More than half of catheterized hospital patients experience complications, a new study finds.
Catheter-associated urinary tract infections are a well-known issue related to urinary catheters. However, a new study in JAMA Internal Medicine finds the devices can cause more issues than previously thought. In fact, UTIs are five times less common than non-infectious problems caused by indwelling urinary catheters.
In-depth interviews and chart reviews from more than 2,000 patients found more than half of catheterized hospital patients experienced a complication of some kind.
The issues ranged from pain, bloody urine and activity restrictions while the catheter was in, to problems with urination and sexual function after it was removed.
“Our findings underscore the importance of avoiding an indwelling urinary catheter unless it is absolutely necessary, and removing it as soon as possible,” says the study's lead author Sanjay Saint, MD, MPH,chief of medicine at the VA Ann Arbor Healthcare System, George Dock professor of internal medicine at the University of Michigan and director of the U-M/VA Patient Safety Enhancement Program.
A Wide Array of Issues
For the study, Saint and his colleagues from U-M, VAAAHS, and two Texas hospitals analyzed data from 2,076 patients who had recently had a catheter placed for short-term use. Most catheters were placed because the patients were having surgery. Researchers followed-up with patients two weeks after catheter placement and again one month after their catheter placement to ask about their catheter-related experience.
Nearly three quarters of the patients were male, and the catheter was removed within three days of the insertion for 76% of patients. Among the study's findings:
Just over 10% of patients reported infections
55% of patients reported at least one complication of a non-infectious kind
31% of patients whose catheters had been removed at the time of the first interview said it hurt or caused bleeding coming out.
More than half of those interviewed while the catheter was still in place said it was causing them pain or discomfort.
One in four patients reported the catheter had caused bladder spasms or a sense of urgency about urinating.
10% said the catheter led to blood in their urine.
Nearly 40% of patients interviewed while a catheter was still in place, said it restricted their daily activities
About 20% who had their catheters removed said they experienced urine leakage, or difficulty starting or stopping urination.
“While there has been appropriate attention paid to the infectious harms of indwelling urethral catheters over the past several decades, recently we have better appreciated the extent of non-infectious harms that are caused by these devices,” says Saint.
The nurse practitioner group aims to raise awareness of NPs' roles in expanding primary care access.
Access to primary care providers has been a growing concern in recent years, particularly as the U.S. population ages and requirements set forth by the Affordable Care Act take full effect.
However, the organization says the shortage would be lessened if nurse practitioners and physician assistants were integrated into a system that emphasizes team-based care.
Still, some physician groups continue to push back against removing NP scope-of-practice barriers. In November 2017, the American Medical Association called for a resolutionto create a strategic campaign to oppose legislation that includes the National Council of State Boards of Nursing'sAPRN Compact licensure model and independent practice. The model would allow advanced practice registered nurses to have one multistate license that provides the ability to practice in all compact states.
But this week, at its 2018 National Conference in Denver, Colorado, the American Association of Nurse Practitioners unveils a strategic campaign of its own. The multimillion-dollar integrated "We Choose NPs" campaign aims to raise public awareness of the role NPs play in expanding access to primary care.
NPs Boost Access to Care
The latest numbers from the AANP show the NP profession is a growing force. Currently, there are more than 248,000 NPs licensed to practice in the U.S., and about 23,000 NP students enter the workforce each year.
"NPs are the provider of choice for millions of families across the United States," says AANP's President, Joyce Knestrick, PhD, C-FNP, APRN, FAANP, in a news release. "We conduct over one billion patient visits each year. From rural to urban areas, and in every care setting, NPs are leading the way in providing high-quality, accessible health care for all. This year's conference and our new campaign demonstrate NPs' unparalleled commitment to expanding primary care access—and emphasizing patients' choice of primary care providers."
CNO Katie Boston-Leary says bold nurse leaders are the key to moving the nursing profession forward.
Nurses can influence change in healthcare and, if given the opportunity, be drivers of innovation.
But to reach their full potential in improving quality and outcomes, enhancing an organization's culture, and reshaping care delivery, they need strong nurse leaders who are willing to be their advocates in the C-suite.
Katie Boston-Leary, RN, MBA, MHA, BSN, CNOR, NEA-BC, former chief nursing officer and senior vice president of patient services at Union Hospital in Elkton, Maryland, and chief nursing officer at University of Maryland Prince George's Hospital Center in Cheverly, Maryland, recently shared with HealthLeaders Media three ways nurse leaders can help the nursing profession advance healthcare delivery.
1. Be Proactive Leaders
The shift to value-based care, while necessary, is posing a challenge for nurse leaders, who may feel like they have one foot in two boats as they try to manage a dual reality—the long-standing fee-for-service models still in use, plus the outcomes-based models that are increasingly being adopted.
"The value-based approach to care, which is a much-needed change, has many challenges for leaders and organizations as we are making tough changes with declining reimbursement and the financial penalties that come with it while we continue to care for very sick patients," Boston-Leary says.
Yet, however large these obstacles are, they also present an enormous opportunity for nurse leaders to reshape care by creating new ways to best utilize nurses in this updated care model.
"We are now recognizing that we are appropriately in the business of maintaining wellness, so how do or will our bedside nurses fit into that strategy? Strategies should not be constrained to providing care within the four walls, but well outside of that, and we should be able to measure impact on outcomes," she says.
Nurse leaders should be taking a proactive approach and creating solutions that will move nursing and healthcare into the future. "It's that adage of skating to where the puck is going," Boston-Leary says.
2. Be C-suite Advocates
The key to moving forward is having strong nurse leaders who are willing to advocate for nursing in the C-suite.
"It is really being able to have nurse leaders that can stand with their finance person, with their CEO, and work to get proper data analytics or IT resources to better utilize and manage nursing resources," she says.
"When our frontline nurses are stretched with managing volume and high acuity, nurses barely have time to perform value-added care that is meaningful versus what we see today—less critical thinking and largely computer-driven protocols, which is 'color by numbers' nursing care," she explains.
In addition, she notes, "in many organizations, nursing productivity and [patient] acuity is not measured well. Yet in most cases, staffing decisions are being based on singular data points that are forcing nurse leaders to make decisions that will hurt their team and will cause them to lose top talent."
Boston-Leary points to the hospital census as an example of this. When one of Union Hospital's pediatric units had issues with patient volume and nurse retention, instead of relying on the traditional low-census day model of nurse staffing, Boston-Leary came up with an alternative solution.
"At Union Hospital, we had a small pediatric unit challenged with declining volumes and occasional spikes without having enough staff to care for patients. We also had high turnover and low retention with nursing," she says.
"A quick phone call from me to the large reputable pediatric hospital, pitching an idea for that hospital to run our pediatric unit, resulted in a management service agreement with that hospital two years later. Nurse leaders need to take the lead with these types of collaborative strategies with the support of their peers in the C-suite," Boston-Leary says.
Boston-Leary advises nurse leaders to look at data trends and put together a proposal for their C-suite peers on how they plan to manage workforce and labor expense.
"That innovation and taking that entrepreneurial approach and using analytics is what we need to do in a more proactive way," she says. "Otherwise, of course your CFO or CEO is going to need answers and implementation of changes that nurse leaders will not be comfortable with, and you're not going to be left with much choice. Then you're sunk. When you're in the red in terms of your variances, that doesn't leave enough lead time to try new innovative ideas without the financial pressures for an immediate turnaround."
3. Empower Your Nurses
C-suite level support for nursing innovation is necessary to effect organizational change.
"For you to be able to impact your nurses at the grassroots level, you need to be able to be at the table as a nurse leader and impact decisions," says Boston-Leary, "because in a lot of organizations nursing is the largest resource."
And nurses can come up with amazing solutions when they have support, she says.
"Empowerment reveals the goldmine of talent and innovation you have within your building that we typically don't take advantage of. I think taking that lid off and being less oppressive with our policies and empowering people breeds innovation," she says.
That is why Union Hospital stresses empowerment during its nurse residency program.
"That's the one thing that we impress upon folks when they come in here new to practice—that you are a leader at the bedside. That is important for people to know early in practice," says Boston-Leary. "There's no submission here. You have a voice, these are your avenues, and we want you to be an innovator, too."
In fact, each nurse residency cohort at Union Hospital puts forth a research-based idea that the hospital can implement. "We have a major presentation at graduation that we also turn into actionable items for change in our organization," she says.
One example is the creation of a tranquility room where staff members can go when they need to de-stress during a shift. "We saw marked improvement with our RN satisfaction scores in almost every domain in comparison to two previous years, as nursing felt that they were being listened to," Boston-Leary says.
AACN and AONE join forces to advance new care models and improve nursing workforce readiness.
Nurse leaders have several concerns regarding the nursing workforce. First off, will there be an adequate supply of RNs to care for those in need of healthcare? Second, will these nurses have the education, skills, and training to function in an evolving, value-based environment?
To address these issues, the American Association of Colleges of Nursing and the American Organization of Nurse Executives have formed a new national strategy to strengthen alignment between practice and academia. The goal of the collaboration is to advance innovative solutions to meet the demands of the current and future healthcare system.
As part of its mission, the newly formed AACN-AONE Advisory Committee will “co-create models of care, workforce readiness, and a lifelong continuum of learning to optimize the impact of nursing on health and wellness.”
“AACN and AONE have made the commitment to speaking in one voice on the need to work together to create new models of care and nursing education that support a highly educated nursing workforce,” says committee co-chair Judy Beal, in a news release. “We acknowledge the urgency with which we must as partners address serious workforce issues that have an impact on the health and wellness of not only the nation but also our nurses. While the AACN and AONE have been partnering since 2013 on the development of guiding principles and a toolkit for leaders to enhance academic-practice partnerships, the AACN 2016 report, "Advancing Healthcare Transformation—A New Era for Academic Nursing," has created new momentum for action"
At its May meeting in Washington, D.C., the committee outlined two strategic priorities:
Develop and implement a campaign for nursing leaders from academia and practice to influence appropriate leaders that they must partner to address expected workforce shortages through models of care and models of learning
Encourage and facilitate academic and practice leaders to identify opportunities and challenges to forging effective partnerships
“The public trusts that an expert nurse will care for them in their time of need. We have the responsibility to live up to that trust,” said committee co-chair Deborah Zimmerman. “It is time for us to change traditional paradigms and ensure synergy between the needs of the population, sufficient nurses across the continuum, and that models of care impacting health align."
The new AACN-AONE Advisory Committee will advance previous collaborative work, which centered on developing exemplar academic-practice partnerships, by the two nursing organizations.
AACN and AONE join forces to advance new care models and improve nursing workforce readiness.
Nurse leaders have several concerns regarding the nursing workforce. First off, will there be an adequate supply of RNs to care for those in need of healthcare? Second, will these nurses have the education, skills, and training to function in an evolving, value-based environment?
To address these issues, the American Association of Colleges of Nursing and the American Organization of Nurse Executives have formed a new national strategy to strengthen alignment between practice and academia. The goal of the collaboration is to advance innovative solutions to meet the demands of the current and future healthcare system.
As part of its mission, the newly formed AACN-AONE Advisory Committee will “co-create models of care, workforce readiness, and a lifelong continuum of learning to optimize the impact of nursing on health and wellness.”
“AACN and AONE have made the commitment to speaking in one voice on the need to work together to create new models of care and nursing education that support a highly educated nursing workforce,” says committee co-chair Judy Beal, in a news release. “We acknowledge the urgency with which we must as partners address serious workforce issues that have an impact on the health and wellness of not only the nation but also our nurses. While the AACN and AONE have been partnering since 2013 on the development of guiding principles and a toolkit for leaders to enhance academic-practice partnerships, the AACN 2016 report, "Advancing Healthcare Transformation—A New Era for Academic Nursing," has created new momentum for action"
At its May meeting in Washington, D.C., the committee outlined two strategic priorities:
Develop and implement a campaign for nursing leaders from academia and practice to influence appropriate leaders that they must partner to address expected workforce shortages through models of care and models of learning
Encourage and facilitate academic and practice leaders to identify opportunities and challenges to forging effective partnerships
“The public trusts that an expert nurse will care for them in their time of need. We have the responsibility to live up to that trust,” said committee co-chair Deborah Zimmerman. “It is time for us to change traditional paradigms and ensure synergy between the needs of the population, sufficient nurses across the continuum, and that models of care impacting health align."
The new AACN-AONE Advisory Committee will advance previous collaborative work, which centered on developing exemplar academic-practice partnerships, by the two nursing organizations.
To improve access to care, a project at Florida Atlantic University aims to educate nurses in primary care delivery.
As the healthcare system shifts to one that emphasizes value over volume, an important question becomes, "What should the nursing roles of the future look like?"
It's a given that nurses will remain key to achieving optimal clinical outcomes, quality metrics, and patient satisfaction scores. However, how and where they accomplish these objectives may look very different than it has in the recent past.
Florida Atlantic University’s Christine E. Lynn College of Nursing recognizes this and, as a result, is launching the four-year project, "Caring-based Academic Partnerships in Excellence RNs in Primary Care,” to change the way it educates registered nurses.
The project's goal is to recruit and prepare nursing students and RNs to practice the full scope of their license in community-based primary care teams.
“The overarching goal of our project is to create healthier communities in rural and underserved populations,” Karethy A. Edwards, DrPH, APRN, project director, associate dean of academic programs and a professor in FAU’s College of Nursing says in a news release. “With this latest grant from HRSA, we will educate and provide clinical training to establish a primary care workforce of students with a bachelor of science in nursing degree who are practice ready and willing to serve our veterans and patients in rural and underserved communities.”
“This grant will position the Christine E. Lynn College of Nursing as a leader in the national initiative to enhance the role of registered nurses in primary care and promote health equity in this region,” said Marlaine Smith, PhD, dean of FAU’s College of Nursing. “We are proud to join forces with our outstanding project partners to help fill the gap in the delivery of primary cares services, especially for our veterans and vulnerable populations.”
The goal of this collaboration is to increase access to care while emphasizing prevention and control of chronic diseases in non-institutional settings.
Serving the Underserved
The state has room for improvement when it comes to delivering primary care.
Yet, many of the state's residents, are in need of these types of services. Approximately 3.3 million Medicare recipients seeking primary care and behavioral health services live in the state. Additionally, the state's minority populations, which often face health disparities like higher rates of heart disease, stroke, and diabetes, are growing. Florida is also home to 1.5 million U.S. veterans.
Together with its community-based partners, the project aims to:
Deliver high-quality and accessible primary care services
Support a diverse group of primary care oriented BSN students
Develop RN preceptors' knowledge, skills, and experiences to enable them to practice at the full scope of their licenses
Create and implement evidence-based learning experiences
Build a value-added model and team to develop and implement strategies to connect program graduates with primary care employment opportunities that serve veterans and rural and underserved populations
The recent deaths of Kate Spade and Anthony Bourdain have thrust the issue of suicide into the spotlight. And for good reason. New numbers from the Centers for Disease Control and Prevention indicate that suicide rates are rising in every state, and in 2016 nearly 45,000 Americans age 10 or older died by suicide.
Suicide is a challenging concern for healthcare workers as well. It's estimated that between 300 to 400 physicians die from suicide in the U.S. each year.
"We had nurse suicides in our own workforce and when we started talking to people, we found that many knew someone who had a nurse suicide in their organization. So, it wasn’t just us," she says. "But then, when we went to the literature, there was no accounting for nurse suicide at a national level."
However, as Davidson explains, that lack of data doesn't mean it isn't an issue.
"My hunch is, if every organization only has one [suicide], you don’t think of it as a problem," she says.
To give context to the issue, she gives the example of pressure ulcers on a med-surg unit. If each med-surg unit only had one patient with a pressure ulcer, they might write it off as "only one."
"But if you add them all together, you’re over the national benchmark for your organization in pressure ulcers," she says.
Looking at nurse suicide through that lens helps to put the issue in perspective.
"It really brings up the concrete message that we cannot hide this," she says. "The more we talk about it the more lives we can save."
Here are three actions nurse leaders can take to prevent nurse suicide.
Offer Screening
After more than one nurse suicide occurred at UCSD Health, the organization piloted an expansion of the Healer Education, Assessment and Referral program to nurses.
The HEAR program was already in use to identify physicians at risk for suicide and to facilitate referrals to mental healthcare.
The HEAR program included 1-hour sessions on the risks of burnout, depression, and suicide; a personal account from a nurse who had experienced suicidal ideation; and a presentation on the purpose of the program from nursing leadership.
The chief nursing officer then sent an invitation for nurses to participate in the anonymous, encrypted, online screening.
Davidson says the screening program uses the PHQ-9 depression risk screening plus other questions that are known to be predictive of suicide risk.
Through the encrypted system, nurses can go online and take the screening. The results, which contain no personal identifiers, go to a counselor who evaluates the results.
If the nurse is high risk, the counselor contacts them through the encrypted system and invites them to come for counseling.
172 of the organization's 2,475 nurses completed questionnaires
43% ranked as high risk
55% were moderate risk
12 individuals reported current active thoughts or actions of self-harm
19 individuals reported previous suicide attempts
44 nurses received in-person or verbal counseling
17 individuals accepted referral for continued treatment
"The report that’s in the literature right now is just the piece on nursing," Davidson says. "But we did extend it to the whole hospital staff. After the success of that pilot, it's funded to go on in perpetuity, and they’re looking at spreading it throughout the UC system across the entire state."
In addition to the HEAR program, UCSD Health has also implemented proactive emotional crisis counseling.
"A crisis response team, the same counselors that do the screening on the back end of the online encrypted screening, will go out to any work team that has gone through a difficult situation and do emotional debriefings," she says. "That has been a big hit with our staff. They want it and they like it."
Previously, when a challenging situation occurred, risk management conducted clinical incident debriefings to uncover what went wrong and how to prevent something similar from happening in the future.
But, those debriefings didn't normally include the emotional aspects tied to those kinds of events.
"Now, when they find out about these cases, risk management lets the crisis team know so that they can go out and do a separate, emotional debriefing of the staff that are affected to try to proactively deal with emotions up front," she says.
Cases can include anything from a medication error to an unexpected death to staff getting assaulted by a patient.
After the crisis team holds a group debriefing, they offer individual counseling to the people who were affected.
Know the Risk Factors
As part of the HEAR pilot study, nurses identified factors that were causing them stress in an open-ended comments section.
"It’s a combination of work and home stressors," Davidson says. "There is some evidence in the literature that when you combine work and home stressors you’re at higher risk of suicide than if you have just work or home stressors."
Work stressors included:
Management issues
Work volume
Staffing
Changing departments
Feeling unappreciated at work
Stress related to learning new skills or teaching others
Lateral violence
Fear of harming patients
Feelings of incompetence
Emotional burden of patient care
Home stressors included:
Marital strain
Financial issues
Personal or family health issues
Grief
Lack of purpose in life
Childcare
Academic stress
Loneliness after moving
Personal or family drug or alcohol use
Many of the work stressors can, and should, be addressed by nurse leaders.
"As nurse leaders we can always work on issues of lateral violence and bullying. We can always work on the issues of staff feeling unheard or feeling like they don’t belong. That’s a very strong risk factor for suicide—feeling like you don’t belong within your work group," Davidson says. "It's the obligation of nurse leaders to identify when these things are occurring and actively work on them."
While many nurse leaders may feel that addressing home stressors is out of their realm, Davidson says simply acknowledging when a staff member is going through home issues can go a long way in decreasing suicide risk.
In fact, some of Davidson's prior research on feeling cared for in the workplace, supports the concept that nurses want to be treated as a "whole person" and to be appreciated personally and professionally.
Feeling cared for also drives health-promoting behaviors and can contribute to outcomes such as feeling valued and important, teamwork, and loyalty to an organization, she says.
"Sometimes nurse leaders feel it’s beyond their purview to recognize those home issues, or that it’s not appropriate in the workplace," she says. "But I think from what we’re finding out from these risk factors for suicide, nothing could be further from the truth. Nurses want to be recognized as whole people."
More of Davidson's insights on the issue of nurse suicide and details on prevention strategies can be found in the National Academy of Medicine discussion paper, "Nurse Suicide: Breaking the Silence."
After implementing a new evidence-based risk assessment tool, SSM Health reduced patient falls by 30%.
Profit margins, mergers and acquisitions, reimbursement: There's an enormous focus on these issues in the industry, but they are not the ultimate goals of healthcare.
"When all is said and done, our mission is caring for people, and the ones who care for people, primarily, are the nurses," says Maggie Fowler, RN, BSN, MBA, NEA-BC, system vice president and chief nursing officer for St. Louis–based SSM Health. "It's not saying that our physicians, pharmacists, respiratory therapists, and all the other disciplines don't—in an acute hospital setting, it's definitely a team effort—but when most people go home, the nurses are still the ones there who are assessing the plan of care. They're the primary communicator in most situations."
At SSM Health, nurses make up one-third of the total workforce. This near-constant contact with patients puts them in a prime position to improve patient care and quality outcomes, and, subsequently, have a positive effect an organization's bottom line.
Fowler has seen this firsthand with the success of SSM's fall-reduction efforts. Here's what nurses did at SSM Health to improve in this area.
"In a healthcare environment, falls can be devastating," she says. "They can lead to a negative perspective for patient morbidity if they're injured during the fall, and have a negative impact to the organization on a cost-of-care perspective."
Recognizing this, the organization's nursing practice councils, which facilitate evidence-based decisions regarding nursing practice standards, policies, and procedures, identified a fall risk assessment tool—the Hester Davis Scale—to help reduce falls at SSM.
SSM worked with Amy Hester, one of the creators of the tool, and its EMR vendor to launch a pilot project in spring 2016 at one of the organization's hospitals.
The pilot occurred on two units, and based on its results, SSM determined that the assessment tool had efficacy for the healthcare system. The pilot had validated the value of implementing the tool systemwide, with investment on the front end being recouped by savings on the back end.
"The outcome of that pilot clearly demonstrated that this assessment tool allowed us to more clearly recognize patients who were at risk for falls," says Fowler. "The Hester Davis
algorithm—once you make this assessment—identifies the steps you take to decrease falls."
The practice was then rolled out to the rest of the SSM system (although Fowler says one hospital still needs to be onboarded to the new procedure). Training was done via "waves" across the system, with three to four hospitals per wave, Fowler explains.
Each wave took three weeks and included webinar and online training. There was also coordination with the supply chain to ensure facilities had the correct equipment (including low beds and fall mats) to address fall risk.
The organization took a whole-hospital training approach that included RNs, physicians, physical therapists, environmental services, and others.
Falls Decrease, Dollars Saved
Based on nearly a full year of data from the facilities where the fall risk assessment has been implemented, total falls have decreased by 30% per 1,000 patient days. That reduction should have a big payoff and save the organization an estimated $2.5 million annually, based on industry cost standards.
Additionally, there has been a 5% reduction in falls with injuries per 1,000 patient days, which equates to a savings of $500,000
The success of the fall risk assessment project has both empowered bedside clinicians to influence change and driven system leadership to increase its focus on the key priorities of safety, quality, and service.
"One of my priorities with nurses is that we have to translate the value [of nursing] and have the ability to translate the work into the bottom line. That is personally a passion of mine," she says. "It's translating it into dollars and cents. We're dealing in an environment with reduced reimbursement, so anything that we do, in turn, should have a positive outcome to lower the overall cost of care. We need to be advocates to help connect the dots for executives and other employees in the organization."
To move the needle on burnout, resilience programs must be designed to meet nurses' specific needs.
Meredith Mealer, PhD, RN, assistant professor, department of physical medicine and rehabilitation at the University of Colorado, Denver, understands challenges bedside nurses face.
"I was a bedside nurse for a number of years and the stress was just overwhelming at times," she says.
"When I decided to get out of bedside nursing, I started to notice that a lot of the really good nurses were leaving. When I asked, 'Why are you leaving the bedside?' they said, 'I’m just stressed out. I can’t handle this work anymore. I’m having anxiety attacks. I'm having nightmares,' " Mealer says.
This experience inspired Mealer to study the prevalence of psychological distress in nurses, specifically those in critical-care, to help them develop coping skills.
"Once I identified that this is a big problem, I started thinking about what can we do to help mitigate some of these symptoms," she says.
One strategy studies have found to be effective in combating issues such as anxiety, depression, post-traumatic stress disorder, and burnout syndrome is resilience—the ability to cope with and recover from stress or adversity.
But, before healthcare leaders dive headfirst into launching a program to promote resilience and prevent burnout among nurses, they should query their staff to identify barriers and concerns that could thwart a program's success, says Mealer.
There were four major areas where differences were identified:
Worldview
Social network
Cognitive flexibility
Self-care/balance
The highly resilient nurses identified that they were able to cope with stress in the work environment through their spirituality, supportive social networks, optimism, and resilient role models.
The nurses with PTSD on the other hand, reported:
A poor social network
Lack of identification with a role model
Disruptive thoughts
Regret
Lost optimism
"The highly resilient nurses had so many more positive coping skills to draw from. They exercised. They had rituals before they would go into work or when they would come home from work. They understood that death was part of life, and they didn’t hold on to the regret and the guilt that some of these nurses that weren’t highly resilient had," Mealer says.
"[Among] the nurses that were not highly resilient there tended to be negative coping skills. So, for example, 'I come home from my shift and I can’t sleep. I’m worried about whether I did something wrong and whether I was part of the reason why this person coded. So, I got home, and took sleeping medication, or I went home, and I had a few glasses of wine.' [They used] these less-than-desirable coping strategies," she says.
Fortunately, there is a body of research that shows resilience can be learned.
MBCT uses mindfulness practices such as breathing and meditation exercises to help people identify and become aware of negative thoughts and feelings. The MBCT techniques help interrupt negative thought patterns.
"MBCT was originally developed as a treatment of relapsing depression but since then it has been modified for anxiety, and for PTSD," Mealer says.
Based on her prior work, Mealer knew nurses were open to MBCT to develop resilience, but for the purposes of this study, she wanted to assess whether nurses wanted the program delivered in the traditional 8-week MBCT format or if needed to be modified.
For the study, she moderated 11 focus groups with members of the American Association of Critical-Care Nurses. There were a total of 33 participants working as critical care nurses in the U.S.
Results
Based on the participants' feedback, it was determined the traditional 8-week course of two hour sessions needed modification.
"We found that was too much for the nurses. They just didn’t have the time to commit to two months of classes," Mealer says. "We have modified it, and now we have four weekly 4-hour sessions and that seems to be working well."
While there is no one-size-fits-all approach to resilience training, healthcare leaders can address their staff's needs by getting their input to design a program that works for them.
"No single design was accepted, suggesting that institutions will need to modify interventions to fit the needs of their staff," Mealer said. "We know that positive coping skills can be learned, but more research is needed to understand which interventions and resources are effective and feasible."
Researchers will use the results to refine a pilot MBCT resilience program, which will be evaluated to identify additional modifications needed. They then plan to conduct a larger trial to determine effectiveness.
3 Barriers to MBCT
During her study, Mealer discovered the following barriers for nurses using the MBCT program:
1. Session timing
Nurses had different preferences on the best time to offer the program. Some reported childcare would be an issue that would prevent them from coming in on their day off to attend a session. Others said because of the mentally taxing nature of their job, they preferred training on a day off rather than directly after a shift because they would be more alert and engaged.
2. Homework assignments
Daily homework assignments are a part of MBCT but participants said shift length, consecutive shifts, and physical fatigue at the end of a shift would make completing daily homework assignments difficult. They suggested homework would be more doable if the assignments were short and if mindfulness practices could be done at work.
3. Travel
Nurses also cited travel distance to the group sessions as a potential barrier.
"It was interesting because we interviewed critical care nurses from around the country and, depending on where they were working, they had specific requests. So, if it was in a rural-type setting, they would be fine coming in on their days off and participating in the intervention. But then if you talked to someone who worked in Washington, D.C., the traffic is so terrible, they didn’t want to have to drive back to work on a day off and battle with traffic," Mealer observed.
Improving Adherence
In conducting the study, Mealer found that the following participant suggestions would improve nurse adherence to the MBCT program:
Hybrid model. Participates felt a combination of online and face-to-face sessions would help with adherence to the program.
Short exercises. Nurses said short mindfulness practices that could be done while working would help with adherence.
Instructor background. Participants said having multiple instructors lead a session would be helpful, but they also wanted consistency that the same instructors would be at subsequent sessions to facilitate a connection between the nurses and teachers. They also preferred the instructor be a nurse with an ICU background rather than a physician.
70% of hospitals now require that employees receive flu vaccines.
Though there's a temporary reprieve from the illness over the summer, the flu will be back again in a few months, and hospitals and health systems will begin their annual vaccination campaigns with the goal of protecting staff, patients, and visitors against the virus.
While mandatory flu vaccines have long been controversial, a new study shows the percentage of hospitals requiring flu shots rose from 44% to nearly 70% from 2013 to 2017. However, during this same time frame, flu vaccine mandates at Veterans Affairs hospitals only rose by 1%.
“In just four years, the non-VA hospitals have really stepped up on requiring the vaccine, rather than just encouraging it,” says Todd Greene, PhD, MPH, the University of Michigan and VA researcher who led the study. “Studies have shown that vaccination mandates, coupled with an option of declining vaccination in favor of wearing a mask, are most effective in reaching high percentages of vaccination.”
To Vaccinate or Not To Vaccinate
While it does not have a flu shot mandate, a national VA directive last fall set an expectation that employees would get vaccinated or wear a mask when caring for patients during flu season.
But all hospitals without a mandate do not have such clearly established directives, the study finds.
Only 41% of non-mandate hospitals required unvaccinated workers to wear a mask during patient interactions in flu season.
Only 21% had penalties for non-compliance with the hospital’s policy.
Two-thirds of non-mandate hospitals had a formal policy outlining how workers could officially decline to get vaccinated.
However, all hospitals with vaccination mandates had formal declination policies in 2017.
Hospitals with mandates:
Allowed medical contraindications and/or religious reasons as allowable reasons to decline vaccination
Under 13% allowed workers to give any reason for declining
Nearly 83% of hospitals with mandates required unvaccinated healthcare workers to wear masks during patient interactions.
Nearly three-quarters of hospitals with a mandate had penalties in place for non-compliance for those who did not get vaccinated or sign a declination form
The researchers also looked at differences by hospital-level characteristics.
Nonprofit hospitals were much more likely to mandate flu vaccination.
One-third of the non-VA hospitals were teaching hospitals, but they were no more likely than non-teaching hospitals to require flu vaccination by 2017.
80% of the VA hospitals were teaching institutions.
Under the Hospital Inpatient Quality Reporting Program, hospitals were required to tell the CDC what percentage of their healthcare workers were vaccinated against the flu. The results were posted online starting in October 2014, and showed that 90% of workers at participating hospitals were vaccinated.
The researchers note that some VA hospitals have made special efforts to increase vaccination by bringing vaccines to workers on inpatient floors or even offering extra time off for workers who get vaccinated.