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MEETING THE PERIOPERATIVE LEADERSHIP CHALLENGE

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SPOTLIGHT ON

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INDUSTRY INSIGHTS

11 News & Notes 16 I AHCSMM: AORN Releases Updated Attire Guidelines 18 CCI: Why Accreditation Matters in Certification 20 ASCA: Changing Lives in Honduras

ACCOUNTING Diane Costea

IN THE OR

25 Market Analysis: Personal protective equipment (PPE) 26 Product Focus: Personal protective equipment (PPE) 30 CE Article: Critical Thinking

OUT OF THE OR 48 Spotlight On 50 Fitness 52 Health 54 EQ Factor 56 Nutrition 58 Recipe 60 Pinboard 62 Index

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The Mexican Academy of Surgery (Academia Mexicana de Cirugía A.C.), an advisory body of the Mexican Federal Government, named Joe Kiani an honorary academic of the organization. Kiani is the founder of Masimo, creator of non-invasive monitoring technology and the Patient Safety Movement Foundation. His appointment was made at the 85th annual Academic Ceremony at the Mexican Academy of Surgery Auditorium. The Mexican Academy of Surgery strives to achieve excellence in surgical specialties through the continuous development and vigilance of academic programs. It is committed to the development of education and investigation in all branches of surgery to maintain the health of all Mexicans. “It is an honor to be named an honorary academic by the Mexican Academy of Surgery and to further advance patient outcomes and reduce the cost of care through advanced technologies and improved processes,” said Kiani. “The goal of Masimo and the Patient Safety Movement is to create actionable solutions for patient safety around the globe and eliminate preventable patient deaths.” Earlier, at the symposium hosted by the Mexican Academy of Surgery, Kiani discussed the importance of patient safety and how to ensure it. Patient Safety Movement Foundation CEO, David Mayer – and others – discussed achievements and proposed next steps related to patient safety and the diverse national and international programs in place. •

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Mölnlycke Acquires Patent From Innovation Skåne The Swedish medical solutions company, Mölnlycke, is acquiring a patent from Innovation Skåne, that will help detect infections in wounds. Once developed, the patent will play a major role in reducing the unnecessary use of antibiotics in wound care. The incidence of infection in hard-to-heal chronic wounds, such as diabetic foot ulcers and venous leg ulcers, is high – and one in 20 patients undergoing surgery will develop a surgical site infection. However, infected wounds are costly, difficult to manage and hard to detect. In many cases, expensive antimicrobials are used prophylactically to prevent infections or to treat them once they have been established. Mölnlycke has agreed to acquire the patent from Swedish regional innovation company, Innovation Skåne. This technology can detect infections and alert caregivers that the wound needs attention. It will help to minimize the prophylactic use of antibiotics and reduce the risk of complications related to infections. “This is an example of innovations originating from employees in Region Skåne and demands in their daily work. We share Mölnlycke’s goal of driving innovative improvements in health care and we are delighted Mölnlycke will be able to use this patent to help tackle a serious public health care issue,” said Joakim Nelson, CEO of Innovation Skåne. •

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news & notes

FDA Clears TEEClean Automated TEE Probe Cleaner Disinfector

Healthmark Offers New Insulation Tester Healthmark Industries has introduced the Insulation Tester with optional Bi-Polar fixture to its ProSys Instrument Care product line. Designed for electrically testing electrosurgical instruments, the low-frequency, high-voltage Insulation Tester is used to detect and locate defects such as pinholes, cracks and bare spots in the jacket or coating of laparoscopic and bi-polar electrosurgical instruments. The Insulation Tester is a handheld, portable unit that tests the insulation integrity of electrosurgical equipment for flaws in protective coatings applied over conductive instrument surfaces in order to prevent inadvertent tissue burns, which may occur during electrosurgical instrument procedures. Manufactured with a rechargeable battery, the Insulation Tester maintains applied test voltage with constant current source, features full test current at low voltages, limited output current for operational safety, easy-to-read LED indicators, as well as LED display of alarm and battery charge. The Insulation Tester comes with the following reusable and interchangeable accessories: ground wire with alligator clip, ring electrode, tri-hole electrode, brush electrode, saddle and case. The Bi-Polar Fixture accessory that works in conjunction with the saddle, ground wire and brush electrode can be purchased separately. Additionally, an optional Wire Tester accessory used with an HV Red Lead Wire is available for testing wires by locating and identifying defects such as pinholes or cracks in the conductive core. • For more information, visit www.hmark.com.

12 | OR TODAY | AUGUST 2019

S.S. White Technologies Provides Custom Flexible Shaft for Medtronic EVAR Device S.S. White Technologies has announced that a custom S.S. White flexible shaft drives a new Medtronic device for Endovascular Aneurysm Repair (EVAR). Central to the innovative Heli-FX EndoAnchor System, the S.S. White shaft maneuvers and installs a staple to secure endografts in Abdominal Aortic Aneurysm (AAA) and Thoracic Aortic Aneurysm (TAA) cases. Flexible shafts transmit rotary motion much like a solid shaft, but can be curved over, under and around areas in ways a solid shaft cannot. This allows the minimally invasive Medtronic applicator system to position the proximal and distal ends of an implant (an anchor) within a blood vessel and to deploy the spiral anchor into the vascular wall. The Heli-FX EndoAnchor System shaft design includes laser-welded fittings for a reduced diameter. Flexible shafts are commonly used in surgical applications, especially in surgical power tools and tools used in minimally invasive procedures. In addition to AAA and TAA endograft anchoring, S.S. White provides highly flexible shafts for hand held screwdrivers, heart valve repair, laparoscopic and endoscopic surgical equipment, and robotic assisted surgery technology such as the Da Vinci surgical system, as well as for other medical applications. •

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CS Medical has announced the successful clearance of a new Class II medical device by the U.S. FDA, TEEClean Automated TEE Probe Cleaner Disinfector. TEEClean is the first medical device cleared in North America which provides cleaning and high-level disinfection of a TEE ultrasound probe. The health care professional places a bedside-cleaned TEE probe into TEEClean and follows prompts on the color touchscreen display. TEEClean guides the health care professional through an FDA validated workflow for effective reprocessing of soiled TEE probes. Electronic record retention is part of TEEClean with the ability to store more than 15,000 sessions in system memory. The user interface allows data entry through a scanner or manual keypad entry on a seven-inch color LCD touch screen. TEEClean utilizes the same disinfection technology as the TD 100. TD 5 or TD 8 high-level disinfectants can be used in TEEClean while the cleaning is completed with TEEZyme enzymatic detergent. TEEClean utilizes the same vapor management system as the TD 100 and incorporates a new, high-quality water filtration system through an FDA registered Class II device. TEEClean rinses each TEE probe with a 5 nanometer (.005 micron) water filter that retains bacteria, viruses and endotoxins. “Today’s news marks the next era in the reprocessing of TEE ultrasound probes, cleaning, and disinfection within one machine, an automated TEE ultrasound reprocessor. Here at CS Medical, we have listened to our TD 100 customer base and have delivered the next generation in TEE ultrasound probe care. TEEClean is the combination of years of research, development and commitment by our entire staff.” CS Medical President Mark Leath said. “TEEClean is another example of our continued commitment to working with health care professionals and other professional organizations in the reduction of HAIs and increase awareness for a better and safer health care system. In addition to our employees, I am thankful and appreciative of the cooperation and assistance given to us by the TEE ultrasound probe manufacturers, without whom TEEClean would not be the product it is today.” •

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Medical-Grade Touch-Screen Monitor Debuts

Clorox Healthcare Announces Collaboration with HP Healthcare At the Association for Professionals in Infection Control and Epidemiology (APIC) 2019 annual conference, Clorox Healthcare announced that HP has tested its latest HP Healthcare Edition products[i] to be compatible with Clorox Healthcare Bleach Germicidal Wipes and designed to support infection prevention protocols.[ii] Computers and electronic devices in health care facilities are commonly contaminated with pathogenic microorganisms[iii] and regular cleaning and disinfection is needed to keep them from becoming a vehicle for pathogen transmission, but not all equipment is designed to support daily disinfection. “Cleaning and disinfection play a critical role in patient safety, and technology can’t be exempt from the daily practices facilities rely on to support their infection prevention protocols,” said Raja Bhadury, head of care delivery solutions, HP Inc. “HP Healthcare Edition products are specifically designed for health care environments and engineered for easy, repeatable cleaning and disinfection with germicidal wipes every shift, every day.”[iv] Clorox Healthcare’s collaboration with HP builds on a legacy of innovation in disinfectant efficacy and surface compatibility and a longstanding commitment to support safe and compliant product use. In addition to introducing new and reformulated products engineered to provide powerful disinfection efficacy with improved compatibility and aesthetics, Clorox Healthcare also created the Clorox Healthcare Compatible program. Through the program, Clorox Healthcare helps health care facilities identify cleaning and disinfecting solutions that are compatible with the surfaces and equipment they need to treat and helps manufacturers ensure their products support essential infection prevention protocols. By working with manufacturers to screen a broad platform of chemistries and provide surface compatibility expertise and access to a third-party lab for testing, the program ensures health care facilities can feel confident the products they use to reduce the risk of infections won’t damage surfaces and equipment. It also helps manufacturers provide the best instructions for the maintenance, cleaning and care of their products. “As a leading manufacturer of health care surface disinfectants, Clorox Healthcare continuously strives to deliver solutions that combine broad antimicrobial efficacy with the compatibility and aesthetics health care facilities need for consistent, compliant use,” said Amy Harmon, associate director, marketing, Clorox Healthcare. “We believe that all products, materials and equipment created for the health care environment must be designed to support patient safety and are excited to work with companies like HP who are equally committed to innovation that enhances patient safety.” •

TRU-Vu Monitors, a supplier of medical and industrialgrade displays, has released the new MMZBTP-21.5GX 21.5-inch medical-grade touch-screen monitor. It is certified to UL 60601-1 Version 3.1,and IEC 60601-1 4th Edition. This new model features 1920 x 1080 full HD resolution; DVI, HDMI and display port video inputs; external medical-grade power supply with Green Dot power cord; built-in speakers; and super wide 178° x 178° viewing angles. The Projected Capacitive (P-Cap) touch screen provides multi-touch capability (up to 10 simultaneous touch points) and is resistant to false-triggering. It can be activated via bare fingers or with surgical gloves. The enclosure is a white ABS with rear VESA mount holes. The zero-bezel, all glass front (with no side bezels) eliminates germ build-up and simplifies cleaning. The MMZBTP-21.5G-X is ideal for use throughout hos-

pitals in the OR, on medical carts or to control functions on medical diagnostics systems or machines. It features a sturdy design and is backed by a three-year warranty.

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[i] Tested on select platforms including HP EliteBook 840 G6 Healthcare Edition, HP EliteOne 800 G5 Healthcare Edition, HP EliteBook 840 G5 Healthcare Edition, HP EliteOne 800 G4 Healthcare Edition, HP Healthcare Edition HC270cr Clinical Review Display, HP Healthcare Edition HC271 and 271p Clinical Review Displays, and HP Healthcare Edition HC241 and 241p Clinical Review Displays. [ii] S olution tested as of February 2018. Chemical composition is subject to change. Tested to simulate up to 10,000 wipes with germicidal towelettes over a 3-year period. See user guide for cleaning instructions. Repeated use of these germicidal wipes may cause some cosmetic changes to the product. [iii] I de N, Frogner BK, LeRouge CM, Vigil P, Thompson M. What’s on your keyboard? A systematic review of the contamination of peripheral computer devices in healthcare settings. BMJ Open 2019;9:e026437. doi: 10.1136/bmjopen-2018-026437. [iv] Tested by up to 10,000 wipes with germicidal towelettes over a 3-year period. See user guide for cleaning instructions and approved cleaners.

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INDUSTRY INSIGHTS

IAHCSMM

“OR Today’s webinar’s presentations are timely, and spot on to the important

AORN Releases Updated Attire Guidelines Recommendations Included for Sterile Processing Professionals By Susan Klacik, ACE, CIS, CRCST, FCS n July 1, 2019, the Association of periOperative Registered Nurses (AORN) released its updated Guideline for Surgical Attire. AORN updated the guideline after several new published studies were released regarding attire that were significant enough to consider practice changes, according to Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN director of evidence-based practice and lead author of the update.1

The evidence-based guideline provides recommendations for Central Service/Sterile Processing (CS/SP) staff because the preparation and packaging, sterilization and sterile storage areas are classified as semi-restricted. In addition, CS/SP staff may enter the surgical department and must comply with these recommendations. This article highlights some of the main areas of focus in AORN’s 2019 Guideline for Surgical Attire. Many of the basic requirements for attire have not changed. Clean surgical attire laundered by a health careaccredited laundry facility or at the health care organization – in accordance with state regulatory requirements – and donned at the facility protects patients from exposure to microorganisms that could contribute to surgical site infections (SSIs). Scrub attire should be removed before leaving the facility. Surgical attire should not be laundered at home since it is not monitored for quality, consistency or safety. Home laundering also does

16 | OR TODAY | AUGUST 2019

not provide for the necessary parameters to reduce the microbial levels in soiled scrub attire. There is not a recommendation for wearing long sleeves while preparing instrumentation (wearing personal attire under scrub attire was reviewed, with no recommendation being made). The AORN guideline recommends establishing and implementing a process for managing personal clothing that may be worn under scrub attire. Some of the features to consider include: the type of fabric, the amount of fabric that can be seen outside of the scrub attire, and type of laundering and frequency. For head attire, it is recommended that the scalp and hair be covered. Head attire must be removed at the end of the shift or when contaminated. When working in the preparing and packaging area, beards must be covered. There are also recommendations for employee identification badges because it is possible that badges can become contaminated with pathogens.

established to prevent contamination of the CS/SP areas by designating a location to place such items or establishing a process to clean and contain them. Hand-held electronic devices such as cellphones and tablets are a new area of concern. Research has shown that these items can also be highly contaminated with microorganisms, including some that are potentially pathogenic. Before entering the surgical suite, it is recommended that these devices be cleaned according to their manufacturers’ instructions for use; proper hand hygiene must also be performed. Note: The full Guideline for Surgical Attire is available at www.aorn.org. AORN is also offering the “Guideline Update: Surgical Attire Webinar Replay” (free for AORN

topics facing today’s OR managers and directors.“ G. Harmon, Director of Perioperative Nursing Services

WEBINAR SERIES

Reference Association of periOperative Registered Nurses. 3 Tough Attire Challenges Solved. May 22, 2019. 1.

Susan Klacik, ACE, CIS, CRCST, FCS, is an IAHCSMM Clinical Educator.

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Susan Klacik, ACE, CIS, CRCST, FCS

If employee identification badges become contaminated with blood, body fluids or other potentially infectious materials they should be cleaned with a low-level disinfectant. Bringing items from outside of the health care facility into the CS/ SP preparation and packaging area is a concern because they may be difficult to clean and may harbor pathogens, dust and bacteria, which can contaminate the area. Some of the personal items of concern include briefcases or backpacks brought in by vendors for demonstration, or by repair personnel. It is recommended that a process be

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members and $11 no non-members) at http://shop.aorn.org/guideline-update-surgical-attire-replay/ ?_ga=2.257711560.299790932. 1559493945-1051531303. 1559493945. Additionally, AORN published the May 22, 2019, article “3 Tough Attire Challenges Solved,” which includes three common surgical attire-related questions and evidence-based answers to help health care professionals adapt to the new practices.

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CCI news & notes

CCI

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By Lisa Alikhan o matter the industry or profession, certification matters, period … but so does accreditation. In fact, a certification program’s accredited status is an important underpinning of its value in the market, and enhances its overall worth. It should thus be considered when making a decision whether to certify, or to pursue certain professional development activities.

As the manager of both governance and program accreditation for the Competency and Credentialing Institute (CCI), I am sometimes asked by those who are newly certified or new to the industry of professional certification, why accreditation matters. Beyond providing a basic definition of the term, I hope to be able to explain the benefits of accreditation in this article. Accreditation, as defined by the Institute for Credentialing Excellence (ICE) is “the process by which a credentialing or educational program is evaluated against defined standards by a third party. When in compliance with these standards, it is awarded recognition.” Further, according to ICE, accreditation: • Enables credentialing organizations to demonstrate to the profession it represents,

18 | OR TODAY | AUGUST 2019

and to the general public its certificants serve, that their program has met the stringent standards set by the credentialing community. • Enhances a program’s credibility and legitimacy by providing impartial, third-party oversight of a conformity assessment system. • Provides organizations with a way to answer the question “who reviewed your certificate/certification program?”, a question often posed by members of an occupation, employers and sometimes courts. This means that accredited programs are not evaluated only on the quality of their content. The qualifications of those involved in program development, volunteer management and program administration are also evaluated, and the organization is required to demonstrate financial solvency through submission of current and prior years’ financial records. For new programs, a budget and proforma is required for the associated new offering. Additionally, the certifying organization’s governance practices and operations are scrutinized, including the submission of all records pertaining to the board of directors (and certification council, as applicable), as well as a review

of the organization’s bylaws, policies and operating procedures. Industry partnership agreements are also reviewed to ensure the absence of any conflicts of interests or endorsements in the program development process. An accredited program must be able to demonstrate legal defensibility of its certification mark and inherent properties. In other words, what is the value of the credential to both the certifying organization and the credential holder, and what do the letters behind a name signal to the public? The answer to these questions lies in whether there is a sound basis to either award or deny a specific credential. Before a competency-based program can be accredited, it must be able to demonstrate compliance with a conformity assessment system. Instruments used to assess competency must be psychometrically sound, meaning a uniform performance standard must be established, and regular statistical analysis performed to support the methodology’s validity and reliability over time. As well, accredited programs must supply evidence of maintenance of quality assurance (QA) measures. These measures provide for continuous analysis of a program’s certification operations and administered assessments. In accordance with program policies, anomalies are flagged and addressed.

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Accreditation is a rigorous peer review process against defined standards. It validates a certain level of quality content, qualified expert involvement in program design and development, and disciplined organizational controls in program administration. Based on the industry, there are multiple organizations involved in the business of certification. Similarly; there are multiple agencies involved in the business of accreditation. CCI currently has two nationally accredited credentials, CNOR and Certified Surgical Services Manager (CSSM). CNOR is dual accredited by the American Board of Specialty Nursing Certifications (ABSNC) and the National Commission for Certifying Agencies (NCCA). CSSM is accredited by ABSNC. ABSNC currently certifies over 65% of specialty nursing credentials against a set of 18 standards for exam-based certifications. NCCA developed the first set of standards for professional certifications and accredits a wide range of professions and occupations against 24 standards. Accreditation terms for CCI programs are three or five years, and are linked to the frequency of the program’s job analysis cycle, which correlates with the pace of change within the profession’s body of knowledge. The accreditation process is approximately 12 to 18 months. Having read this, I hope that you now have a better understanding of the accreditation process and why it truly does matter.

Reference “Accreditation,” Institute for Credentialing Excellence, Retrieved from https://www.credentialingexcellence.org/ page/what-is-accreditation Lisa Alikhan is the Manager of Governance & Program Accreditation at Competency and Credentialing Institute. She may be reached at lalikhan@cc-institute.org.

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ASCA

Changing Lives in Honduras By William Prentice, ASCA Chief Executive Officer ate last year, I introduced readers of this column to the Holy Family Surgery Center – an ASC one hour north of Honduras’s capital city, Tegucigalpa. Inside that facility, Hondurans who are unable to afford the surgery they need are receiving life-changing surgical care for free. It’s time for an update on that program.

three to five physicians and 20 nurses and other clinical support staff such as surgical techs and sterile processors. Volunteers without medical experience perform administrative and support duties in the surgery center and assist on the children’s home, Nuestros Pequeños Hermanos (NPH), that shares the 2,000-acre ranch with the Holy Family Surgery Center. You do not have to be an ASCA member to join a misThe ASC continues to be owned and operated by One sion trip, but thanks to a partnership agreement between World Surgery, a U.S.-based nonprofit organization comthe ASCA Foundation and One World Surgery, if you are mitted to providing access to high-quality surgery globally. a nurse, surgical tech, scrub tech or – this year, for the Working in three operating rooms and seven overnight first time – a CRNA or sterile processor who works at an recovery bays, the local staff at the Holy Family Surgery ASCA member facility, you might be eligible for an ASCA Center and volunteers performed more than 1,000 surFoundation scholarship. These scholarships cover one coach geries during a single year for the round-trip airfare and the program fee first time last year. The ASC also “ Our mission is not only that pays expenses like food and lodgadded spine surgeries to its case mix ing, ground transport in Honduras, recently, and professional staff at the about transforming our and emergency medical and evacuacenter are confident that they can tion insurance. continue to offer those procedures patients’ lives, it’s also If you are an ASCA member and into the future. want to learn more about the opporBuilding on the success of this about transforming the tunities available through ASCA, go center in Honduras, One World to ascassociation.org/ows-scholarships. Surgery is now working to open lives of our volunteers If you are not an ASCA member, go a second ASC in the Dominican direct to oneworldsurgery.org to learn Republic. If all goes as planned, that and igniting that spirit of how to join a medical mission trip. center will begin providing surgerAnother first for the Holy Famies to the citizens of that country in service within them.” ily Surgery Center this past year 2021. was the opportunity to host its first Amid this expansion and growth, - Maria Doria, Medical Missions all-women’s medical mission. The one important aspect of the program Manager, One World Surgery center worked with the Surgical Care remains largely unchanged. One Affiliates (SCA) Women’s Network to World Surgery continues to coordinate one-week medical coordinate that trip, which brought more than 30 women, missions that give physicians, other clinical staff, noncliniincluding an all-female clinical team, to Honduras. The cal personnel and family members an opportunity to travel women involved helped in the ASC, conducted a donation to Honduras and help at the center. Each medical mission drive and led empowerment workshops with local women. team includes up to 60 volunteers, and the ASC welcomes ASCA board member and SCA Vice President, Strategy an average of two teams each month. In 2018, these volunand Payer Engagement Marie Edler, MPH, was a part of teers provided more than 30,640 hours of service. that team. Typically, about half of the members of every mission In a recent ASC Focus magazine article, Cathleen Mcteam have clinical experience, and team members include Cabe, MD, vice president of the Outpatient Ophthalmic

20 | OR TODAY | AUGUST 2019

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Surgery Society and the OOSS Gives Foundation spoke about her involvement with medical mission programs over many years. “Medical missions transform the lives of everyone involved,” she says. “I am inspired to do more and leave each mission with a renewed sense of purpose and energy. In our profession, burnout is real and turnover is expensive. The intensity of our line of work can impact our well-being, but these opportunities to give to others in a life-changing way keep giving back to me and my team long after we return home.” “Organizations that thrive have a giving component to them,” she adds. “The dynamic of your team changes when you focus on something greater than yourself.” One World Surgery Medical Missions Manager Maria Doria says that she hears comments like those regularly

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performance, labeling and intended use to demonstrate substantial equivalence. One way substantial equivalence may be demonstrated, in part, is by conforming to consensus standards for barrier performance and resistance to tears and snags. Voluntary consensus standards may also be used to demonstrate sterility (when applicable), biocompatibility, fluid resistance and flammability. Manufacturers must validate the methods used to test conformance to standards and support each product with appropriate performance test data. The health care segment of the global PPE market is expected to see rapid growth in the coming years, according to a MarketWatch new release. The PPE market is expected to grow from $38.52 billion in 2015 to $62.86 billion by 2022, according to the news release. “Health care segment is expected to witness maximum growth on account of rapidly launching new and advanced products,” according to the release.

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Improving Critical Thinking, Clinical Reasoning and Clinical Judgment BY ROSALINDA ALFARO-LEFEVRE, MSN, RN, ANEF

ealthcare providers have never experienced such significant changes. Each day brings new challenges, from learning to use health information technology to juggling multiple priorities for several patients. Having sound critical thinking (CT) and clinical reasoning (CR) skills makes the difference between keeping patients safe and putting them in harm’s way. Yet, as at least one study points out, there seems to be a crisis in critical thinking: only 23% of graduate nurses entering into practice in a large hospital demonstrated critical thinking and clinical reasoning competency.1 New graduates find that becoming a competent, critical thinking clinician, it is intellectually, emotionally, and physically challenging, and leaves many feeling overwhelmed and underprepared.1,2 Because of these issues, retaining new nurses at a time when we really need them is becoming increasingly difficult.1-5

This module will help new and seasoned staff to develop the knowl-

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edge, skills, and attitudes needed to be competent in CT and clinical reasoning. It details the relationships among CT, CR, and clinical judgment (CJ), and gives strategies for developing the thinking skills needed to function as a 21st century healthcare provider. Let’s start by examining what CT and CR entail. Keep in mind that one of the first steps to improving your ability to think critically is gaining insight into what critical thinking entails, what factors affect reasoning, and how your thinking is affected by personal preferences and perspectives.

What are Critical Thinking and Clinical Reasoning? Because thinking is a complex process that involves feelings, past experiences, and individual perceptions, there are numerous definitions of CT and CR. There’s no one right way to define either of these terms. Rather, as you’ll see in this course, there are many ways of looking at CT and CR. Looking at these concepts from different perspectives, helps you “peel the CT and CR onion” and get to the core of what’s important. Let’s begin by looking at some synonyms: • Reasoning is a commonly used synonym for thinking. • The term critical in critical thinking is synonymous with important, necessary, or required.6-8

Relias LLC guarantees this educational program free from bias. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. See Page 39 to learn how to earn CE credit for this module.

Goal and objectives The goal of this continuing education program is to help nurses, dietitians, dietary managers, health educators, laboratory professionals, occupational therapists, physical therapists, respiratory therapists, and social workers improve their critical thinking and clinical reasoning skills. After studying the information presented here, you will be able to:

Applying the above points, critical thinking is “important thinking (or reasoning) that needs to be done to assess and manage any problem or concern.” For example, you need to know how to assess systematically and comprehensively, how to prioritize, how to prevent and control undesirable situations, and how to evaluate progress.5,6

The diagram below shows that critical thinking and clinical reasoning are the processes clinicians use to make clinical judgments (conclusions, decisions, or opinions). Notice that clinical judgments are the results or outcomes of thinking and reasoning.7

Critical Thinking Versus Clinical Reasoning

While problem-solving is a key part of critical thinking, some leaders believe substituting problem-solving for critical thinking is misleading. You can’t be satisfied with having just a “problem-solving mentality.” You could be demonstrating good problem-solving skills, but if you aren’t proactive — using prevention and health promotion to avoid problems and improve health — you’re not thinking critically. If you don’t have a sincere desire to improve — to find ways to broaden your knowledge and skills and make current practices more efficient and effective — you’re not thinking critically. You may find that clients and peers, who know the value of constant improvement and professional growth, will leave you

The terms critical thinking and clinical reasoning are often used interchangeably, but there’s a slight difference between them. CR is a specific term that usually refers to assessment and management of patient problems at the point of care (e.g., reasoning at the bedside or during clinic visits). For reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow), healthcare professionals usually use the term critical thinking. CT is a broad term that includes CR and refers to “important thinking” that must be done to assess and manage any situation (inside or outside of the clinical setting).

• Describe critical thinking and clinical reasoning in the context of your practice • Identify characteristics and skills that demonstrate critical thinking • Use specific strategies to improve your critical thinking and clinical reasoning skills as well as those of other healthcare professionals

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Problem-solving Versus Improvement

behind. A holistic way to define critical thinking is a commitment to look for the best way, based on the most current evidence. This means asking questions such as: • What are the outcomes? • How can we do this better? • How satisfied are our patients with their care? • Are we applying the most up-todate evidence? The following summarizes key points on CT and CR.6-8 CT and CR are outcome-focused thinking that: • Are guided by standards, policies, ethics codes, and laws (individual state practice acts and state boards of nursing). • Are based on principles of nursing process, problem-solving, and the scientific method (requires forming opinions and making decisions based on evidence). • Focuses on safety and quality, constantly re-evaluating, self-correcting, and striving to improve. • Carefully identifies the key problems, issues and risks involved, including patients, families, and key stakeholders in decision making early in the process. (Stakeholders are the people who will be most affected [patients and families] or from whom requirements will be drawn [caregivers, insurance companies, third party payers, healthcare organizations]). • Is driven by patient, family, and community needs, as well as nurses’ and other healthcare professionals’ needs to give competent, efficient care (e.g., streamlining charting to free nurses for patient care). • Calls for strategies that make the

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continuing education

most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using technology and overcoming the powerful influence of personal views).

Three Stages of Thinking Because CT and CR are contextual (they change with circumstances), you should consider reasoning in three different stages or circumstances: 6-8

Thinking in Action: thinking in the moment — rapid, dynamic reasoning includes considering several cues and priorities at once, making it difficult to describe. Thinking in action is highly influenced by previous hands-on experience. It’s more intuitive and prone to “knee-jerk” responses than the other types of reasoning listed here. Example: An ICU nurse notices that a patient is having trouble breathing, sees a rapid heart rate

OUTSIDE THE CLINICAL SETTING q q q q q q

IN THE CLINICAL SETTING

Daily Life R eas oning & Decis ion-making T eaching/Learning T es t-T aking S tres s Management/Health P romotion T ime Management Long-term Life P lanning & Management

Effective Communication Knowledge-Based Thinking Reflective/Analytical Thinking Intuitive & Logical Thinking Evidence-based Thinking Standards-based Thinking Creative Thinking Collaborative Thinking

q Nurs ing P roces s , C linical R eas oning, Decis ion-making, C linical J udgment q Moral/E thical R eas oning q T eaching/Learning q Nurs ing R es earch q Quality Improvement

P artnering W ith P atients & C aregivers C larifying Des ired Outcomes As s es s ing S ys tematically Identifying P roblems , Is s ues , & R is ks P roblem-S olving & P revention Developing & Implementing Action P lans P reventing E rrors --Learning F rom T hem Maximizing P otential Monitoring P rogres s /E valuating Outcomes Improving P roces s & P erformance

Thinking Ahead: being proactive — anticipating what might happen and what you can do to be prepared. For new nurses, being proactive is difficult and requires expert guidance and keeping references handy. Examples: Practicing what to do if things go wrong when encountering a patient who isn’t breathing; bringing extra sterile gloves when doing sterile procedures.

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and increased blood pressure on the monitor, raises the head of the bed, and asks whether there’s any pain or dizziness. Thinking back (reflecting on thinking): deconstructing and analyzing the reasoning process to identify assumptions, look for flaws and omissions, gain insight, and correct and improve thinking. Experienced clinicians reflect on their

thinking during thinking-in-action, double checking themselves to make necessary corrections. However, this doesn’t replace reflective thinking that happens after the fact. Deliberate reflective thinking that happens after the fact — for example, chart reviews, journaling, and open dialogue with others — brings new insights and greater accuracy. You can objectively identify “lessons learned” from experience. Example: A preceptor realizes the importance of having debriefing session with a new nurse who has just had her first experience with a patient who had a cardiac arrest. During debriefing, they do a chart review and discuss what went well and what was problematic.

Shifting to a Predictive Clinical Reasoning Model Today, there’s a major shift in how we manage healthcare delivery that affects how we describe critical thinking: we are more proactive. We’ve moved from a diagnoseand-treat (DT) model to a predict, prevent, manage, and promote (PPMP) model.6,7 The difference between these two models is that the PPMP model is more proactive. The DT model implies that we wait for evidence of problems before starting treatment. For example, in the past, we monitored people with fractured hips for emboli, but we didn’t do much about preventing them. We monitored patients closely until, sure enough, they threw an embolus. Now, we apply the PPMP model and focus on preventing venous thromboembolism (VTE) by using pulsating anti-embolism stockings during and after surgery is standard practice. Implementing a program to detect and prevent VTEs, including the use

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of anticoagulants, is a major concern in healthcare.9 Another example of the PPMP model is how we manage HIV exposure. In the past, we simply monitored people who were exposed to HIV until symptoms appeared (then treatment began). Today, when someone has significant exposure to HIV, we begin treatment immediately (post-exposure prophylaxis), before the virus even appears in the blood. The DT model has a narrow approach that’s strong on treating problems but weak on preventing them and their complications. PPMP is based on evidence. We now know the typical course of most health problems. We know how to alter the course by identifying risk factors and intervening early. You may be thinking that the PPMP approach isn’t new because we’ve always focused on prevention and early intervention. But, realize that today — thanks to health information technology (HIT) and hard work on the part of many expert clinicians and researchers — we have more reliable evidence addressing how to predict, prevent, and manage problems in various situations and populations. As a critical thinker, it’s your job to pay attention to new technology and evidence-based approaches that improve outcomes. Think about how many years we used X-rays after central venous line insertion to confirm placement. Today, with new evidence and technology, we are much more proactive, using live ultrasound to monitor how lines are inserted, thereby reducing risks of serious complications, such as a collapsed lung. Remember the importance of the “fourth P” (promote). At every patient encounter, think about how to promote function.

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For example, point out the benefits of walking daily and using stressmanagement techniques to promote optimal physical and mental function. Keep patients active and engaged in their care as much as possible every day.

Thinking With Electronic Health Records Today’s healthcare professionals do much of their thinking with the help of electronic health records (EHR) and HIT. These systems are designed to help clinicians make critical patient care decisions in a timely way. For example, there are diagnostic generators (programs that determine the diagnoses you should consider based on presenting signs and symptoms) and there are clinical decision support systems that suggest specific lab studies and interventions that should be initiated as soon as possible.7 When you use well-designed EHR and HIT, two things happen that promote critical thinking:7 1. As you use the same electronic tools repeatedly in various situations, your brain creates a mental file of what’s most important (e.g., how to prioritize your assessment). 2. The electronic documentation gives you and the rest of the team a record you can reflect on to identify patterns and pick up omissions. Because EHR and HIT often cue you to important information, interventions, or consultations that should be considered, it’s more important than ever to chart as soon as you can. Not only will your mind be fresh, but entering the data may help you set care priorities. While EHR and HIT are important in preventing errors and

promoting critical thinking, remember these tools don’t think for you. Keep an open active mind, look for flaws, and decide how the information you see on your computer applies to your patients’ individual circumstances, right now.7 You — not the computer — work in “real time.” While using EHR and HIT speeds up care management decisions, they can impede thinking in those who are task-oriented not thought-oriented. These people complete tasks in a linear way. They don’t assess, reflect, evaluate, or change approaches as needed. Sometimes we see staff who are so influenced by knowing the predicted care that they rush through assessments and make dangerous assumptions. Healthcare providers of all disciplines must realize the importance of assessing their patients directly themselves before following computer-generated plans of care. They must also remember to supervise task-oriented workers closely.

What do Critical Thinkers Look Like? Surprisingly, research shows that most critical thinkers are women between the ages of 30 and 35, fairskinned, and have broad foreheads. However, if you aren’t questioning this statement, you’re not thinking critically about what you’re reading. When we ask, “What does a critical thinker look like?” we mean, “What characteristics do we see in someone who thinks critically?” For more than a decade, AlfaroLeFevre has surveyed experts to determine the characteristics and behaviors of critical thinkers, updating the Evidence-Based Critical Thinking Indicators (CTI) document every three years.8 (Level C) This

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document and textbooks are used throughout the world to promote critical thinking in clinical practice and facilitate critical thinking research.10,11,12 Lets look at how considering CTIs can help you decide what critical thinkers “look like.”

Critical Thinking Indicators CTIs are behaviors that evidence shows promote critical thinking in nursing and healthcare. They help you know what you need to do to think critically. Think about the following summary of what critical thinking indicators entail. CTIs are divided into three categories:6-8 1. General attitudes/characteristics indicators: These are behaviors that indicate the healthcare provider possesses CT characteristics/attitudes (e.g., inquisitive, persistent, reflective, openminded, proactive, resilient, self-aware). 2. Knowledge indicators: These are behaviors that indicate the healthcare provider has required knowledge (e.g., ability to discuss ethics codes and professional standards, to describe signs and symptoms of common health problems and related complications, to explain the difference between nursing and medical models, and to give key details of pharmacology, anatomy, and physiology). 3. Intellectual skill indicators/competencies: These are behaviors that indicate the healthcare provider has required intellectual skills/competencies (e.g., ability to assess systematically and comprehensively, distinguish relevant from irrelevant, identify missing information, recognize inconsistencies, identify assumptions,

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continuing education

Personal Critical Thinking Indicators A critical thinker is: • Self-aware: Identifies own learning, personality, and communication style preferences; clarifies biases, strengths, and limitations; acknowledges when thinking may be influenced by emotions or self-interest. • Effective communicator: Listens well (shows deep understanding of others’ thoughts, feelings, and circumstances); speaks and writes with clarity (gets key points across to others). • Curious and inquisitive: Asks questions; looks for reasons, explanations, and meaning; seeks new information to broaden understanding. • Alert to context: Looks for changes in circumstances that warrant a need to modify approaches; investigates thoroughly when situations warrant precise, in-depth thinking. • Reflective and self-corrective: Carefully considers meaning of data and interpersonal interactions, asks for feedback; corrects own thinking, alert to potential errors by self and others, finds ways to avoid future mistakes. • Analytical and insightful: Identifies relationships; expresses deep understanding. • Logical and intuitive: Draws reasonable conclusions (if this is so, then it follows that because …); uses intuition as a guide; acts on intuition only with knowledge of risks involved. • Confident and resilient: Expresses faith in ability to reason and learn; overcomes problems and disappointments. • Honest and upright: Looks for the truth, even if it sheds unwanted light; demonstrates integrity (adheres to moral and ethical standards; admits flaws in thinking). • Careful and prudent: Seeks help as needed; suspends or revises judgment as indicated by new or incomplete data. • Open and fair-minded: Shows tolerance for different viewpoints; questions how own viewpoints are influencing thinking. • Sensitive to diversity: Expresses appreciation of human differences related to values, culture, personality, or learning style preferences; adapts to preferences when feasible. • Creative: Offers alternative solutions and approaches; comes up with useful ideas. • Proactive: Anticipates consequences, plans ahead, acts on opportunities. • Courageous: Stands up for beliefs, advocates for others, doesn’t hide from challenges. • Flexible: Changes approaches as needed to get the best results. • Improvement-oriented (self, patients, systems): • Self — identifies learning needs; finds ways to overcome limitations, seeks out new knowledge. • Patients — promotes health; maximizes function, comfort, and convenience. • Systems — identifies risks and problems with healthcare systems; promotes safety, quality, satisfaction, and cost containment.

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and draw valid conclusions). Personal CTIs (see left) describe attitudes and characteristics seen in individuals who are critical thinkers. If nurses demonstrate the CTIs, it’s quite likely that they are a critical thinker and will readily gain the knowledge and skills needed to think critically in various situations and specialties. If you want to assess your own CT characteristics, consider each of the CTIs in the side bar and decide where you stand in relation to each one, using a 0 to 10 scale (0 = This indicator is not easy for me; 10 = This indicator is pretty much habit for me). You can access the complete Evidence-Based Critical Thinking Indicators document at www. AlfaroTeachSmart.com. This document provides a comprehensive list of CTIs, explains how they were developed, and details how the indicators relate to other key critical thinking studies. It also includes the Alfaro-LeFevre 4-Circle CT Model that can help you target areas you may want to develop to improve thinking. The four circles address the following: 1. CT characteristics (e.g., curious, confident, creative, proactive. 2. Theoretical and experiential knowledge (e.g., knowing the anatomy and physiology of the lungs; knowing how to listen to breath sounds). 3. Interpersonal and self-management skills (e.g., teamwork, conflict resolution; knowing how to respond to constructive criticism). 4. Technical skills (e.g., managing IVs and other technical equipment, such as nasogastric suction. A recent study published in the

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“Worldviews on Evidence-Based Nursing” concluded that a questionnaire based on the 4-Circle CT Model is a valid instrument in measuring critical thinking.10 The use of CTIs and the 4-Circle CT Model is also addressed in a review of the literature published in the “International Journal of Nursing Practice.”11

Nursing and Other Healthcare Provider Processes The American Nurses Association standards state that the nursing process serves as a critical thinking model that promotes a competent level of care.13 While you may use electronic programs that guide thinking about patient care, remember that you must have nursing process principles — assessment, diagnosis, outcome identification, planning, implementation, and evaluation — in your head. The nursing process gives you an organized way of thinking at the point of care. Also, remember that when legal systems examine documentation to evaluate the standard of care, they look to see how you implemented the nursing process phases. You need a strong foundation in nursing process principles to apply other care models (e.g., case management) and to do the critical thinking needed to pass standard tests, such as the National Council Licensure Examinations and other certification tests. For instance, to pass these types of tests, you must know that the first step in clinical reasoning is assessment. Suppose you have a test question about a patient who complains of unrelieved pain and you’re asked, “What would you do first?” and had the following answers to choose from: a) give pain medication; b) teach pain management; c) activate the chain of

command; or d) assess the pain. The correct answer is: assess the pain. Registered dietitians use a model that’s similar to the nursing process. The Nutrition Care Process consists of four distinct, yet interrelated steps: nutrition assessment, diagnosis, intervention, and monitoring/ evaluation. Critical thinking is an integral part of this dynamic process, as each patient must be constantly re-assessed and re-evaluated because heath status and treatment often change from one encounter to another.

Reflecting on Care — Including Patients As we realize the importance of reflecting on care and including patients in decision making, consider the importance of asking the following questions about the care we give: 1. Has patient participation in the process been at an optimum level? 2. Is information accurate and complete? 3. Have assumptions been identified, and thinking tailored to the individual patient and circumstances? 4. Are conclusions based on facts (evidence), rather than guesswork? 5. Have alternate conclusions, ideas and solutions been considered?

Developing Critical Thinking Unlike today’s youth, who are being taught very specific strategies to improve their thinking, most of us have learned how to think rather haphazardly, partially from observation and experience, and partially from school. Many adults haven’t learned the basic criticalthinking skills that their children have.

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For example, think about the following discussion overheard between two 8-year-olds: Chuck: Is your friend sleeping over? Chelsey: Yes, she is. Chuck: No, she’s not. Chelsey: Yes, she IS! Chuck: Is NOT! Chelsey: How do you KNOW she’s not? Chuck: A bunch of contextual clues! (He saw no backpack, suitcase, etc.) From a very early age, Chuck was taught the importance of considering the context (circumstances) of each situation. Thinking is a skill, just like tennis, skiing, or golf — a skill that must be learned, adapted, and practiced to succeed in the fast-paced game of life and work. Learning how to think critically requires insight, knowledge, experience, practice, and feedback. More specifically, you need to: 1. Gain insight. Develop an understanding of what critical thinking is and an awareness of how you and others think. Become familiar with common descriptions and relevant critical thinking indicators. Learn how to put your thinking into words (think out loud). There’s often more than one solution to a given problem. Be sure you can explain and support the thinking behind the solutions you choose. 2. Acquire specific theoretical and experiential knowledge related to diagnosis and management of patients and problems commonly seen in your practice setting. Classroom and simulated learning experiences are important, but they can’t take the place of the lessons learned from taking care of many patients over time (e.g., you won’t be able to consistently recognize abnormal breath sounds until you’ve listened to the lungs of many patients). Until you have good technical skills, such

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continuing education

as managing IVs and other equipment, most of your brainpower goes toward mastering these types of skills, leaving little energy for critical thinking. 3. Learn strategies that promote CT and CR (addressed in the next section). 4. Practice. “Use it or lose it” applies. Unless you practice the skills required in your setting; for example, assessing systematically and comprehensively, you’re unlikely to gain or maintain competency. 5. Ask for feedback. Ask trusted colleagues and supervisors to tell you what they think about your CT skills and give you tips for improvement.

• Develop good habits of inquiry (habits that help in the search for the truth, like always keeping an open mind, verifying information and taking enough time). • Develop interpersonal and selfmanagement skills, such as conflict resolution and getting along with those who have different communication styles. If you don’t have good interpersonal skills, you’re unlikely to get the help or information you need to think critically. If you aren’t self-aware and able to manage your emotions, you’re likely to feel stressed and be ineffective. • Turn errors into learning opportunities. Examining mistakes is a powerful way to learn.

Strategies Promoting CT and CR7

Evaluating CT and CR

Think about the following strategies for improving CT and CR. • Use simulation. From using roleplaying to high-fidelity (life-like) mannequins, using simulation is a powerful way to begin to develop thinking and communication skills in a safe environment. • Ask “What if” questions like “What if something goes wrong?” or “What if we try?” This helps you be proactive and creative. • Look for flaws in your thinking. Ask questions like “What’s missing? Do I recognize my biases? How could this be made better?” • Ask someone else to look for flaws in your thinking. You’re usually too close to your own work to be objective; others bring a fresh eye and new ideas and perspectives. • Anticipate questions others might ask, such as, “What will my supervisor want to know? What will the physician ask?” This helps identify a wider scope of questions that must be answered to gain relevant information.

Evaluating CT and CR is a complex task. It’s not easy to determine what goes on in someone else’s head. Many factors affect how someone thinks in each situation and no one’s a mind reader. If you’re looking for a “magic bullet” to evaluate thinking, you’re unlikely to find one. Use of critical thinking instruments (tests that aim to predict critical thinking abilities) is controversial because, as a recent review of the literature concluded, the available standardized instruments do not seem to be sensitive for measurement of critical thinking in clinical nursing.11 There are some practical ways to evaluate critical thinking. You can gain an understanding of healthcare providers’ critical thinking abilities, by considering three things:7 1. Patterns of verbal communication and behavior: What healthcare providers say and do over time tells you how they think. Can you think of colleagues who are, or are not, critical thinkers, just by reflecting on how they communicate and behave? How well does the provider

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communicate with patients, families, and coworkers? 2. Documentation and written or electronic communication: How is the healthcare provider’s charting? Is it timely? Are there omissions? Does it give a good picture of the patient’s status? Electronic health records often dictate what’s recorded. However, you should see original observations now and then. 3. Outcomes (results): This requires direct assessment of the healthcare providers’ patients. How patients fare under a healthcare provider’s care is often a result of critical thinking (or lack thereof). When you assess those patients, is the environment safe? Are major needs met? Do they understand their plan of care for the day? What do they tell you their care provider has told them? Considering patient results to evaluate thinking is helpful when working with diverse thinkers. You may have a methodical approach to care and be supervising a colleague who seems haphazard and scattered. To determine if this is simply a style difference, check the patients. If they are well cared for, you may have a style difference, not a critical thinking problem. Remember that teaching and evaluation go hand in hand. Start by being very specific about what pieces of clinical reasoning you want the healthcare provider to learn (e.g., one of the first skills clinical practitioners need to have is how to prioritize their assessments and gain accurate, relevant, complete data). Evaluation shouldn’t be a surprise. If you are a preceptor or manager, you might teach your new employee by saying, “Here’s a list of behaviors (or indicators) that we look for in our nurses and here are the evaluation tools we use.” Take the time to talk with them to get their viewpoints on evaluation tools

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and expected behaviors (for example, ask what behaviors are challenging for them). Getting on the “same page” about CT means asking other team members to “write on that page.” If you are a new team member, ask for competency and evaluation tools early so you can use them as learning guides. Whatever you do, keep the lines of communication open and be sure you build positive relationships. New staff struggle with sensory bombardment because of the new environment with lots of new people. They also lack confidence. Sensory bombardment and lack of confidence are brain drains that leave little energy for CT. Healthcare providers of all disciplines need time, peer support, and good mentors to build the confidence needed to develop sound reasoning and judgment. Empathizing with the difficulties of someone who is inexperienced or new to the job helps new staff realize that you understand the struggle of becoming competent. For example, you might say something like, “I remember when I first started, I was so afraid of making mistakes that I was constantly stressed.” Think about the healthcare providers who helped or hindered your growth. Take the time and patience to mentor and support new staff. Not only will you help them, but you’ll help yourself and your patients. Life is easier and care is better when you have competent caregivers on your team.

tions behind usual practices, by looking for new approaches, and by developing the theoretical and experiential knowledge you need to think critically in your practice setting.

Key to Success

4. Johnson N. Why good nurses leave the profession. Minority Nurse Web site. http://minoritynurse.com/whygood-nurses-leave-the-profession/. Published May 6, 2015. Accessed May 21, 2018.

Today’s workplace is challenging. The healthcare providers who will survive, even thrive, are those who are clearly aware of how they think, how others think, and how to use strategies and tools to promote critical thinking. Learn to work smarter, not harder. Make a commitment to improve thinking by engaging in open and honest dialogue, by identifying and examining assump-

Rosalinda Alfaro-LeFevre, RN, MSN, ANEF, is the president of Teaching Smart/Learning Easy in Stuart, Fla. She’s known nationally and internationally for her writings and programs on teaching critical thinking and improving personal and professional performance.

References 1. Kavanagh JM, Szweda C. A crisis in competency: the strategic and ethical imperative to assessing new graduate nurses’ clinical reasoning. Nurs Educ Perspect. 2017;38(2):57-62. doi: 10.1097/01.NEP.0000000000000112. 2. Boyer SA. Valdez-Delgado KK. Huss JL, Barker AJ, Mann-Salinas EA. Impact of a nurse residency program on transition to specialty practice. J Nurse Prof Dev. 2017;33(5):220-227. doi: 10.1097/ NND.0000000000000384. 3. Buttaccio JL. 3 Reasons many nurses are leaving the profession. Daily Nurse Web site. http://dailynurse.com/3-reasons-many-nursesleaving-profession/. Published March 22, 2017. Accessed May 21, 2018.

5. Gupta S. Why America’s nurses are burning out. Everyday Health Web site. http://www.everydayhealth. com/news/why-americas-nurses-are-

AUGUST 2019 | OR TODAY |

CE168-60

IN THE OR

continuing education burning-out/. Published May 6, 2016. Accessed May 21, 2018. 6. Alfaro-LeFevre R. Applying Nursing Process: The Foundation for Clinical Reasoning. 9th ed. Philadelphia, PA: Lippincott-Williams & Wilkins; 2015. 7. Alfaro-LeFevre R. Critical Thinking, Clinical Reasoning, and Clinical Judgment: A Practical Approach. 7th ed. Philadelphia, PA: Saunders-Elsevier; In Press. 8. Alfaro-LeFevre R. Evidence-based critical thinking indicators. Teaching Smart Learning Easy Web site. http:// www.alfaroteachsmart.com/NewCTIReq.htm. Published 2016. Accessed May 21, 2018.

How to Earn Continuing Education Credit 9. Armstrong Institute for Patient Safety and Quality. Preventing Venous Thromboembolism. The John Hopkins Hospital Web site. http://www. hopkinsmedicine.org/armstrong_institute/improvement_projects/VTE/. Accessed May 21, 2018. 10. Zuriguel-Pérez E, Falcó-Pegueroles A, Roldán-Merino J, AgustinoRodriguez S, Gómez-Martín MDC, Lluch-Canut MT. Development and psychometric properties of the nursing critical thinking in clinical practice questionnaire. Worldviews Evid Based Nurs. 2017;14(4):257-264. doi: 101111/ wvn.12220.

Critical thinking in nursing: scoping review of the literature. Int J Nurs Pract. 2015;21(6):820-830. doi:10.1111/ ijn.12347. 12. Kramer M, Maguire P, Schmalenberg C, et al. Components and strategies of nurse residency programs effective in new graduate socialization. West J Nurs Res. 2013;35(5):566-589. doi: 10.1177/0193945912459809. 13. Nursing: Scope and Standards of Practice. 3rd ed. Washington, DC: American Nurses Association; 2015.

11. Zuriguel Perez E, Lluch Canut MT, Falcó Pegueroles A, Puig Llobet M, Moreno Arroyo C, Roldán Merino J.

1. Read the Continuing Education article. 2. Go online to ce.nurse.com to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at https://www.nurse.com/ sign-up for $49.95 per year.

Deadline Courses must be completed by 6/15/2020 3. If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer. 4. Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test. 5. All users must complete the evaluation process to complete course. You will be able to view a certificate on screen and print or save it for your records.

Accredited Clinical Vignette

1. What is the best response to Sarah?

a. Nancy has always been hard on new nurses. b. I’ve been new myself, and I know that it’s hard. c. Does Nancy write things down for you to do? d. You are putting me in a difficult position. 2. Sarah’s lack of confidence is:

a. A sign that she needs leadership skills b. Due to her lack of knowledge c. A sign that she will struggle learning d. Normal for a new nurse

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3. Lack of confidence is:

a. A “brain drain” that leaves little energy for critical thinking b. Innate, therefore difficult to overcome c. Good because it motivates people to learn d. Usually due to previous bad experiences 4. Which is MOST important in helping Sarah improve her critical thinking skills?

a. B uilding a trusting relationship and keeping lines of communication open b. G iving her a list of competencies and telling her when she’ll be tested c. H elping her to realize she needs to be an independent learner d. Asking her what she knows about critical thinking skills

OnCourse Learning is also an approved provider by the Florida Board of Nursing, the District of Columbia Board of Nursing, and the South Carolina Board of Nursing (provider #50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. Relias LLC is approved by the California Board of Registered Nursing, provider # CEP13791.

Clinical VignettE ANSWERS 1. B – Empathizing with Sarah by acknowledging you’ve had similar experiences opens a dialogue with her. 2. D – Until nurses become comfortable with their coworkers and new surroundings, many of them struggle with confidence. 3. A – Dealing with confidence issues takes a lot of energy. Your brain can only do so much at a time. If you build confidence, there’s more brainpower to focus on critical thinking. 4. A – Improving critical thinking skills requires open, honest dialogue.

You’re at work doing your usual job. You overhear Nancy, an experienced colleague, say to a new nurse: “The problem with you, Sarah, is that you just don’t think. You’ve got to start thinking! If I don’t see improvement, this is going to be a problem!” Later, looking very upset, Sarah comes to you and says, “I don’t know what I’m going to do. I’m trying to do what I’m supposed to do, but all Nancy says is that I’m not thinking. I am thinking. But, I need more guidance than she’s giving me. I want to do a good job, but I need help. This is all very new to me. It’s not helpful to hear, “You’ve got to start thinking!” It’s vague, and it wrecks my confidence. Can you please help me?”

In support of improving patient care, OnCourse Learning (a Relias LLC company) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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ONLINE

Questions

Nurse.com You can take this test online or select from the list of courses available. Prices subject to change.

Questions or for a complete listing of our courses Phone: 877-843-8374 Email: nursesupport@relias.com

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Company SHowcase

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protection from this type of damage. After service, Ruhof provides a detailed service report including before and after photos of the sterilizers (inside and out) along with recommended follow up actions. A Ruhof representative will also follow up to provide a sample of our effective, quick foaming autoclave cleaner (F.A.C.T.S.) for sterilizer maintenance between visits.

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Ruhof Corporation In 1976, Frank Bass and Bernard Esquenet teamed up to create The Ruhof Corporation. Frank Bass’ initial role in the company was one of sales, marketing and research while Bernard Esquenet was the chemist behind Ruhof’s success. Prior to the launch of Ruhof, Bass recognized the need for hospitals to use more than simple dishwashing detergent in cleaning surgical instruments. Esquenet had created cleaning solutions for the Navy that were used to clean barnacles and other crustaceous marine residues from the heat exchangers and water evaporators of submarines and other naval vessels. When Bass approached him to develop cleaning solutions for hospital instruments, Esquenet realized that the enzymes he was using to eat

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away at the marine organism residues would also dissolve proteins off of surgical instruments. Thus, Protozyme, the very first enzymatic cleaner for surgical instrumentation was born along with Surgistain, a product for refurbishing corroded stainless steel instruments. Since then, Ruhof has dedicated itself to the research, development and manufacturing of state-of-theart products to ensure the complete cleaning and reprocessing of all surgical instruments and scopes. Addressing the ever-increasing concern of cross contamination in hospitals, Ruhof’s research and development department revolutionized the cleaning industry with its enzymatic detergents, cleaning brushes and foam sprays. Additionally, the comprehensive ScopeValet™ line of endoscopy products supports the steps of

the scope reprocessing cycle from bedside cleaning to transport and storage. These GI offerings help endoscopy suites improve operating efficiencies while adhering to guidelines and protecting patients and staff alike.

Q: What are some advantages that your company has over the competition? A: Ruhof Healthcare sells the only enzymatic detergent on the market (ENDOZIME® BIO-CLEAN) clinically tested to pass the difficult ISO standard 15883 Annex F by dissolving bioﬁlm and exposing underlying bacteria to high-level disinfectants or liquid chemical sterilants. Our products are of the highest quality available and we offer the most complete line of surgical instrument cleaning, scope cleaning and reprocessing supplies in the marketplace. In addition, the company is

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A: New from Ruhof are the single use ThomasTrap™ and PearlCatch™ polyp traps for the suction retrieval and transportation of endoscopically removed polyps for histological examination. Both traps are easy to use and provide effortless visualization and simple transportation of the collected specimen. Ruhof has also recently launched two product delivery systems, the PrepValet™ FOAMER and the ForeverPrep™ Pretreatment Sprayer. The Ruhof PrepValet™ Foamer quickly and easily applies foaming Prepzyme® over your instrument sets and into cannulas prior to manual cleaning to prevent the adhesion of bio-burden. This automatic delivery system eliminates hard to use trigger sprayers and produces enough foam to cover an entire tray of instruments in just seconds! The Ruhof ForeverPrep™ Pretreatment Sprayer is an automated application system for Prepzyme® Forever Wet Humectant Pre-Cleaner which also makes the job of coating surgical instruments fast and easy.

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" We understand the importance of cleanliness in the health care field and are guided by our commitment to excellence." Q: Can you highlight any recent changes? A: We are excited to announce that Ruhof now offers Sterilizer Chamber Cleaning Services! Chamber cleaning is the removal of scale and debris from the sterilizer chamber to remove the possibility of unwanted substances contaminating sterilized items during usage. We remove scale, oxidation in the form of rust, green copper oxidation, melted on stickers, and baked on plastic without damaging any surface of your sterilizer. Sterilizers use steam that is inherently alkaline to prevent scale buildup in the piping. When this “scale” is deposited, it leaves a concentrated alkaline material that etches or scars the surface of the chamber. This effect can actually be felt with the bare hand. The alkaline material also causes severe discoloration of the chamber walls. Using Ruhof services for routine chamber cleaning will provide

A: Ruhof has a most knowledgeable and responsive customer service department and sales team ready to help our customers with questions, orders, troubleshooting, etc. Our user-friendly website and informative technical data sheets/IFUs also provide support. We offer a program of free accredited continuing education for nurses and CS/SPD techs, as we understand that ongoing education, training and mentoring are critical to the success of any clinical department. These CE opportunities are offered at both national and local trade shows, as well as right on our website www.ruhof.com/ pages/education.

Q: What is most important to you about the way you do business? A: At Ruhof, we understand the importance of cleanliness in the health care field and are guided by our commitment to excellence. We demonstrate this by offering reliable solutions and individualized service to help health care facilities meet and exceed their decontamination and infection prevention challenges. We are always finding new solutions and new ways to help fight HAIs and to provide a safe work environment for patient and staff. We value our customers as much as the patients that they care for. For more information, visit Ruhof.com.

AUGUST 2019 | OR TODAY |

Meeting the

P E R I O P E R A T I V E

LEADERSHIP

CHALLENGE BY DON SADLER

“NURSES DON’T LEAVE ORGANIZATIONS – T H E Y L E A V E M A N A G E R S .” -ROSE SHERMAN

he field of perioperative nursing is going through a profound transition when it comes to the workforce. By 2020, more than half of all perioperative nurses will be Millennials born between 1980 and 1996. Members of this generation tend to look for different things in their work than other generations did. In particular, they seek a career development path and continuous professional growth. When they don’t receive these, they are likely to look for another employer, which has contributed to the high turnover rate seen among perioperative nurses. All of this points to the need for strong perioperative leadership, says Rose O. Sherman, EdD, RN, NEA-BC, FAAN, Professor Emeritus at the Christine E. Lynn College of Nursing at Florida Atlantic University. “Nurses don’t leave organizations – they leave managers,” says Sherman. “So, strong leadership really matters today.”

A CHALLENGING SPOT

According to David A. Wyatt, PhD, RN, NEA-BC, CNOR, vice president, perioperative enterprise, Vanderbilt University Hospital, perioperative leadership has been in a challenging spot for several years.

“The challenge lies in having enough clinical perioperative nurses who aspire to leadership,” says Wyatt. “Many younger nurses aren’t sure they’re willing to make the commitment required. Perioperative leadership isn’t a clock-in, clock-out job – it’s a 24/7/365 job. “The stress sometimes gives young nurses pause … and rightfully so,” Wyatt adds. Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the CEO and executive director of the Association of periOperative Registered Nurses (AORN), concurs. “Young OR nurses sometimes see the OR director working 10- or 12-hour days and not being given the opportunity to be innovative or transformational with developing new models of care,” says Groah. “And they quickly make the assumption that ‘perioperative leadership is not for me.’ ” Groah stresses that there are “pockets of excellence” in facilities where the OR director’s skill and knowledge in managing perioperative services are seen as a valuable asset to the C-suite. “In this situation, the attitude of young perioperative nurses regarding leadership positions thrives and is rewarded,” she says. According to Wyatt, another challenge in developing perioperative leaders is the fact that most organizations now require advanced degrees for leadership roles. “I’m absolutely supportive of this,” says Wyatt. “But there just aren’t as many AUGUST 2019 | OR TODAY |

people today with advanced perioperative nursing degrees as there are in other specialties, though this is changing.”

WHY PERIOPERATIVE LEADERSHIP IS CRITICAL

Wyatt notes that the perioperative nursing environment is “an interdisciplinary model all the way through. This necessitates strong leadership – otherwise, the voice of perioperative nursing is non-existent.” Meanwhile, Groah points out that perioperative services are frequently the highest revenue producer in the hospital, representing up to 70% of total revenue. And in the ASC, perioperative services are the only revenue producer, she notes. “It’s critical that the nurse manager, as a strong leader, be able to provide the incentives and rewards to promote a healthy patient and worker safety culture,” says Groah. “A commitment to safety must be articulated at all levels of the organization and safety must be valued as a high priority, even at the expense of productivity.” To be most effective, Groah believes that OR directors and managers must be in the C-suite. “This is where discussions occur regarding the management of perioperative services,” she says. “These discussions include things like ensuring quality surgical care and meeting the challenges nurses face in managing a safe OR.” Wyatt stresses the need for health care organizations to “wake up and be more intentional about developing and growing perioperative leaders. We’re past the time of just waiting for this to happen organically.” “Perioperative leaders should be developed from both an academic and experiential standpoint,” Wyatt adds. “I’m not sure we’ve done a good job of this in the past across our specialty.”

THE LEADERSHIP CHALLENGE MODEL

Sherman believes that health care organizations can adopt components

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of The Leadership Challenge Model in their efforts to strengthen perioperative leadership. “This is an evidence-based framework developed from over 30 years of research with thousands of leaders in a wide range of industries throughout the world,” Sherman explains. The model was developed by researchers James Kouzes and Barry Posner. “A key finding of the research is that followers want their leaders to be honest, forward-looking, competent and inspiring,” says Sherman. Based on the research, Kouzes and Posner have identified five key practices of exemplary leadership: 1. Model the way. According to Sherman, this is a fundamental practice because it’s how leaders earn, sustain and build credibility. “Effective leaders do what they say they will do,” she says. 2. Inspire a shared vision. The best leaders are always looking toward the future with optimism and hope, notes Sherman. “They are able to imagine the possibilities in any change and get others involved and inspired by asking questions like ‘What’s next?’ and ‘How can we contribute to this future direction?’ ” she says. 3. Challenge the process. Sherman believes that perioperative leaders should actively look for ways to make things better while innovating and growing the organization. “This often means you will need to challenge the status quo to bring new methods, ideas and solutions into use,” she says. 4. Enable others to act. “Leaders who enable others to act are able to foster collaboration and build trust on their teams,” says Sherman. “They also make it possible for others to do their best work by maximizing their strengths versus focusing on their weaknesses.” 5. Encourage the heart. Sherman believes this might be the most important leadership component in the perioperative environment. “Leaders who encourage the heart bring others to

life by recognizing their unique contributions and who they are as individuals,” she says. Sherman adds: “These five practices are especially relevant in the perioperative environment where patient outcomes are dependent on excellent communication, strong teamwork and patient engagement.” Groah says she had an opportunity to hear James Kouzes present a one-day workshop on “Encourage the Heart” when she worked as a perioperative leader at a major health care organization in the 1990s. “I have not found another leadership model that fits the perioperative nursing environment better than this one,” says Groah. “I strive to incorporate these five practices into my leadership every day.” When asked about her leadership style, Groah describes it is a “contingency style. I respond to each situation according to the needs of the individual or the situation, but my North Star is always the five practices that Kouzes’ and Posner’s research identified.”

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According to Groah, AORN offers resources that can help health care organizations grow and develop perioperative leaders. “For example, the Nurse Executive Leadership Seminars give OR directors and supervisors the opportunity to concentrate on management issues and hot topics focused on leading in the complex perioperative environment,” she says. Nurse Executive Leadership Seminars are held in 10 cities nationwide in the spring and fall. In addition, AORN launched a Leader Membership Package this year that Groah says is designed for perioperative nurse leaders in search of solutions beyond clinical challenges, such as staffing and budgeting. For more information, visit aorn.org.

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“ W E W E R E C O N S T A N T LY B E I N G CHALLENGED TO DO IT BETTER, BUT WE

SPOTLIGHT ON:

Theresa Mottes

W E R E G I V E N T H E S U P P O R T T O D O I T .”

APRN, CPNP-AC, CDN

BY M AT T S KO U FA LO S

Critical Care Nephrology Nurse Practitioner Theresa Mottes has worked in the nursing field since she was 20 years old. In that time, she’s gone from a high school graduate to become a leader in her field and a nursing advocate in her chosen specialization of pediatric nephrology. Mottes credits a supportive professional environment with helping clear the path for her to achieve these things, but it was her determination and studiousness that put her where she is today. Nursing was “what I was always going to do,” Mottes remembers, and her first job in pediatrics opened the door to a 25-year career at C.S. Mott Children’s Hospital in Ann Arbor, Michigan. (Today, she works at Texas Children’s Hospital in Houston, Texas.) “I just kept getting opportunities to expand what I do and learn something new,” Mottes said. “I was a young mother, I had a family, and staying in the area was really important to us while raising our family.” “From there, I just had incredible opportunities to start a career and move around a little bit,” she said. Although she put down firm roots early in her career, Mottes points out that “nursing is never stagnant.” From opportunities to relocate, to shifting specialties, to continuing her education, “the nursing brain” led Mottes through a career that has been varied considering the bulk of it was spent within a single health system. She started as a pediatric nurse on a

48 | OR TODAY | AUGUST 2019

floor of school-aged patients in the late 1980s. At that time, the hospital hadn’t established diagnosis-based floors, and the generalized care she provided there taught her how to treat patients dealing with everything from asthma to renal failure. Mottes thought she might enter the transplant program at the facility, but then discovered “one of my two loves,” which was critical care. “It was always changing; I loved it,” she said. “I was exposed to a continuous form of dialysis while I was in the ICU, and became the lead for that program.” Mottes enjoyed the critical care environment and the technical aspects of providing dialysis care, but the idea of getting to know her patients on a routine basis was an unexpected perk. Treatments brought the same patients under her care about four to five times a week, and Mottes began to know them better, “really becoming a part of their lives and watching them grow,” she remembers. As roles within the institution began

to change, she was invited to manage the entire pediatric dialysis program; when acute care split from chronic care, she became the director of that section. “There were just opportunities happening, and when they worked out for me, I just took advantage of them,” Mottes said. “I was surrounded by incredible leaders from the pediatric dialysis world – some of the godfathers of some of the therapies – and that was an opportunity alone. They gave me opportunities to learn.” Among them was pediatric nephrologist Timothy Bunchman, whom Mottes describes “as an innovative leader” inviting participation from the nurses in the program. Bunchman often “took a step back and said to the nurses, ‘Tell us what you think will work, and let’s try it,’ ” Mottes remembers. “We were constantly being challenged to do it better, but we were given the support to do it,” she said. “It was never a stagnant environment.” WWW.ORTODAY.COM

CAPTION Critical Care Nephrology Nurse Practitioner Theresa Mottes has worked in the nursing field since she was 20 years old.

Furthermore, the association of C.S. Mott with the University of Michigan health system meant that nurses like Mottes were encouraged to write conference abstracts, to present papers, “and get out there in a supportive environment.” She said the positive workplace dynamic provided her the freedom to see the best in herself. It’s a hallmark of leadership she carries on today. “Without that original support, I would not have had the courage I have to be able to speak in multiple different conferences and be a published author,” Mottes said. “I certainly credit those early days with laying that foundation that I just stepped onto and continued going.” Critically, Mottes said she and her coworkers “were never put down for stumbling.” Instead, when colleagues happened upon ideas for performance improvement, their suggestions were WWW.ORTODAY.COM

embraced rather than dismissed. By creating an attitude of continuous improvement, the feeling that “there was always room to do it a little bit better,” gave staff inspiration to exceed their current boundaries. “We were always a team,” Mottes said. “I think that’s one of the things in this dynamic environment: success isn’t based on hierarchy. It’s about having a level playing field, and respecting what everybody brings to the table.” Those lessons have never left her. Today, she’s president of the Nephrology Nursing Certification Commission (NNCC), a group she joined 12 years ago as a writer. NNCC is responsible for developing and executing the certification tests for all nephrology and dialysis technicians, and making sure that work reflects current best practices. As a researcher, Mottes continues to improve her own skills – she’s currently

pursuing a nurse practitioner degree – while she leads the next generation of nurses in the expansion of their abilities. “One of the things I always tell younger nurses is, if someone is asking your opinion, always say ‘yes,’ and get involved, because you just don’t know where it’s going to take you,” Mottes said. “And then follow that with, ‘I’m going to need some guidance,’ but do it.” “There’s so many moving parts in this field,” she said. “Whether it’s outpatient, whether it’s nephrology clinic, or acute dialysis, it’s very dynamic, and there’s so many moving parts. It requires a really strong multidisciplinary team to execute it well.”

Would you like to nominate someone for the spotlight article? Visit ortoday.com/nominations/

AUGUST 2019 | OR TODAY |

SPEAKER SPOTLIGHT

OUT OF THE OR fitness

When I received my doctorate in health related sciences from Virginia Commonwealth University in 2009, I never thought I’d be in a classroom again. When colleagues from Otterbein University (where I earned my bachelor’s in 1983) found out about my doctorate degree, they offered me a position as a nursing faculty member. I’ve always taught, from a podium at conferences and lecture halls, but never in the classroom. I was intrigued, so I accepted the position. I immediately realized the power in helping educate future nurses and was delighted when I was asked to create the university’s first perioperative nursing course. For years, perioperative nursing has been disregarded in nursing undergraduate curricula. This was my chance to bring it back for students. I’ve been teaching Introduction to Perioperative Nursing at Otterbein since 2013 and have sparked a passion in students who are captivated by nursing in the surgical setting. This full simulation class has been extremely popular and has reinvigorated the passion for perioperative nursing once again. •

Using Personal Records to Push Yourself

Kay Ball, Ph.D., RN, CNOR, CMLSO, FAAN, Professor, Nursing, Otterbein University

AUGUST 18-20 | LAS VEGAS, NV

By Miguel J. Ortiz

e would love to have all of our goals be meet right now, but the reality is we cannot eliminate the work that must be done to get where we are going. Whether you’re trying to increase speed or strength, the journey or process to get there cannot be skipped over or ignored. All your fitness goals will require a quality amount of work, understanding and learning to ensure progress is being made. We know working hard is important but when do you push the envelope, and what should we expect when we do so?

First, let’s take a look at what is known as a Personal Record (PR). Setting yourself up with a baseline is important because before you can get to where you’re going you need to know where you’ve been. You can have several different baselines. For example, you can set a goal for running a mile within a certain amount of time or maybe you have a push up, pull up or squat goal. Regardless of the goal, you’ll need

50 | OR TODAY | AUGUST 2019

to first understand how long it takes to run a mile, or see how many push-ups, pull ups or squats you can do, etc. For beginners in fitness, I recommend setting aside one day per month to do a test out. What I mean is that during this day you’re going to push yourself to the max and try to beat your previous records, ultimately creating a new PR. If you are more advanced, and depending the type of training you are doing, you might want to set aside two days as beating your previous PR can be pretty taxing on the body. You might need a day to recover before jumping into the next movement or exercise. Nonetheless, we now have a planned day in our training routine where we know we need to turn it up. The nice thing is that setting yourself up with an initial baseline or PR will help you determine how hard you were working in the previous days leading up to test out. For example, if you only did one more push up during your PR test out and you had a month to train, as much as that may be progress you still need to check yourself and ask, “Did

FIND OUT MORE about Kay and her experience in educating as she presents, “The Secret to Perioperative Nursing Excellence: Taking care of yourself first!” at the 2019 OR Today Live Surgical Conference.

I work hard enough?” or “Could I have pushed myself further?” These reflective questions will help you challenge yourself appropriately and can lead to new PRs. Let’s keep in mind that this type of goal setting has nothing to do with weight loss or body fat percentage. Your hard work, eating habits and consistency will be the only thing that determines your weight loss or decrease in body fat and that can’t be controlled because that’s relative to one’s metabolism and other factors. This is solely about knowing when and when not to push yourself to the max by planning accordingly. So, go out and set a new PR, create a plan to work hard every day, be disciplined about your daily objectives and have fun crushing your goals.

KAY BALL,

PHD, RN, CNOR, CMLSO, FAAN

www.ortodaylive.com

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Miguel J. Ortiz is a personal trainer in Atlanta, Georgia. He is a member of the National Personal Trainer Institute and a Certified Nutritional Consultant with more than a decade of professional experience. He can be found on Instagram at @migueljortiz.

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AUGUST 2019 | OR TODAY |

OUT OF THE OR health

Choose to Be Happy By Marilynn Preston r. Amit Sood – professor of medicine at the Mayo Clinic College of Medicine – grew up and went to medical school in Bhopal, India. Throughout his medical training, he writes, he experienced “the scourge of poverty, malnutrition and disease” that created tremendous suffering in his country.

In 1995, Sood came to America. He did a two-year residency in New York, followed by six years in rural Washington, all the while practicing a different kind of medicine than he had in India. In America, his patients were, on the whole, healthier, wealthier, better nourished, with many more resources. Here’s the shocker. “To my surprise,” he writes, “the suffering was the same. It’s nature, intensity, pervasiveness ... I had naively assumed that everyone (in America) would be happy and having a good time. The extent of stress made no sense to me.” And that led Sood to his lifelong quest to understand the scientific basis of human suffering, and to come up with practical things that ordinary humans can to do to live extraordinary lives of peace and calm, with better relationships and greater happiness. He describes his methods and philosophy in his playful and profound book called “The Mayo Clinic Handbook for Happiness” (Da Capo Press). It features detailed step-by-step practices to help you decrease negative stress and intentionally choose happiness. “Happiness is a habit,” says Sood, now chair of the Mayo Mind Body Initiative and director of research at the Mayo Clinic Complementary and Integrative

52 | OR TODAY | AUGUST 2019

Medicine program. (Just knowing this place exists makes me happy.) “Some of us are born with it; others have to choose it. This book will help readers ‘choose’ happiness.”

HIS BIG DISCOVERY: IT’S NOT YOUR FAULT “After years of studying and learning from patients, students, spiritual luminaries, scientists and philosophers,” Sood writes, “I realized that human suffering is often not caused by our conscious thoughts and actions.” Our minds are hard-wired to attach to the negative, to see the world as a dark and threatening place because that gave us a survival advantage in days gone by. These days, that evolutionary tendency keeps many of us stressed and anxious. “The brain and mind work very hard to keep us dissatisfied and stressed,” he writes, and that pretty much bypasses any hope for happiness, unless we intentionally redirect its focus. “Our suffering is nobody’s fault,” writes Sood. “We can all do something about it.” Sood prescribes a four-step 10-week program in the “Handbook for Happiness”: 1) Train Your Attention. Neuroscientists have proven that the human mind is instinctively restless and wandering. That’s the default mode, and to counteract it, you want to develop deep and sustained attention – intentional attention – so that you can command your thoughts, shift your perspective, detach from the negative and embrace the positive. Joyful attention practices include waking up with gratitude, being in nature, resisting judgment and expressing kindness. “Your attention is like a muscle,” he

writes, “Training makes it stronger.” 2) Cultivate Emotional Resilience. Emotional resilience is crucial to happiness, Sood says, because it helps you focus on positive actions and uplifting emotions. He asks his happiness seekers to actively pursue five principles: gratitude, compassion, acceptance, meaning and forgiveness. “When things go wrong,” he advises, “try to focus on what went right within what went wrong.” 3) Start A Mind-Body Practice. Sood encourages people to develop a relaxed mind, using a wide range of activities including reading, exercise, music, art, prayer, meditation, yoga and deep breathing. “A relaxed mind is a humble mind that isn’t struggling with fear, greed or selfishness.” 4) Pick Healthy Habits. Decrease your dose of daily news. Get up and get moving. Simplify your life. Pick your battles. Lighten up. “We often take life more seriously that we need to. Humor brings you into intentional presence.” You can read more about Sood’s SMART program (Stress Management And Resiliency Training) on his website, www.stressfree.org. He developed it after 20 years of research and practice, and it’s been used to train 150,000 people at Mayo with “consistently positive” results. Now, according to his website, Sood intends to set up franchises in cities throughout the country, teaching people how to choose happiness and improve their health. How SMART is that? – Marilynn Preston is the author of “Energy Express,” America’s longest-running healthy lifestyle column. For more on personal well-being, visit www.MarilynnPreston.com.

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SPEAKER SPOTLIGHT

OUT OF THE OR EQ Factor

I’ve been coaching professionally for 20 years. In the beginning, my services centered on conventional issues such as assistance deciding on the right graduate program, resume writing and interview preparation. About 10 years ago, I received a call from a nurse requesting my help finding a position that did not require direct patient care. I immediately assumed that she was either battling an illness or challenged by an ergonomic injury. When I asked her to share her physical stamina without divulging too much personal health information, she laughed and said, “I’m strong and healthy! I just don’t want to take care of patients any more and if I never have to work in a hospital again, that would be OK too.” It was then that I realized, I was speaking to my first client battling compassion fatigue. Since then, 85% of individuals seeking my assistance are struggling with role transition, compassion fatigue or bullying and incivility at work. The mission and goal of my coaching practice is now re-focused on working with professional and family caregivers to build their resilience and reconnect with the joy of what they do. I am also devoted to working with leaders and administrators in the creation of healthy work environments. •

How Emotional Events Create Motivations

Phyllis S. Quinlan, PhD, RN-BC Founder, President of MFW Consultants To Professionals, Inc.

PHYLLIS S. QUINLAN, PHD, RN-BC

By daniel bobinski AUGUST 18-20 | LAS VEGAS, NV

n the realm of emotional intelligence, recognizing our own and others’ motivations is very important. Knowing our own is important for selfmanagement, and recognizing other people’s motivators helps in relationship management, especially in the area of showing empathy.

When we practice empathy, it’s helpful to know that many of our attitudes and motivations are formed when we’re small children. In fact, most are in place before the age of five! What are the catalysts for this? The answer is, “Emotionally significant events.” Put another way, when we experience a strong positive emotion during a particular event, we are imprinted to find value in those types of events. The opposite is true if we experience a strong negative emotion during any given event. For example, let’s say a young couple has recently bought a home in a quiet suburban neighborhood. It’s a beautiful spring day, and the couple is in their front yard with their 18-month-old identical twins. Dad is a dog lover. He grew up with dogs and thinks dogs make the best pets. Conversely, mom is a cat lover. She thinks dogs are slobbery, disgusting creatures and she wants nothing to

54 | OR TODAY | AUGUST 2019

do with them. While the family is enjoying the beautiful sunshine, a neighbor comes down the street walking his large, undisciplined German Shepherd. The dog sees the couple’s children in the yard and starts barking as he pulls on the leash while trying to make his way toward the kids. Dad thinks nothing of it. All he sees is a beautiful animal, and he tells the neighbor, “Nice dog!” However, mom is terrified. Visibly shaken, she runs toward her children, fearful that her twins will become the dog’s afternoon snack. With the commotion of the dog barking, both young children are wondering what to make of this new situation. The child closest to dad looks up and sees dad smiling and calm, giving the neighbor a thumbs up. Taking a cue from dad, the child relaxes and smiles, and the result is a positive emotional imprint. The child closest to mom looks up at her and sees extreme fear. Taking a cue from that impression, the child starts crying, and the emotional imprint is decidedly negative. And thus, identical twins receive very different imprints from the same event. If this happens a few more times, the first child will grow to love dogs while the second child will despise them.

If you think about your own viewpoints and realize that significant emotional events helped form them, then it’s easier to have empathy when interacting with people who hold distinctly different values from yours. People’s attitudes about money, aesthetics, the acquisition of knowledge, power, altruism, and systems for living are formed, in large part, because of emotional imprints. This is valuable to know because these attitudes drive our decisions and behaviors. One key to remember is that it’s in these areas where we tend to ascribe the ideas of right and wrong. Good emotional intelligence suggests that we look past the right/wrong paradigm, exercise empathy and strive for win-win outcomes.

Find out more about Phyllis and her experience in coaching as she presents, “Understanding and Effectively Managing Bullying & Incivility in Your Perioperative Department” and “Emotional Intelligence at Work: Focus on social awareness and relationship management” at the 2019 OR Today Live Surgical Conference.

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Daniel Bobinski, M.Ed. is a certified behavioral analyst, a best-selling author and a popular speaker at conferences and retreats. He loves working with teams and individuals to help them achieve workplace excellence. Reach Daniel through his website, www.MyWorkplaceExcellence.com.

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AUGUST 2019 | OR TODAY |

SPEAKER SPOTLIGHT

OUT OF THE OR nutrition

10 Things to Know About the Mediterranean Diet health.com iet fads tend to come and go: One day we’re eating low-fat, low-calorie and low-sugar foods; the next we’re eating like cavemen, or giving up meat, or eating only cabbage and grapefruit. But while many diets have had their moment in the spotlight, there’s one diet that has endured – the Mediterranean diet.

Research proves over and over again that people who put an emphasis on produce, fish, whole grains and healthy fats not only weigh less, but also have a decreased risk for heart disease, depression and dementia. So, what are you waiting for? Here are the basics: Shop the market perimeter, eat seasonally and break (whole-grain) bread with people who make you smile. Now for the nitty-gritty.

compounds called polyphenols. • Pick seeds, nuts and legumes: These are a great source of fiber and protein; nuts and seeds also provide healthy fats and antioxidants. Eat a serving of legumes (1/2 cup, cooked) – found in hummus or lentil soup – at least twice a week, and a small portion of nuts daily (about 1 tablespoon, or 10 to 12 almonds or walnut halves). • Focus on fish and eggs: Aim to eat a 4-ounce serving of fish (about the size of a checkbook) two to three times a week. Eggs are also on the menu: whip them into a vegetable frittata. Lean meat and poultry are OK, too, in moderation.

• Pile on fruit and vegetables: Fresh, nonstarchy produce is the star of this diet. Eat 5 to 10 servings a day (1/2 cup cooked or 1 cup raw equals one serving). • Choose healthy fats: Olives and their oil are cornerstones; go for 4 to 6 servings per day (a serving could be 1 teaspoon of olive oil, 5 olives or 1/8 of an avocado). Olive oil delivers healthy monounsaturated fats and plant

• Get grain-wise: Refined carbs lack nutrients and can wreak havoc on your blood sugar. Whole grains are best; have four small daily portions of whole-wheat bread, or try a pasta made from quinoa. And always eat

grains with healthy fats and protein. Incorporate sprouted or fermented grains (hello, sourdough!) for easier digestion and better nutrient absorption. Or, look for creative ways to swap out grains, such as using spaghetti squash in place of noodles. • Add herbs and spices: They’re full of plant compounds with antioxidant and inflammation-fighting effects – and you can often use less salt when your food has more flavor. • Rethink what you drink: Make water a go-to. Many Mediterraneans sip espresso after meals to aid digestion. In North Africa, they choose antioxidantrich green tea combined with mint for the same reason.

SHARON A. MCNAMARA,

Sharon A McNamara RN, BSN, MS, CNOR Perioperative ConsultantOR Dx + Rx Solutions for Surgical Safety

AUGUST 18-20 | LAS VEGAS, NV

• Do have (some) dairy: Work in some dairy from cultured milk (kefir, yogurt, fresh curd cheeses like ricotta); it’s easier to digest and supplies beneficial bacteria that contribute to digestive health. Enjoy one to three servings daily (a serving is 1 cup of milk or yogurt or 1 ounce of cheese).

56 | OR TODAY | AUGUST 2019

In 2005-06 I was national President of the Association of periOperative Registered Nurses (AORN). Our prime initiative that year was medication safety. We had a comprehensive medication toolkit to assist practitioners with implementation of evidence-based safe medication preparation and administration. As part of a national rollout campaign there was a TV camera crew filming medication preparation during a surgical procedure at the hospital where I was Director of Surgical Services. I was overseeing the cameraman for patient confidentiality appropriateness when I noted that the RN circulator was called from the bedside. The patient appeared anxious so I stepped up, took his hand and told him the surgeon was minutes away and that I would keep him comfortable and we would wait together. The patient immediately stopped moving and relaxed. What followed was a great “ah ha” moment for me. The media person waiting out of the patient’s view immediately honed in and was photographing the patient and my hands. He pointed out with his camera the difference being made in that room by one nurse who assessed the patient’s anxiety, communicated to the patient what was happening, offered the comfort of waiting together and allayed the patient’s anxiety. Perhaps it took the photographer’s eye to see the visual symbol of all the nursing expertise in holding a patient’s hand. A simple act that we, as Registered Nurses, perform daily but there was much more assessment, planning, and communication happening during that compassionate care act and it took a photographer’s eye to point it out. I am so proud to be among the many hand holding RNs that give competent, safe, quality care to patients across this globe. •

RN, BSN, MS, CNOR

Find out more about Sharon and her experience in patient care as she presents, “Leadership Across the Generations” and “Sharps Safety — Are We on the Cutting Edge?” at the 2019 OR Today Live Surgical Conference.

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• Eat locally: By following the seasons, you’ll broaden the range of nutrients you take in over the year. • Make it social: Relaxed meals with family and friends are a core part of life in this region. This positive attitude toward eating helps improve digestion and can lower stress too. – Health delivers relevant information in clear, jargon-free language that puts health into context in peoples’ lives. Online at www.health.com. WWW.ORTODAY.COM

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OUT OF THE OR

Recipe

recipe

the

58 | OR TODAY | AUGUST 2019

OUT OF THE OR

Grilled Cornish Hens with Peach Glaze and Grilled Peaches

Cornish Hens Ideal for Grill

INGREDIENTS: • 2 Cornish game hens (about 1 to 1 1/2 pounds), each • 2 small peaches, pitted and halved • Mint leaves, for garnish

• • • •

For the marinade: 1/3 cup olive oil 1/3 cup lemon juice Zest of 1 lemon 1 medium shallot, finely

eople are often confused on what the difference is between a Cornish game hen and a small chicken. Actually, the Cornish game hen is a cross between a Cornish hen and White Plymouth Rock chicken. It may be a different breed than a regular chicken, but it is in fact a small chicken, usually weighing about 1 1/2 pounds. I often roast these small birds alongside cabbage and apples in the cold weather. For warm weather, I like to cook them on the grill. This recipe, with grilled peaches served alongside, receives repeated requests from friends and family throughout the season. These small birds are not particularly flavorful, so the marinade is a big taste enhancer. Butterflying the birds and then flattening them allows them to cook quickly and evenly. It’s best to use a heavy weight on top while grilling to keep the birds flattened. It’s easy to butterfly the hens, but feel free to ask your butcher to do it for you,

chopped • 2 garlic cloves, minced • 1/2 cup peach nectar, I use Kerns • Coarse ground black pepper, to taste • 1 1/4 teaspoons favorite seasoning salt For the glaze: • 7 1/2 ounces peach nectar (I use Kerns)

recipe

making sure the backbone is removed. The marinade does double duty as both a marinade for the chicken and then a foundation for the peach glaze. I use Kerns nectar, which is in an 11.5-ounce container. You will need the whole can here for both the marinade and the glaze. You’ll notice that the hens are grilled completely on both sides before you brush on the glaze so that they will not burn. The grilled peaches are a nice accent to the slightly sweet and tart hens. You can serve these whole, but I prefer to cut them in half with poultry shears and overlap them on a platter with the peaches surrounding them. If you aren’t a fan of peaches, you can substitute apricot nectar and apricot halves. You can also double this recipe, but the reason this recipe says it serves 2 to 4 is because some people will only want half while others may enjoy a whole hen. Serve these hens with rice, pasta or farro.

Grilled Cornish Hens with Peach Glaze and Grilled Peaches SERVES 2 TO 4 1.

2. 3.

4. 5.

BY Diane Rossen Worthington is an authority on new American cooking. She is the author of 18 cookbooks, including “Seriously Simple Parties,” and a James Beard Awardwinning radio show host. You can contact her at www.seriouslysimple.com.

6. 7.

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Butterfly the hens by cutting out the backbone. Turn the birds skin side down, and use kitchen shears to cut out their backbones. Use your hands to flatten the birds so they will cook evenly on the grill. (You can ask your butcher to do this for you.) In a medium bowl combine all marinade ingredients. Divide marinade in half, reserving half of the mixture for the glaze to baste hens. Place hens in a large lock-top plastic bag. Flatten them in the bag. Pour half of the marinade (about 3/4 cup) over the hens. Release excess air from bag and seal. Move marinade around so it coats the hens evenly. Refrigerate and allow hens to marinate for 2 to 8 hours. For the glaze: Place the nectar in a small saucepan on medium-high heat. Reduce the mixture to a glaze consistency, about 5 minutes. Add the remaining marinade to the glaze and mix to blend. Reserve. Heat the grill for medium-high heat grilling. Remove hens from marinade and place, skin side up, on the grill. Flatten with a heavy brick covered in foil or a heavy press. Grill for about 12 minutes, or until golden brown. Turn the hens over, skin side down, flatten with the heavy brick or heavy utensil, and grill another 10 to 12 minutes or until hens are golden brown. Turn hens back over and brush with the glaze on both sides. Finish grilling when the skin is brown and crisp. While the hens are finishing on the grill, brush the flat-sides of the peach halves with remaining glaze and grill flat side down for about 5 minutes or until the peaches have grill marks and are hot. Place the hens on a cutting board, and let rest 5 minutes. Cut each hen in half and then overlap the halves on a platter. Arrange the peaches around the side, garnish with mint leaves and serve.

AUGUST 2019 | OR TODAY |

The News and Photos

OUT OF THE OR

that Caught Our Eye This Month

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Ely Bloomenson Community Hospital Surgical Department

Kids are still out of school and parents are looking for ways to get them outside and active. One of the best ways to get kids to put the tablet down is to explore the fun that can be had hiking.

•

Have them carry snacks such as trail mix, raisins and candy bars.

•

If a child is missing, begin your search immediately and call 911 as quickly as possible.

•

“My company creates hand-crafted, high-quality,

Preparation is essential when hiking with children.

made in the U.S. hiking and walking sticks. We’re

Preparation should include mapping out the hiking trails

also happy to help spread the message of follow-

ahead of time. Hikers should also be ready to keep kids

ing simple safety steps to ensure fun is had on

hydrated, warm and fed.

every family hiking excursion,” explains Owen.

Warren Owen, Director of Brazos Walking Sticks, who

•

What parents should teach their child to do if they get lost while hiking, according to Warren Owen:

produces incredibly beautiful and functional walking sticks for hikers says the following safety tips should be

•

Stay calm.

followed when hiking with kids:

•

Stay put. Hug a tree near a clearing to make your-

•

Keep children in your sight.

•

Dress them in brightly colored clothing with

self more visible. •

ible but out of the wind.

multiple layers to accommodate the changing temperatures. •

Give them a whistle in case they get lost. A

Stay warm. Find a protective spot that is still vis-

•

Stay noisy. Frequently blow your whistle or yell as loud as you can.

whistle can be heard farther than a child yelling.

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AUGUST 2019 | OR TODAY |

INDEX

advertisers

Alphabetical ACT-Paragon……………………………………………………… 4

Cygnus Medical…………………………………………………… 9

ORT Webinar Series…………………………………………IBC

Action Products, Inc.…………………………………………17

Healthmark………………………………………………………… 24

Pure Processing………………………………………………… 10

AIV Inc.…………………………………………………………………19

ImageFIRST…………………………………………………………15

Ruhof Corporation……………………………………………2, 3

ALCO Sales & Service Co.……………………………… 57

Innovative Medical Products………………………… BC

TBJ Incorporated…………………………………………………41

ASCA……………………………………………………………………51

MD Technologies inc.……………………………………… 55

Tetra Medical Supply Corp.………………………………21

Avante Patient Monitoring……………………………… 53

MedWrench……………………………………………………… 40

TIDI………………………………………………………………… 22, 23

BD……………………………………………………………………… 47

Microsystems……………………………………………………… 5

C Change Surgical……………………………………………… 6

Mobile Instrument Service & Repair………………13

categorical ANESTHESIA

GENERAL

APPAREL

HOSPITAL BEDS/PARTS

ASSET MANAGEMENT

INFECTION CONTROL

ACT-Paragon……………………………………………………… 4 ImageFIRST…………………………………………………………15 Microsystems……………………………………………………… 5

AIV Inc.…………………………………………………………………19 ALCO Sales & Service Co.……………………………… 57

ACT-Paragon……………………………………………………… 4

ALCO Sales & Service Co.……………………………… 57 Cygnus Medical…………………………………………………… 9 Healthmark………………………………………………………… 24 Pure Processing………………………………………………… 10 Ruhof Corporation……………………………………………… 2 TBJ Incorporated…………………………………………………41 TIDI………………………………………………………………… 22, 23

CARDIAC PRODUCTS

INSTRUMENT STORAGE/TRANSPORT

ASSOCIATION

ASCA……………………………………………………………………51

BIOMEDICAL

C Change Surgical……………………………………………… 6

CARTS/CABINETS

ACT-Paragon……………………………………………………… 4 ALCO Sales & Service Co.……………………………… 57 Healthmark………………………………………………………… 24 ImageFIRST…………………………………………………………15 TBJ Incorporated…………………………………………………41

CS/SPD

Cygnus Medical…………………………………………………… 9 Ruhof Corporation……………………………………………… 2 TIDI………………………………………………………………… 22, 23

INSTRUMENT TRACKING

Microsystems……………………………………………………… 5

MONITORS

Avante Patient Monitoring……………………………… 53

WEBINAR SERIES

REPROCESSING STATIONS

Pure Processing………………………………………………… 10 Ruhof Corporation……………………………………………… 2 TBJ Incorporated…………………………………………………41

SAFETY

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62 | OR TODAY | AUGUST 2019

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START LEARNING TODAY! ORTODAY.COM/WEBINARS OR TODAY HAS BEEN APPROVED AND IS LICENSED TO BE A CONTINUING EDUCATION PROVIDER WITH THE STATE OF CALIFORNIA BOARD OF REGISTERED NURSING. LICENSE NO. CEP 16623

who understands patient and surgeon needs Enhanced Humbles LapWrap® Positioning Pad

Loop the LapWrap® tab around the side rail of the OR table.

The LapWrap’s® tab configuration also makes positioning bariatric patients easier.

Bariatric Patients are no problem.

Now you can secure your patient in place.

Designed to prevent tissue injury. Arms stay where you put them during the procedure.

Use the optional extensions to secure the extremely obese.

Adaptable to all size patients.

Keep arms securely positioned.

Now even more secure with two-way performance! Anesthesiologist Frank Humbles, M.D. knows the importance of patient positioning. The Enhanced Humbles LapWrap®. • • • •

Positions patients arms while allowing easy access for leads and IV’s Secures patient to OR table Is dual sided for increased flexibility Optional extensions can be attached for the extremely obese

Free Sample Evaluation

Call 800-467-4944 and reference promo code “Secure” for your free Humbles LapWrap® sample today.*

The operative word in patient positioning. www.impmedical.com

For more info or to order call 1-800-467-4944

Designed to meet

AORN

recommendations *While supplies last

The LapWrap® was designed to meet AORN recommendations in “Recommended practices for positioning the patient in the perioperative practice setting” to prevent tissue injury and ischemia that may be caused by tucking a patient’s arms at his or her side.

US Patent No. 8,001,635 AORN is a registered trademark of AORN, Inc. AORN does not endorse any commercial company’s products or services.