A review of disease surveillance records by Massachusetts health authorities has found asthma is the one chronic condition that is far more common than any other among patients hospitalized with H1N1 infections. Asthma was present in 31% of swine flu patients who entered Massachusetts hospitals already suffering from longstanding health problems. By comparison, 6% of those swine flu patients had heart problems, and 6% had kidney disease. The findings led specialists to reinforce their admonition that patients with asthma, chronic obstructive pulmonary disease, and other respiratory conditions should be vaccinated against H1N1 as well as the seasonal strain, the Boston Globe reports.
The U.S. Supreme Court's involvement next year on a privacy case regarding text-messaging on work cell phones in the public sector could have implications for private companies like hospitals, experts told HealthLeaders Media.
The case involves text messages sent by members of a California police department—some of which were sexual in nature, according to The Tennessean—and whether or not the employees should have had a "reasonable expectation of privacy" through work cell phone use.
HIPAA privacy and security officers juggle compliance headaches each day because of text-messaging on work phones. Experts told HealthLeaders Media the California case serves as a good reminder for covered entities to treat cell phones and texting as they would any other device that includes protected health information (PHI):
Use appropriate safeguards to avoid breaches
Know HIPAA's privacy and security rule
Consider a policy that prohibits personal text messages on work phones
Be clear that work devices alone do not guarantee the user's privacy
"If text messaging is allowed, it will need to be encrypted and only be sent and received by people with a 'need to know' and within minimum necessary guidelines," says John C. Parmigiani, president, John C. Parmigiani & Associates, LLC, in Ellicott City, MD.
Organizations must have "comprehensive, feasible, and well-written information on security and privacy policies, along with regular training and ongoing awareness communications," says Rebecca Herold, CISM, CISSP, CISA, CIPP, FLMI, an information privacy, security and compliance consultant, author and instructor for out of Rebecca Herold & Associates, LLC, in Des Moines, IA.
"Even though this case is specific to government agencies," Herold adds, "the ruling will likely still be used as an example for all types of organizations with regard to what personnel can reasonably expect with regard to privacy of electronic communications, not only on equipment and systems owned by the organization, but also for non-company-owned equipment that is used for business purposes."
Herold says compliance boils down to a hospital's policy and training programs.
"Hospitals should ensure their policies cover the use of organization-owned computing equipment for non-work purposes, along with using non-organization-owned equipment used for business purposes," Herold says, "and ensure their training and ongoing awareness communications effectively educate their personnel about the requirements and their responsibilities."
Texting is "fairly common" between physicians when communicating about a patient, says Chris Apgar, CISSP, president, Apgar & Associates, LLC, in Portland, OR.
Apgar says he likens text messages sent from company-owned phones to e-mail messages sent via the company's e-mail system.
"In both cases, the employer [covered entity or not] owns the device and, as it has been determined in the past with e-mail, I believe the same legal principle will hold true with text messages—the employer 'owns' the text messages, whether they are work related or not," Apgar says. "The moral of the story is if an employee wishes to send a personal text, he or she should use his or her own mobile device and then, like Web messaging, the text message becomes 'personal property' of the employee or the sender."
During the current COVID-19 pandemic and the outbreak of H1N1 in 2009, the use of N95 respirators versus surgical masks for protection has been a sticking point.
The global COVID-19 pandemic has moved beyond simply dominating daily headlines, it has started to impact Americans' day-to-day lives. Many employees are being told to work from home, schools are closing, and some states have even closed bars and restaurants.
Yet, those who work in healthcare don't necessarily have the ability to do their jobs remotely. Those working on the frontlines need to protect themselves, their patients, their colleagues, and their families from the COVID-19 virus.
But there have been challenges obtaining proper personal protective equipmentduring this outbreak, particularly N95 respirators and facemasks. According to the Centers for Disease Control and Prevention, orders "are up to 10-fold normal demand for these items." On March 10, the CDC updated its recommendations and advised that facemasks for clinical providers are an acceptable alternative when there is a shortage of N95 respirators.
The American Nurses Association has taken issuewith this. While acknowledging the difficulty of ensuring an adequate PPE supply, the organization is concerned that the updated CDC recommendations are based solely on supply chain and manufacturing challenges, according to a news release. Instead of focusing on supply chain demands, recommendations should be based on "evidence that reflects a better understanding of the transmission of COVID-19."
This is not the first time the use of N95 respirators has been debated during a large-scale outbreak. In 2009, there was also disagreement over the useof N95 respirators versus surgical masks during the H1N1 pandemic.
Editor's note: The rest of the article describes this disagreement. This section of the article was written in 2009, but remains popular to our readers and is still timely as the U.S. grapples with a shortage of much needed PPE. For more on the current COVID-19 pandemic, visit this link.
N95 Supply During the H1N1 Outbreak
Since H1N1 outbreaks surfaced in April, infectious disease doctors, employee health managers, healthcare workers, and infection prevention associations have debated a variety of factors regarding the new virus. But without question the most hotly contended issue has been the use of N95 respirators versus surgical masks for protection.
Meanwhile, many wondered if OSHA would take a side, and it released a clarification supporting CDC guidelines that require N95s for protection against H1N1. Healthcare facilities that do not comply could be cited for serious violations under the General Duty Clause or the Respiratory Protection Standard.
"I think these guidelines tell the players and the referees the rules of engagement," says Marge McFarlane, PhD, MS, CHSP, safety consultant and owner of Superior Performance, LLC. "I look at it as tell me what you expect and I'll see what I can do, rather than you come and say, 'Well you didn't make my expectations.' People don't have time to be a mind reader, so for better or for worse OSHA compliance takes the guessing out of what is expected."
Smaller facilities such as outpatient clinics, ambulatory surgery centers, or physician offices may find their procedures don't involve high-risk exposure, or they can initiate other preventative measures to protect staff members.
For example, the first procedure listed on the hierarchy of controls—a list of prioritized infection prevention procedures created by the CDC—is eliminating the hazard of H1N1 whenever possible. Outpatient offices are in a unique position to easily reschedule patients who may have contracted H1N1, reducing exposure to staff and minimizing the need to wear N95s.
"It's really crucial to do a risk assessment because ambulatory care is far, far different from acute care, which is different than long-term care," says Irena B. Kenneley, PhD, APRN-BC, CIC, community health clinical nurse specialist and assistant professor at Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland. "In a risk assessment, you see who is most at risk and what prevention measures can be taken to reduce the risk for each area."
Reusing N95 respirators
One important addition to your respiratory protection plan should be reuse of N95 respirators during a shortage. The OSHA directive indicates that a respirator can be reused as long as it "maintains its structural and functional integrity and the filter material is not physically damaged or soiled."
"Employers must address in their respiratory protection program the circumstances under which a disposable respirator will be considered to be contaminated and not available for extended use or reuse," the directive reads.
Outpatient facilities and doctor's offices may have particular trouble receiving N95 shipments, so reuse of N95s may be a priority. Educate employees to wear a surgical mask over the N95, wash their hands when donning and doffing the respirator without touching the inside, and store it in a breathable bag, McFarlane says.
"Does that take more work than just slapping it on and taking it off? Yes it does, but desperate times call for more attention," she says.
Managing N95 supplies
One of the primary complaints from IPs and safety officers has been that N95s from state or federal stockpiles are often a different brand or style from the hospital, which means employees need to be fit tested again if they are going to use the masks.
Although it is certainly a daunting task to fit test every employee in your hospital a second time, MacFarlane suggests siphoning any outside N95 supplies to a captive population of employees.
For example, ER staff members rarely work outside of the ER, and would have access to their masks all the time, MacFarlane says. Therefore an IP could use the outside supply of respirators to refit that specific population, and save the in-house supply for the rest of the hospital staff members.
"Depending on the size of your hospital you might only have to re-fit test 15, 20, 30 people," MacFarlane says.
Not only will this system save time fit testing employees, it will also provide an effective respiratory protection system, and ensure a sufficient supply for the time being.
"I talked to an infection control practitioner at one of the hospitals and she really thought that idea of just fit testing a captive population might be a good way to transition, and it might buy you just enough time until your regular supplier brings out the masks again," MacFarlane says.
For more guidance on OSHA regulations including the directive for respiratory protection against H1N1, fit testing for N95s, and pandemic preparedness tools, visit OSHA Healthcare Advisor.
Third quarter tax revenue for state and local governments in 2009 fell 6.7% when compared with the third quarter of 2008, marking the fourth consecutive quarter of negative revenue growth, the U.S. Census Bureau announced today.
As in the past, the continuing revenue declines identified in the latest Quarterly Summary of State and Local Government Tax Revenue could prompt more budget cuts for state and local governments, which will likely negatively impact hospitals and other healthcare services that rely on public funding.
Tax revenue for the third quarter totaled $266.5 billion, compared with $285.6 billion reported for third quarter 2008. Of the four largest tax categories only property tax increased; general sales tax, individual income tax, and corporate income tax all continued to decline in the third quarter of 2009.
A further breakdown shows that:
Total property tax revenue increased 3.5% in the third quarter of 2009 to $80 billion from $76.9 billion in the third quarter of 2008. Individual income tax growth was negative over the past four quarters, dropping by 11.7% from the same quarter the prior year. 2009 3Q revenue was $58.2 billion, down from $65.9 billion in 2008, 3Q.
General sales tax growth was down 9%, resulting in the fourth consecutive quarter of negative sales tax growth. General sales tax revenue fell $6.9 billion from $76.6 billion in 2008, 3Q to $69.7 billion in 2009 3Q.
Corporate income tax growth was negative once again, down 18%. 2009 3Q revenue was $9.5 billion, down from $11.6 billion in 2008 3Q.
Orientation is an overwhelming time for new nursing employees, who are faced with learning many systems, processes, and people as quickly as possible. The situation is even more difficult for new graduate nurses, who must overcome the transition from school to practice.
New grads have a tricky balancing act to perform involving learning new skills, committing policies and procedures to memory, prioritizing patients' needs, and even remembering where the supply closet is. Wouldn't it be nice if they had a safe environment in which to practice those skills before being thrust onto the unit and dealing with real patients?
That's the idea behind Phoenix-based Banner Health System's new simulation center. The organization is hoping that simulation holds the key to successfully onboarding new nurses and helping them transition swiftly to become competent, confident nurses.
Waste not, want not
Banner Health opened its first simulation center in 2006 at Banner Good Samaritan Medical Center in Phoenix. The facility proved so popular with the nine Banner facilities in the state that it soon became too small.
Around this time, Banner's Mesa Hospital was moving into a new facility, leaving the organization wondering what to do with an empty medical center. It decided to turn the building into a state-of-the-art simulation training center to be used by all of Banner's facilities in Arizona.
The center was extensively renovated to house the largest simulation center in the country, which passes for a real-life hospital. It includes a 20-bed ED, an 18-bed med-surg unit, a 14-bed ICU, and two ORs. It is filled with a variety of high- and low-fidelity simulation modalities and offers some virtual training. It also hopes to develop virtual avatars to facilitate behavioral health training.
Standardizing training
Carol Cheney, MS, director of simulation and innovation at Banner Health, says the organization decided to create a standardized onboarding program for all nursing staff in the Arizona region, which would involve time at the new simulated medical center.
Previously, each facility had its own orientation and precepting structures. "We did an audit and [found that] all units trained in different ways," says Cheney. "We wondered, who produces the better nurse? And no one had an answer."
Cheney spearheaded a project to create a standardized orientation for all new nursing employees and ushered everyone through the program at the simulated medical center.
She brought teams together to examine what needed to be part of orientation, what was required by regulation, as well as problem areas that could be identified as common across Banner facilities.
"We created a comprehensive curricula surrounding these topics," says Cheney. "We double-checked all policies and procedure guidelines against [Agency for Healthcare Research and Policy and Institute for Healthcare Improvement], so we could bring forward the best evidence-based practice standards."
Skills and scenario-based training
All new hires, whether experienced nurses or new graduates, first go to their own facilities to receive facility-specific orientation. Afterward, they go to the simulation medical center, where they participate in skills training and scenario-based training.
The experienced nurses are guided through short scenarios, but the new nurses must experience four-hour scenarios that are set in the department in which they will work. For example, if they will be working in the ICU, new nurses have a one-to-two patient ratio just like they will have in reality.
The four-hour scenarios involve all aspects of unit life that new nurses will experience. For example, they:
Learn how to perform patient handoffs
Practice patient assessments
Distribute medications
Contact physicians or ancillary services for items their patients need or for patient orders
Enter their documentation in the electronic medical record
"We have a facilitator on the floor to help them," says Cheney. "The real goal is to immerse them in that environment, on a somewhat simplistic level—we're not trying to scare them—to show them the reality of the unit they will be on." After the scenario is complete, the new nurses are debriefed and encouraged to talk through the scenario and what happened. Because the facilitators know exactly what occurred, they can provide coaching and guidance specific to each nurse.
"We do it in a nonpunitive way," notes Cheney. "We don't say, 'Susie, you didn't do this.' What we'll do is talk about the patients and what was happening with the patients."
In essence, the scenarios allow new nurses to practice patient care, critical-thinking skills, documentation, and all of their new responsibilities in a safe environment. "And the beauty is that their [fictional] patients are essentially plastic," laughs Cheney.
Measuring outcomes
Before the program began, Banner surveyed preceptors to identify common problems they were seeing among new graduates. The facility turned these common issues into scenarios for new grads to practice at the simulation center.
Cheney says Banner doesn't want new nurses' time with preceptors to be spent on learning tasks such as how to hook up an IV pump, which can be done in the simulation lab.
Banner wants time spent with the preceptor to be an opportunity for new nurses to develop critical thinking and focus on learning clinically advanced knowledge. The new simulation training center also allows Banner to create a report on each new graduate and his or her particular skills and competence.
"Orientation used to be really arbitrary," Cheney says. "Now we're saying, 'Let's not look at time; let's look at competence.' "
Report summaries based on a series of measurements help identify new nurses' competence level. The reports are provided to each learner and his or her manager, preceptor, and educators, which allows units to individualize training.
The simulation medical center identifies new nurses who are ready to take on a greater patient load, as well as those who struggled with suctioning or tracheotomy care so the unit can help them in that area.
Cheney is also collecting data to refine the training for the long term. "We're able to see, where do people make their errors? Are they procedural errors or are they decision-making errors?" she says.
Cheney plans to examine the data Banner is collecting to identify what really needs attention and what does not. This will allow the organization to refine the program over time and continually work to ensure that new nurses receive the best orientation possible.
Editor's note: This is the second article in a two-part series about nurse residency programs. Part one, which discussed the benefits provided by residency programs, appeared in the November 17 edition of the NurseLeaders weekly e-newsletter.
Benner (1984) told us that upon becoming a nurse, individuals develop in stages based on gaining experience. It is important to note that Benner describes experience not as longevity with the passage of time, but rather as the refinement of knowledge through encounters with many practical situations. Nurses are typically exposed to a variety of patients and care situations along the path to becoming competent. A well-structured nurse residency program can guide the new graduate nurse through exposure to many circumstances, thereby increasing experience, which in turn supports quicker development of competence.
Structuring a program
A nurse residency must be more than an extended orientation. New graduate nurses are not just transitioning to a new job environment, they are transitioning to a new role. This role development includes not only developing clinical skills, but learning to apply critical thinking and becoming acquainted with leadership skills. Residents are no longer nursing students; the focus of a nurse residency should be guidance for application of their knowledge.
Most organizations accept nurse resident applicants as a cohort, which helps manage the program efficiently. Participants also gain an informal support system in their resident peers.
Many programs struggle with how to integrate a didactic component into a nurse residency. Keeping didactics within the cohort can be beneficial, but as residents are working in various clinical specialties, topics must have a general focus. Although clinical exposure is the foundation of a nurse residency, didactics that enhance the experience of the specialty need to be incorporated. In addition, leadership skills should be touched upon during a nurse residency.
The desired outcome of a nurse residency is new graduate nurses who quickly develop into competent, efficient, and confident staff members. Offering flexibility within the clinical structure to consider the nuances of various nursing specialties is crucial to the success of a program.
A successful program also requires preceptors and mentors who are committed to facilitating the growth of nurse residents.
Strong preceptors support the clinical component and guide residents gradually from shadowing to independent practice while ensuring exposure to different situations that lead to competence. Strong mentors support the didactic component by posing various challenges to residents that facilitate their assimilation of knowledge and clinical exposure into competent nursing practice.
Sometimes, the roles of preceptor and mentor may be fulfilled by the same individual. Other times, depending on the scheduling needs for residents or the unit, multiple preceptors may be used. Communication among all those involved with residents is crucial to monitor progress and must extend to the unit's nursing leadership and the nurse residency program coordinator. This can be a formal or informal process but should be defined as part of the program.
Benefits of a nurse residency group
In developing or updating a nurse residency program, the initial considerations should look at activities to support the cohort. A nursing core orientation usually offers an in-depth overview to organizational nursing practice for newly hired nurses. Offering a separate core orientation for the resident cohort may better meet the new nurse graduates' needs.
Bringing the cohort together at defined intervals for education provides the opportunity not only to review various topics relevant across the practice spectrum, but also allows the individuals to build stronger relationships with other nurse residents.
Socialization is an important consideration in job satisfaction, and each nurse resident will integrate with his or her unit's team. But the shared experience of entering the nursing profession together makes the residents true peers who can support each others' development as nurses. And as the cohort successfully completes its journey through the residency, a recognition celebration for the group is in order.
Curriculum and activities
Developing unit-based activities for the nurse residency requires flexibility in guiding the structure of the program. Flexibility allows for program adaptation at the unit level, ensuring that it meets the needs of residents and the unit. Nurse residents typically should not “count in the staffing numbers” for an extended period, so a variety of learning opportunities can fit into scheduled shifts. By having residents and preceptors teamed for patient assignments, there is flexibility for residents to be guided for clinical opportunities or be relieved for didactic components.
Consideration should be given to developing tools or strategies that will help assess and monitor progress. A tracking tool that notes residents' exposure to skills and processes can offer insight. Creating a unit-specific tool can outline various assessment skills, equipment, procedures, specific medications, or documentation standards needed within the unit's specialty. It could be formatted for daily or ongoing use and it can note opportunities to observe or perform. Whatever tools are developed should be simple to use and have the purpose of guiding the resident-preceptor teams in structuring the clinical experience for variety and challenge.
The didactic component of a nurse residency should guide and support residents as adult learners and be addressed at the unit level and for the cohort. Mentors can facilitate residents' incorporation of clinical experiences and knowledge. It is this incorporation that leads to competency and efficiency and gives new nurses confidence in their practice.
Routine meeting time between residents and mentors away from the clinical setting can be used for discussion and review. This time may include going over new clinical experiences, knowledge that is important to the specialty area, or case studies, all avenues to reinforce learning.
Additional education can be accomplished through granting self-study or guided time. Residents can complete assignments that will benefit integrating specifics into their practice. This might include review of unit-based competencies or unit-based policies and procedures or specific classes such as ACLS. Residents may be assigned to visit alternative sites that give insight into the continuum of care for the patient. For example, a resident on a cardiac care unit might visit the cath lab, or a resident on a postsurgical unit might visit the operating room.
Residents should also have exposure to understanding nursing leadership. Mentors should take responsibility for introducing residents to issues such as resource utilization, peer review, and quality improvement. Shadowing a nurse leader at the organizational or unit level can give residents perspective on the demanding challenges of a nurse leader.
Length
Organizations offer various timelines for their programs, but be flexible with the prescribed program length to accommodate the needs of each specialty practice. Whatever the required length of time, participant evaluation is needed to monitor progress. Input for the evaluation should come from the preceptors, mentors, and unit nurse leaders and be shared with the resident program coordinator. Self-evaluation should be offered to residents, and peer evaluations from other nurses could be considered. In addition, nurse residents should have the opportunity to evaluate their preceptors and mentors.
When developing or updating a nurse resident program, start by setting objectives for participants to accomplish. There may be objectives for the cohort, with additional objectives for the resident's unit. The program's main goal is always competent nurses, regardless of the outlined objectives. By combining the structure of a nurse resident cohort with flexibility at the unit level, this goal will be accomplished.
Reference
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.
Vicky Goeddeke, RN, MS, CEN, CPEN, is the ANCC Magnet Recognition Program® and nursing excellence manager at Northwest Community Hospital in Arlington Heights, IL.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
What New Year resolutions are nurse executives making this year? Savvy ones are vowing to pay attention to nurse retention once again.
The recession saw an easing of RN shortages and turnover rates around the country, allowing many facilities to put nurse retention initiatives on the back burner. Budgets for recognition and reward initiatives were slashed as belts were tightened everywhere.
But with many economists predicting the green shoots of recovery will flourish into leaves in 2010, the effects will be felt in nurse employment. The recession and high unemployment caused a drop in RN vacancy rates nationwide. As spouses lost their jobs or feared layoffs (70% of RNs are married), nurses picked up extra shifts or went from part-time to full-time. Some returned to the workforce and many who had been considering retiring delayed their plans.
Organizations saw their turnover plummet and their vacancy rates look healthier than they had in years, so they eased up on recruitment and retention efforts. But 2010 looks set to bring back the twin issues that have plagued nursing for the last few years: RN shortages and turnover.
Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies in the Institute for Medicine and Public Health at Vanderbilt University Medical Center, predicts that as the economy recovers, nurses who returned to the workforce or who took on more hours to make ends meet will leave the workforce again. Those who delayed retirement will start considering their exit strategies, although they may still have to work a little longer to rebuild retirement incomes that were devastated by stock market declines.
Of course, many economists are predicting unemployment will remain high in 2010, which could delay the return of the shortage, but that doesn't help organizations that want to begin expansion work in 2010, who will need additional nurses to staff the new construction.
So it's worth taking a look at your workplace development strategies and examining what might be in store in the next year. Your RN demographics will show you what percentage of your staff is likely eyeing retirement and you can also examine turnover and vacancy statistics to consider historical trends.
It's also a good idea to conduct an RN satisfaction survey if you haven't done one in a while. If your organization has suffered through layoffs, you may think the last thing you want to do is ask nurses how unhappy they are. But surveying them now could elicit interesting findings. If you find out what your nurses' priorities are, you may be surprised that many, if not all, do not involve money.
There are many ways to improve the nurse working environment without significant financial expenditure, and savvy organizations are looking at:
Restructuring care delivery systems to match the needs of key patient populations
Redesigning nursing roles, including cross-training staff for increased flexibility
Paying attention to the needs of older employees and offering options such as shorter shifts
Focusing on succession planning and starting career development pathways so that nurses possess the skills needed to fill key positions as they become available
Offering recently retired employees options to return to work in some capacity, such as specialized roles mentoring or training new nurses or tackling committee work
It's also worth noting that the long-term nursing shortage is not going anywhere. Buerhaus says the shortfall in the number of nurses needed is expected to grow to 260,000 by the year 2025. To increase the nurses in your pipeline, there are long-term strategies to focus on now that can increase the supply of staff for your organization:
Partner with schools of nursing to provide adjunct faculty and increase opportunities for clinical placements where nursing students can gain experience
See whether local colleges and universities will agree to tuition reduction for staff interested in continuing education
Partner with public schools to offer job shadows, career exploration programs, and summer internship programs
Putting nurse retention on your list of resolutions now will ensure your plans are in place for whatever 2010 brings.
Note: You can sign up to receiveHealthLeaders Media NursingLeaders, a free weekly e-newsletter that offers concise updates on the top nursing leadership headlines of the week from top news sources.
The U.S. Health & Human Services Department plans to build a universal database of claims records from all healthcare payor organizations in an effort to strengthen its analysis of healthcare trends and treatment outcomes. In a notice outlining the project, HHS said the database, which could be expanded to include other types of health records, would broaden the data field against which to conduct comparative effectiveness research, Government Health IT reports.
International Business Machines Corp. is providing financing to help at least four companies put their medical records into digital format, aiming to extend its benefits from the U.S. healthcare stimulus bill. IBM has signed financing agreements with Siemens Healthcare, which develops electronic medical records, and three other healthcare businesses whose clients are converting data into digital form, IBM announced. IBM, the world's largest computer-services provider, said it has hardware and consulting services that can be packaged with the financing agreements, Bloomberg.com reports.
This article in the Wall Street Journal shows how one patient is keeping tabs on the doctor appointments and medication lists of his elderly father, who lives 80 miles away; how a patient is monitoring her asthma daily with a free mobile application; and how another person improved her diet and health with a free body-weight, exercise, calorie, and energy tracker that can be accessed through an iPhone.
