our back was really exciting in a strong wind and deadly boring in a light wind. Again there were techniques
to help win the race. In a light wind you hardly moved a muscle so as not to rock the boat. In a heavy wind, you “threw” a spinnaker to take advantage of the wind. As I grew older, I realized Dad had actually taught me how to live my life. Living your life is like sailing a boat. You set a course, assess the weather conditions, make a plan and adjust as necessary to win the race. Jimmy Dean said it perfectly, “I can’t change the direction of the wind, but I can adjust my sails to always reach my destination.”
KAYE LILLESAND NURSINGMATTERS EDITOR
Have we forgotten what optimal health looks like?
I
think nursing schools do a wonderful job of instilling the vision of nursing. Nurses are the gatekeepers, the eyes and ears that see, hear, and assess what is going on with our patients. We are at the patient’s bedside when the physicians and primary-care providers are analyzing and interpreting results, and engineering the best course of action. We hold our patient’s hand, we listen to his or her fears, and we translate concerns to the doctor. We also have the critical thinking and technical skills to determine when a patient is in trouble. We often have the opportunity to hear what is in a patient’s heart and soul. We develop a broad base of skills and have the ability to use all our talents. Unfortunately in the crunch of modern healthcare, when I am taking care of my patients, the compassion of nursing often is pushed aside for the technical aspects and I find myself focusing on their Pneumonia and Dehydration. My job description requires I focus on the details of their medications, diet, bowel movements, intake and output, and vital signs. I pass medications, do treatments and chart. I look for treads to determine if my patient is improving or declining. I focus on preparing them for discharge. What if I am so caught up in the war of fighting disease, infection, cancer and pain that I have lost sight of what I am fighting for? What if I have spent so much time taking care of the details, that I have facilitated diminishing the life of the whole organism I am fighting for? What if we have forgotten what
BRENDA ZARTH WHAT IF ... Optimal Health looks like? What if, as healthcare providers we change our focus from treating those who are sick, to helping our patients and families be well? I’m talking about shifting our perspective. What does health look like? After all, if you don’t have a clear definition of health, how can you work toward achieving it? My definition of Health: Healthy is waking up in the morning feeling refreshed, having the physical energy and clarity of thought to easily get through an eight-hour day. Health is fluid movement, and freedom to focus on tasks and events around us. Health is having the power to dream and the imagination to accomplish those dreams. Health is feeling strong enough to see life as an obstacle course full of challenges but knowing we have the strength and endurance to tackle them because we are surrounded by family and friends who have been there and can
advise us when needed. Life is a team sport and we are all in this together. Health is fueling our bodies with healthy foods. Eating and digesting, deriving satisfaction from the taste and wholesomeness from what we put in our bodies, deriving strength and sustenance. A healthy body digests a wholesome meal in three to 12 hours and eliminates the byproducts. A healthy person is composed of approximately 85 percent water and hydrated well enough that what comes out looks like clear water. Healthy is understanding that everything that touches us has the potential to leave an imprint. What we put in our minds, in our mouth, and on our skin matters because we can internalize it. Treat your body with value and respect. Returning to nurses as being the Gatekeepers, I see Nurse Case Managers as having the ability to look at the whole picture. With education on all aspects of health and wellness, we have the insight and knowledge to work with our patients to achieve optimum health. We can direct patients through all healthcare services and resources to achieve Optimum Health. All we need is to learn what additional resources we have available to us and how and when to use them. What Case Management, Alternative Medicine, Integrative Medicine, and Complementary Medicine Resources do you use? Please email me at BrendaZarth@gmail. com or comment on my blog brendashealthplan.blogspot.com to tell me your thoughts.
Healthy is waking up in the morning feeling refreshed, having the physical energy and clarity of thought to easily get through an eight-hour day. Health is fluid movement, and freedom to focus on tasks and events around us. Health is having the power to dream and the imagination to accomplish those dreams.
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June-July • 2015
Population is your patient Prevention is your intervention
Do you want to impact the health of an entire community? Are you interested in promoting health and wellness, and preventing disease before it starts? Does it appeal to you to work collaboratively with other professionals and citizens in your community to create upstream intervention strategies that decrease the most common causes of injury? If so, have you considered working as a public health nurse at your local or state health department? Although most people think of nurses caring for individuals, the American Nurses Association points out that public health nursing “focuses on population
health through continuous surveillance and assessment of the multiple determinants of health with the intent to promote health and wellness; prevent disease, disability, and premature death; and improve neighborhood quality of life.” Hence, clients of public health include not only individuals, but also communities and systems, from a population perspective, as public health nurses carry out the core public health functions of assessment, assurance, and policy development. Instead of assessing the health status of individuals, public health nurses conduct a health assessment of the entire population. They gather and analyze quantitative epidemiological data on the most common causes of illness, injury, disease and death in the community, as well as qualitative data obtained through interviews, focus groups, and surveys, in order
EVIDENCE Continued from Page 1 In 2014, one of the strategic priorities identified by the Wisconsin Organization of Nurse Executives Board of Directors was to “broadly disseminate the evidence that links nurse staffing, practice environments and education levels to patient outcomes.” There has been significant research conducted and published in recent years that has provided the much needed evidence to take us from opinion-based to evidence-based staffing decisions. The 2010 report from the Institute of Medicine on the Future of Nursing creates additional urgency to ensure that nurses are well positioned to “lead change to advance health.” The staffing standards, first published in 2005, have been revised to reflect contemporary understandings of the relationships of nurse staffing, practice environments and BSN preparation to patient outcomes. Current evidence requires that we expand our understanding of excellence in staffing to a holistic and systemic approach that encompasses the downstream outcomes and sustainability of staffing decisions. The title of the document has been changed to both “raise the bar” by articulating “excellence” as the desired outcome – as opposed to “appropriate” – and expand the use of the standards beyond acute care to every setting in which nursing is practiced. The title of the 2015 revision is Guiding Principles in Achieving Excellence in Nurse Staffing: Standards of Practice for the State of Wisconsin. The Standards have now been finalized and are available on the Wisconsin Organization of Nurse Executives website at
w-one.org located under “Publications/ Position Papers. In 2015, the Wisconsin Organization of Nurse Executives is developing a tool kit of resources to assist nurse leaders, who are charged with managing staffing budgets, in advancing evidence-based staffing decisions within their organizations. In order for healthcare organizations to be positioned to produce exceptional outcomes and experience for those who are served, it is critical that they make the shift from opinion to evidence in management decision-making. Note: Portions of this article are taken from the “Guiding Principles for Achieving Excellence in Nurse Staffing: Standards of Practice for the State of Wisconsin” with permission from the Wisconsin Organization of Nurse Executives. Joan Ellis Beglinger has practiced for 28 years as a tertiary medical center vice president/ CNO, building expertise in transforming the professional practice environment from traditional hierarchy to shared decision making through shared governance. She is a champion of advancing the profession of nursing through investment in the direct care nurse, enabling ownership of practice at the point of care. Beglinger has spoken extensively both nationally and internationally. She authors a quarterly Department in the Journal of Nursing Administration. Her numerous presentations and publications have focused on the development of an organizational culture that supports clinical excellence. Joan is a Fellow in the American College of Healthcare Executives and in the American Academy of Nursing and is the 2015 President-Elect of the Wisconsin Organization of Nurse Executives.
to capture the community’s subjective opinion regarding the most salient health needs. Public health nurses may also drive through neighborhood streets to see the community from a different lens by capturing findings in a photographic portfolio. In addition, underserved populations, health disparities, community strengths and resources are also analyzed. SEE BAILEY, Page 4
MICHELLE BAILEY MSN, RN, PUBLIC HEALTH NURSE CONSULTANT, WISCONSIN DEPARTMENT OF HEALTH SERVICES
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June-July • 2015
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Nursingmatters
Madison VA Graduate Nurse Resident Program: Capturing the heart of veteran care Linda Hohneke MSN, RN, NE-BC
Learning to communicate with present-day veterans are, left to right: Ron Bettencourt, Molly Dittberner, Sean Richter, Megan Pollard and Kelli McSherry.
Healing occurs when engagement happens – when the nurse at the bedside reaches through the fog of anonymity, chaos and pain to connect. At the WM. S. Middleton Memorial Veteran Hospital, the graduate nurse resident program utilizes a variety of strategies to engage the novice nurse resident in the shared value of honoring our Nation’s veterans. As one might
expect, the program utilizes many education strategies to enhance nurse resident job knowledge and technical skill. However, job knowledge and technical skill is not enough to meet veteran culture today. “Today’s returning veteran population is in need of unique, culturally appropriate interventions to improve motivation to access health care.” (Brown 2009). SEE VETERANS, Page 5
BAILEY Continued from Page 3 Based upon the assessment findings, population health priorities are addressed through identification, implementation, and evaluation of universal and targeted evidence-based programs and services that provide primary, secondary, and tertiary preventive interventions. Health promotion is primary prevention, early detection and treatment of health problems is secondary prevention, and minimizing the effects of health problems is
tertiary prevention. Public health nurses conduct all three levels of prevention with individuals, communities and systems from a population-based perspective. For example, attempting to change the attitudes or behaviors of the entire community or a target group within the community, such as a public health nurse leading a suicide prevention coalition to educate teachers on how to ask teens about suicidal thoughts, is prevention at the community level. Public health nurses partnering with early childhood teachers
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to ensure all developmental screenings done by any provider in the community are conducted according to the American Academy of Pediatrics guidelines is an example of system-focused practice because the intent is to change practices or policies of the system. Public health nurses direct interventions towards individuals when those individuals belong to an at-risk population and the larger goal is to improve the health of that entire population or sub-population. For example, some public health nurses provide one-on-one interventions when teaching new mothers safe infant sleep practices in order to reduce the rate of sudden infant deaths in the infant population as a whole. Despite the wide variety of roles public health nurses serve, they are not responsible for providing all the services and interventions identified to address the top health priorities in a community. Instead, they assure that programs and services are reasonably available and accessible to residents. When services are not available and community partners are not able to provide services, then public health nurses may provide those direct client services until that specific system of care can be created within the community. In the past, public health nurses administered immunizations, birth control, or well child physical exams, but over the past few decades, these services have been transitioning to medical providers as health insurance coverage has expanded. Therefore, public health nurses provide additional prevention services to address these issues and the underlying contributing health factors. For example, public health nurses may coordinate with local transportation services to ensure that bus routes to clinics are accessible to parents who cite lack of transportation as a reason their children are behind in immunizations. Public health nurses also have roles related to policy development, the third core function of public health. This
includes working with local government officials to create ordinances to address issues within the community, such as sanitation issues, exposure to tobacco products, and ownership of domestic and exotic pets. In addition, public health nurses may collaborate with mapping specialists to visually show the impact of health issues within their jurisdiction to legislators. Public health nurses may execute the core functions, provide statutorily required services, and coordinate prevention activities as a staff nurse, nurse manager or health officer of a jurisdiction. Opportunities also exist for nurses at the state health department where the entire population of Wisconsin is your client and the health assessment reflects the overall health status of all citizens in the state. Healthiest Wisconsin 2020, the state health improvement plan, strives to “improve health across the life span, and eliminate health disparities and achieve health equity.” Nurses at the state level work in areas such as immunization, chronic disease, or communicable disease to address priority needs to help improve health and quality of life in Wisconsin. Some state public health nurses are consultants who provide support and technical assistance regarding standards of practice, accreditation, and evidence-based practice to local health departments. In addition, administrative and management positions are available at the state health department for nurses. If you are a new nursing graduate or are a seasoned nurse who wants to provide prevention services at the population level, numerous opportunities await you. Local and state health departments, as chief health strategists in their communities, offer a variety of roles for nurses. Nurses’ responsibilities vary between health departments depending upon the needs of the community, resources available, and continually evolving health care policy, but the primary patient is always the population and the primary intervention is always prevention.
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June-July • 2015
VETERANS Continued from Page 4 To capture the heart of veteran care, the nurse resident must learn to connect with the veteran strategically, in terms of life stages, psychosocial and re-integration needs. As the director of the Nurse Resident Program and the wife of a Vietnam Marine veteran, I understand how to help residents connect with this military era. In terms of life stages, this era is nearing retirement, enjoying family and dealing with declining health due to aging. Yet, how do I help the resident connect to today’s returning population? I turned to Jeff Johnson and Jay White, experts in the Operation Enduring Freedom, Operation Iraqi Freedom and Operation New Dawn programs at Madison Veteran’s Administration. Johnson, a retired Marine Master Sergeant, serves as Transition Patient Advocate for the teams at the Madison and Tomah VA medical centers. Johnson entered the Marine Corps in 1982 and was assigned to artillery units in the 1st and 3rd Marine Divisions. He assists severely wounded service members of the Marine Corps Wounded War Regiment. As a veteran and parent of two Marine combat veterans, Johnson has a unique understanding of the challenges that our most recent combat veterans face when they return from war. White, a social worker twice deployed to Iraq, served as squad leader and platoon sergeant for the 83rd Amy Reserve Combat Stress Control unit. His role was to ensure mental-health care was available in the most acute situations. In Madison, White serves as the program manager. He is the son of a Vietnam veteran and has served as a member of the VA’s Special Committee on Post Traumatic Stress Disorder, which recommended initiatives to the VA Undersecretary of Health. SEE VETERANS, Page 6
Nursing residents learn what it means to carry a soldier’s pack; left to right, 1st Sgt. Tim LaSage, Sean Richter RN, Gunnery Sgt. Michael Gillitzer and Ashley Lochner RN.
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June-July • 2015
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Nursingmatters
Helen Denne Schulte: 1889-1971 Signe Cooper
Helen Denne Cooper founded the School of Nursing at the University of Wisconsin — now the University of Wisconsin-Madison. It was the first collegiate nursing program in the state and among the earliest in the nation. Born in Peterborough, Ontario, Canada, Schulte received her BA in 1911 from Queen’s University in Kingston, Ontario. She then enrolled in the nursing program at the Presbyterian Hospital in Chicago, receiving her diploma in 1915. From July 1918 to July 1919, she served in Canada and Great Britain as a nursing sister with the Canadian Overseas Expeditionary Force. For her outstanding military service, Queen Mary of Great Britain presented Schulte with the Order of the Royal Red Cross, a medal established
VETERANS Continued from Page 5 During the first session, Johnson enlisted support from two “brothers in arms” to help with providing nurse residents a realistic portrait of today’s Iraq veterans — Gunnery Sergeant Michael
by Queen Victoria in 1883. At the end of the war, Schulte returned to Chicago and worked for several years at the Presbyterian Hospital before being invited to start school at the university. As was the usual practice at the time, she served as both the Superintendent of Nurses at the new Wisconsin General Hospital — now University Hospital — and as director of the School of Nursing. The first students were accepted in the fall of 1924. Students had a choice between two curricula — a three-year program leading to a certificate of graduate nurse or a fiveyear program granting a BS degree. Schulte was convinced that the university setting provided the sound academic basis essential for both programs. Although the nursing content in the early collegiate program did not deviate substantially from traditional
Gillitzer — now a reservist — and 1st Sergeant Tim LaSage, active duty, wounded twice. The nurse residents enjoyed lunch on their veteran colleagues: Meals Ready to Eat. None of the 24 participants had ever enjoyed the “fine cuisine” before and were impressed with the high calorie and salt count! While dining, Johnson provided an overview of the war eras and then
Assistant Professor of Nursing The Henry Predolin School of Nursing at Edgewood College announces the opening for two full-time tenure track faculty positions beginning with the academic year 2014-2015. Responsibilities include teaching at the undergraduate and graduate (MSN and DNP) levels. Graduate concentrations include Nursing Administration and Leadership. Qualifications: • Earned PhD in Nursing (preferred), or doctorate in related field with a Master’s degree in Nursing; DNP may be considered • Eligible for RN licensure in the State of Wisconsin • Evidence of teaching, scholarly and community services potential • Knowledge and skills in contemporary practice issues related to the AACN Essentials • Demonstrated commitment to promoting diversity, inclusion, and multicultural competence To Apply: Send a letter of application, resume, and references to: Edgewood College Human Resources – APN1 1000 Edgewood College Drive Madison, WI 53711 www.edgewood.edu E-mail: humanresources@edgewood.edu Equal Opportunity Employer
programs, it is of interest to note that one of the aims of the school as stated in the preliminary announcement was, “To stimulate advanced training and research in special fields of nursing...” Helen Denne Schulte was a determined woman who never compromised her educational principles. She withstood attacks by some university faculty who viewed nursing education as vocational education, inappropriate for the university setting. The school she founded was based on sound educational principles, and established a pattern for other schools to follow. She resigned from her position in 1937, at which time she married Walter Schulte and moved to Freeport, Illinois. Although she left her professional career, she never lost interest in the School of Nursing. She died Feb. 5, 1971, and is buried in Freeport.
painted the picture of today’s veteran. Today’s veterans are survivors. Their way of thinking coupled with military culture results in a sense of living and breathing invincibly. There is a denial that is necessary to maintain a sense of self. Of approximately 248,000 active and reserve members, the majority of those serving are between the age of 18 and 30, in a life stage that involves securing self- identity/careers, and establishing and maintaining romantic relationships. Women represent 19 percent, compared to 1 percent in the Vietnam era, so the need to consider gender-specific reintegration, treatment and recovery forces a paradigm shift. Johnson summarized it well by saying we are dealing with the visible and invisible injuries of war. This complexity of injury impacts veterans and families on many levels. The culture of the “Warrior Ethos” prepares the veteran to accomplish all tasks and face all challenges anytime, anywhere. The building blocks include commitment to serve, to embrace honor and integrity, to never quit or leave a fallen “brother or sister,” and to adapt physically and mentally. Controlling emotions is critical in a combat environment but creates barriers for feeling expression in terms of health. Working through the pain at any level is essential for survival. Thus veteran pain is often underreported and untreated, and injuries do not heal. Johnson, Gillitzer, and LaSage work diligently to help their comrades seek healthcare, restore relationships and reintegrate into society. The same strategies work well in the classroom setting to aid understanding in the effects of combat/ post-traumatic stress, blast /traumatic brain or orthopedic injuries. Musculoskeletal injuries place a significant burden on military service members and the healthcare system, and are the leading cause of a disability discharge. In comparison to civilian population the military rate is 10
times higher in ACL, 7 to 21 times higher in shoulder dislocation, and higher in ankle and joint injuries. The rate in spinal injury in the current war setting exceeds all other war eras by 5 percent. The Department of Defense undertakes extensive efforts to improve combat gear, yet it still takes its toll. Carrying weight in excess of 100 to 115 pounds is common. The advanced combat helmet weighs 3.25 pounds alone! The learning curve rises exponentially as the gear passes through the hands of the residents. The donning of the gear, absent of ammunition and a threeday supply of food or water paints a realistic picture and provides a new appreciation for the weight burden and the threat for physical health. The exchange of dialogue between the veteran team and nurses is music to an instructor’s ears. Evidence of learning takes many venues. A resident reflects in a subsequent journal entry, that “talking to those who served in combat is an eye-opening experience. I have a better understanding of the patient’s mentality and it explains the behavior.” The resident goes on to reflect on a patient who refused to stay flat on bed rest following a procedure. The resident tried to educate and re-educate the potential for harm to the veteran, to no avail. Prior to the class, the resident “believed the veteran was a stubborn man! He wants it to be his way.” The journal entry continues: “Now, after the class, I have different thoughts about this case. This man did not ask for help because he is not used to asking for medical attention; he knows how to take care of himself. The take-home message for me: ‘There is no such thing as a difficult patient. Sensitivity to factors that may affect patient’s state of mind and behavior need to be considered in order to deliver care that is mutually enjoyable to both patients and healthcare workers.” The connection begins….
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June-July • 2015
WCN releases 2014 Wisconsin RN Survey Report Judith Hansen, MS, RN Executive Director, Wisconsin Center for Nursing
The 2014 Wisconsin RN Survey Report is now available from the Wisconsin Center for Nursing Inc. This important report provides comprehensive findings on the status of the nursing workforce from the 2014 Wisconsin RN Survey, including state regional information. The volunteer nursing research team for analysis of the 2014 Wisconsin RN Survey was led by Dr. Rachel Schiffman, UW Milwaukee College of Nursing, and also included Dr. Susan Zahner, UW Madison College of Nursing; Dr. Judith Westphal, UW Oshkosh College of Nursing; and Dr. Susan Breakwell, Marquette University College of Nursing. Statistician services were provided by Dr. Jeffrey Henriques, UW Madison. Much gratitude is expressed to these dedicated researchers and their respective institutions for their valuable contribution of time and talent to the project. The data reported in the publication reflect the results of a survey mandated under Chapter 106.30 of the Wisconsin Statutes for all RNs in Wisconsin. The survey was conducted as an element in the biannual license-renewal requirement. The mandate was communicated to nurses through numerous venues and organizations, as well as to employers. The survey instrument was constructed and processed by the Wisconsin Department of Workforce Development. Members of the Wisconsin Healthcare Workforce Data Collaborative and experts from nursing organizations contributed to the survey design and questions. The survey was administered by the Wisconsin Department of Safety and Professional Services. Total responses to the survey were 83,918. Data summarized in the report include only responses from the online survey (n=81,190). It does not include responses from the paper survey
2014 Wisconsin RN Workforce Survey Registered Nurses by Age (n=73,136) 12000
10000
12.9%
13.8% 11.7%
11.6% 8000
9.7%
10.4% 10.5%
9.9%
6000
5.6%
4000 2000
1.9%
1.5%
0.5% 0
< 25
25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74
75+
SOURCE: 2014 WISCONSIN RN SURVEY SUMMARY
(n=2,728). Additionally, responses of RNs who neither lived nor worked in the state of Wisconsin are not included in this summary (n=6,615). Other questionable data removed included respondents who reported becoming an RN prior to earning first degree or certification, providing direct patient care for six or more years prior to first license or six years prior to first degree or certification, or working more than 92 hours a week. The resulting cleaned data set (n=73,136) represents an accurate assessment of the actual nursing workforce employed and/or living in the state. SEE REPORT, Page 8
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Nursingmatters
National Standard considered for handling patients
SOURCE: 2014 WISCONSIN RN SURVEY SUMMARY
REPORT
indication for work to continue in this area, with only 6.9 percent of the workforce being male and only 6.4 percent being racially/ ethnically diverse. Another area of concern Continued from Page 7 Significant findings in the areas of plans for workforce development is the average to leave direct patient care indicate that 21.9 age of faculty at 53 years, with nearly 50 percent of RNs plan to leave within the next percent of faculty over the age of 55. Visit www.wisconsincenterfornursing. five to nine years, and an additional 58 perorg/2014_Wisconsin_RN_Survey_Reports. cent will leave the workforce in 10 or more html to download the 2014 Wisconsin RN years. Findings on the profile of Wisconsin diversity in the nursing workforce also show Survey Report.
On behalf of the Wisconsin Center for Nursing and the many partners involved with the design, implementation and analysis of the Wisconsin 2014 RN Workforce Survey, we wish to thank all who assisted with the survey, and the nurses of Wisconsin for completing the survey. The cooperation and dedication of all involved will aid policy makers and others in assuring a sufficient, competent and diverse nursing workforce for the people of Wisconsin.
WASHINGTON, D.C. â&#x20AC;&#x201D; The American Nurses Association, Rep. John Conyers (D-MI), and healthcare safety experts are urging healthcare employers to implement common-sense, comprehensive programs to protect healthcare workers from career-ending injuries, and safeguard patients from falls. â&#x20AC;&#x153;Nurses and healthcare workers experience the highest rate of non-fatal occupational injuries and illnesses, including the manufacturing and construction industries,â&#x20AC;? said association President Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. â&#x20AC;&#x153;Every day nurses and other healthcare workers suffer debilitating musculoskeletal disorders due to manually lifting patients. In no other profession would we ask workers to lift 90 pounds or more without mechanical support. Nurses and healthcare workers should not be the exception.â&#x20AC;? In an ongoing association survey, 42 percent of nurses said they are at a significant level of risk to their safety from lifting or repositioning patients, and more than half said they experienced shoulder, back, neck or arm pain at work. In a prior Health and Safety Survey, SEE STANDARD, Page 10
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â&#x20AC;&#x153;Nurses and healthcare workers experience the highest rate of non-fatal occupational injuries and illnesses, including the manufacturing and construction industries. Every day nurses and other healthcare workers suffer debilitating musculoskeletal disorders due to manually lifting patients. In no other profession would we ask workers to lift 90 pounds or more without mechanical support. Nurses and healthcare workers should not be the exception.â&#x20AC;? Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN; association President
www.nursingmattersonline.com
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June-July • 2015
Wisconsin Hospital Association names Vice President Steven Rush, RN, PhD, has joined Wisconsin Hospital Association’s staff as vice president of workforce and clinical practice as of March 23. Rush brings more than 30 years of combined nursing, education and clinical experience to this key position in the association’s government relations department. Rush comes from Herzing University where he was dean of healthcare, with oversight of the associate of science nursing program, the traditional BSN program and the LPN program, medical assisting program, and nurse aid training programs. While at Herzing, he dramatically improved the school’s NCLEX-RN exam pass rate, while increasing enrollment in the RN program. Rush served on the Wisconsin State Board of Nursing and chaired the education and licensure committee. “We are very pleased to have Steve join WHA,” said Eric Borgerding, association president/CEO. “He brings not
only clinical knowledge to our team, but immense experience in healthcare education that will enhance our ability to develop statewide strategies that will ensure we have an adequate, wellSteve Rush trained healthcare workforce in an ever-changing environment. Steve’s experience and skill sets will be an asset not only on our public policy work, but also to WHA’s quality-improvement initiatives.” Rush received both his PhD in nursing and a dual pediatric nurse practitioner and clinical nurse specialist master’s degree from the University of California, San Francisco. He holds a B.S. in speech communications from Southern Illinois University and a diploma in nursing from Augustana Hospital School of Nursing in Chicago. Contact Rush at srush@wha. org or 608-274-1820.
Rudd named APN of the Year Nancy Rudd has been selected as the advance-practice nurse practitioner of 2015 by the Wisconsin Chapter of the National Association of Pediatric Nurse Practitioners. Nancy works as a Nurse Practitioner for the Herma Heart Center Adult Congenital Heart Disease Program with Children’s Hospital of Wisconsin and Medical College of Wisconsin. Rudd was nominated by two of her peers who recognized her expertise and holistic approach to patient care. She provides independent and collaborative care for adults with congenital heart disease, both in the inpatient and outpatient setting. She provides extensive and detailed patient and family education in order to improve the quality of life for adults living with congenital heart disease. She provided holistic approach to patient care and is a remarkable advocate for her patients throughout their lifespan. Rudd is recognized for her role in the development of the nation’s first Interstage Home Monitoring Program for children with single-ventricle physiology. She developed family education materials as well as information/data collection binders for families. This program is now used in more than 50 pediatric institutions both nationally and internationally. She is still committed to the home-monitoring program even though her responsibilities have
Nancy Rudd
transitioned to adult congenital patients. She is the key contact for the National Pediatric Cardiology Quality Improvement Collaborative and often attends the Interstage Clinic to help new nurse practitioners and edu-
cate families. Rudd is described as mentor and preceptor for younger APNs. She takes time out of her demanding schedule to teach and demonstrate the best care for these critically ill patients. She has also become involved in the transition program that aides patient and families in transitioning from pediatric to adult cardiac care. Rudd has provided numerous lectures on congenital heart disease and pediatric cardiac assessment and care of the cardiac patient at both the state local and national level. She is also involved in multiple research studies and publications in regards to the care of the cardiac patient. The Wisconsin Chapter of National Association of Pediatric Nurse Practitioners is proud to award the 2015 APN of the Year to Rudd, who exemplifies the best attributes of advance-nursepractice nursing and mentor for the next generation of APNs in the state of Wisconsin.
“We are very pleased to have Steve join WHA. He brings not only clinical knowledge to our team, but immense experience in healthcare education that will enhance our ability to develop statewide strategies that will ensure we have an adequate, well-trained healthcare workforce in an ever-changing environment.” Eric Borgerding, association president/CEO
Edgewood College Henry Predolin School of Nursing School of Nursing Simulation Education Specialist Position Description Edgewood College Henry Predolin School of Nursing (SoN) is seeking a .50 FTE nursing faculty member with expertise in clinical practice to serve as Simulation Education Specialist. Faculty member will provide oversight and teaching as well as assessment of students’ learning. The Simulation Education Specialist collaborates with faculty to develop and implement simulation-based educational experiences designed to enhance patient safety and quality in health care delivery. This person reports to the Dean, SoN. Responsibilities: Curriculum • Assumes leadership role in working with faculty and lab manager to develop curriculum for Patient Care Areas which includes health assessment, clinical skills, low, medium and high-fidelity simulation; • Determines the most effective simulation experiences to assist students in developing competencies; • Actively contributes to the development, conducting and evaluation of simulation-based experiences with particular emphasis on creating life-like scenarios for educational purposes; • Leads small group learning sessions and encourages reflection of simulation experiences. Faculty Partnerships • Collaborates with faculty to integrate simulation experiences (e.g. The Neighborhood software experiences) into the learning environment of theory courses; • Collaborates with faculty in identifying learning needs, and developing and implementing creative learning environments; • Orients new faculty, staff and students to simulation. • Collaborates with faculty in orienting new faculty to the Patient Care Areas of the SoN as well as the Center for Healthcare Education and Simulation (CHES); Knowledge, skills and abilities • Knowledge of curriculum design and evaluation; • Maintains current expertise in clinical skills and with standards of practice; • Effectively teaches with individuals and small groups; • Works collaboratively with faculty in identifying learning needs, and developing and implementing creative learning environments; • Maintains current expertise in use of equipment including but not limited to simulation models; • Possesses effective written and verbal communication skills; • Organizes, prioritizes and multitasks on a daily basis; and Operations/Management • Establishes and maintains current and long term planning, including expenditures and projected budgetary needs for patient care areas and activities. Submits plan to SoN Dean annually in preparation for budget planning; • Works collaboratively with faculty and staff to maintain safe, current, interactive, equipped learning labs. Qualifications: • A master’s degree in nursing is required; DNP preferred. • Certified in Simulation Education preferred (Certified Healthcare Simulation Education (CHSE) • Current Wisconsin RN license required. • Excellent communication and interpersonal skills. • Leadership and organizational skills. • Recent teaching experience in clinical and/or nursing simulation/skills laboratory preferred. • Experience with patient simulations strongly preferred. • Computer skills in Word, Excel, and online learning systems.
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ast week Thursday, I had expectations — expectations for how my third day of preceptorship would order out in the CVICU. My first two days in CV were very busy with sick, but relatively stable post-heart-surgery patients. I was prepared to work with greater autonomy and further gain independence in my nursing cares, knowledge and skills. I had goals, I had plans and I felt ready. But last week Thursday was a day unlike any other I have experienced as a student nurse. God had other plans for me. He wanted me to step outside of the realm of comfort that I cling to and teach me lessons about myself, about nursing, about caring and about the experiences of humanity that we often shy away from — namely, death. Last Thursday my preceptor, Megan, and I were assigned to partner in the cares of an actively dying elderly woman. Superficially, our goal was simple. Preserve life just long enough for all family to say goodbye. Megan and I diligently worked to maintain life in a woman who could not live without the support of medication and technology. Yet another form of clinical knowledge was equally essential for the care of my dying patient and her family — a
June-July • 2015
Nursingmatters
The Finish Line
CARLY ADEMI MSOE SCHOOL OF NURSING knowledge that greatly transcends the physical and tangible skills that are learned in school… You can read about caring, be lectured on compassion and be told to love. But the ability to demonstrate and carry out those acts to a suffering human being must be actively exercised and nurtured. It requires that you make yourself vulnerable and experience paralleled emotion with another person. Our patient was suffering. Her body was failing. Her family was agonizing over an impending loss. This woman, this family greatly needed genuine caring, compassion, reassurance, comfort and love. And under the careful guidance of my preceptor, I humbly strove to
empathize with and meet those needs. As a student I had never cared for a dying patient. I told Megan I understood this patient was different than our previous care encounters. I asked her to coach me. I didn’t want to be a fifth wheel. I didn’t want to be another warm body in, at times, an already overflowing room of physicians, nurse practitioners and family members. I wanted to be a blessing. And Megan graciously navigated my steps through one of the most uncertain, yet fulfilling, days of my nursing education. Although our patient was intubated and under sedation, she would briefly open her eyes. I spoke to her and explained my actions in a calming voice. I may never know if she could actually hear me, but I sought to establish trust with this dear patient in the final hours of her life. I wanted to give her the upmost respect that she deserved. The family decided that the most loving thing to do for their mother was to allow her to die with as much comfort as possible. They feared her continuing to suffer. They taught me that sometimes love is wanting what is best for another person, even if it means that love causes you great loss. At approximately 1200, cares were
withdrawn from my patient. And at 1205, my patient passed. I remember looking up at the monitor and seeing asystole. I remember seeing the grief in the faces of her loving family, the tears streaming from their eyes. It was a very powerful experience. To be present when someone dies is to be present when they are ushered into their next life, into eternity. I was privileged to be part of the final steps of my patient’s pilgrimage on this earth. And I sought to carefully and compassionately walk beside her as she reached the finish line. But I could not pass over it with her. It is my earnest prayer that she crossed that finish line with peace and no fear. But I couldn’t help but wonder… if in the last leg of her race, my patient could hear our conversations with her family about withdrawing cares. And if she could hear us, did she understand what that meant for her, for her life? Did she want to plead with her family, with God to give her more time? Perhaps another chance? Did she know that this was her last day on earth? Was she afraid? Could I have lessened her fears, been more of a comfort, held her hand even tighter, loved her more deeply? SEE FINISH, Page 12
STANDARD Continued from Page 8 62 percent of RNs indicated that suffering a disabling musculoskeletal injury was one of their top-three safety concerns. And from 2011 through 2013, government figures show registered nurses ranked fifth of all occupations in the number of cases of musculoskeletal injuries, resulting in days missed from work at more than 11,000 each year – a rate that can be reduced considerably through widespread adoption of safe patient-handling and -mobility programs. Healthcare safety experts emphasized that national legislation would signal a “true investment” and “true progress” in preventing injuries to healthcare workers and patients. “We understand how lives can be seriously ruined by on-the-job injuries,” said Rep. Conyers, noting that he is working with a Senator on a companion bill and expects to introduce the measure by the end of June. “For nurses, nursing aides and orderlies, this is what happens, and it’s driving up the cost of healthcare. This is something we want to try to deal with.” Rep. Conyers’ bill, the Nurse and Healthcare Worker Protection Act, aims to reduce costly, potentially
career-ending injuries and preventable harm to patients. The act is the only national legislation that has addressed safe patient handling and mobility. It will establish a national occupational safety standard that will eliminate the manual lifting of patients by direct-care RNs and healthcare workers through the use of modern technology and safety controls. Jean Lucas, a retired RN from New Jersey, is one of those nurses who suffered a career-ending injury. While working on a maternal care unit for women with high-risk pregnancies, Lucas assisted a bariatric patient in pain by lifting her leg onto her bed. She felt immediate pain in her lower back. Diagnostics revealed herniated and bulging discs in her back and neck. Lucas can’t be sure if her injuries resulted from the one-time lift or if it was “just the straw that broke the camel’s back” after 24 years of lifting and moving patients and accumulated strains. The Conyers bill will incorporate principles from Safe Patient Handling and Mobility: Interprofessional National Standards, a framework developed by an expert American Nurses Association panel for establishing a comprehensive program to eliminate the manual handling of patients.
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Revised ethics guide released The American Nurses Association has released “Guide to the Code of Ethics for Nurses with Interpretive Statements: Development, Interpretation, and Application, 2nd Edition.” It is a resource for nursing classrooms, in-service training, workshops and conferences, self-study, and wherever nursing professionals use ANA’s “Code of Ethics for Nurses with Interpretive Statements” in their daily practice. Each chapter of this revised text is devoted to a single code provision, including: • Key ethical concepts. • Theories and models of ethical decision-making. • Historical, professional and societal issues, trends and other influences. • Each interpretive statement’s contribution to interpreting and applying the provision examples and illustrative cases, based on real situations, to facilitate study and discussion. • Bibliographic Web links to key national and international documents For convenience of reference,
the text of ANA’s “Code of Ethics for Nurses with Interpretive Statements” is included as an appendix. The association says the book will challenge each nurse to achieve deeper professional and personal understanding, and will provide a foundation for professional pride. From the classroom to professional practice, nurses in all roles or settings will find the “Guide to the Code of Ethics for Nurses with Interpretive Statements” to be a tool for learning how to examine and apply the values, duties, ideals and commitments of ethical tradition to their practice.
From the classroom to professional practice, nurses in all roles or settings will find the “Guide to the Code of Ethics for Nurses with Interpretive Statements” to be a tool for learning how to examine and apply the values, duties, ideals and commitments of ethical tradition to their practice.
FINISH Continued from Page 10 As a student nurse, so many of my experiences have been about preserving and protecting life — not letting it slip out of my hands. Last Thursday, I learned that death, like life, is a process, a journey. And as a nurse, it is just as much of a privilege to be a part of someone’s life as it is to be a part of someone’s death. I am truly grateful to have been a part of my patient’s life, though for a brief time. And I am thankful I could be a part of her death. I recently read “The Pause” by Jonathan B. Bartels (2014). This article discussed a practice that Bartels implemented in his hospital’s ER following traumatic patient losses. A pause, in which all healthcare providers involved in a patient’s death take a moment to reflect on the loss and their efforts in seeking to prevent that loss. Though not a code or traumatic death, my patient’s passing was certainly a loss. A loss I still feel, though I knew her but a short time. In the moments following asystole, I paused almost instinctively in her room to bow my head and pray. And, again, I pause as I am “called to bear witness to the reality of loss and the acceptance of reality” (Bartels, 2014, pg. 75). I am grateful for this opportunity to reflect. It allows me to have closure. It allows me to cry a few more tears that I had difficulty shedding while on the unit. It is a way for me to praise God for the life He gives and a way to acknowledge His sovereignty in taking it away. It allows me to express thanks to a woman whose death has taught me more about my purpose in life and my purpose as a nurse. Reference Bartels, J. B. (2014). The Pause. Critical Care Nurse, 34, 74-75.
REMARKABLE Nursing Career Event If you’re a critical care RN or have at least one year of inpatient experience, you’ll find remarkable nursing opportunities at Wisconsin’s #1 hospital: • • • • •
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Learn more about these opportunities, apply in person, meet managers and interview onsite: THURSDAY, AUGUST 6 UW Hospital and Clinics • 600 Highland Avenue, Madison Executive Dining Room, J5/130 Apply online at uwhealth.org/careers or RSVP for the event by contacting Mary Jo Casey, professional nurse recruiter, at mcasey@uwhealth.org or 800-443-6164.
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Attend our RN Career Event August 6!