Oral mucositis is an inflammatory process of the oral cavity caused by damage of the epithelium (Cawley, 2005, p.584). It is a common side effect that affects approximately 40%-100% of patients who undergo specific cancer treatments (Cawley, 2005, p.584; Eilers, 2004, p.13).
Oral mucositis may result in complications such as pain, infection, malnutrition, treatment delays and dosage reductions in cancer therapy, and decreased functional status and quality of life (Cawley & Benson, 2005, p. 584; Eilers, 2004, p. 13; Sadler et al., 2003, p. 28-29). Thus, proper management of oral mucositis is paramount in patients treated for specific cancer therapies. Nurses interact with patients during all phases of treatment, which gives them the advantage of playing a pivotal role in the proper management of oral mucositis. Cawley & Benson (2005) and Sadler et al. (2003) review the significance of nurse education and training, patient teaching, and the promotion of self-care by patients. In support, Eiliers (2004) points out that ongoing assessment and monitoring, and utilization of interventions with an evidence-based approach are efficacious and important in managing oral mucositis. Furthermore, Potting’s empirical study may prove to be a novel approach to assessing oral mucositis in daily nursing practice. Collectively, knowledge, proper and sufficient oral assessment skills and tools, and the delivery of adequate evidence-based palliative care by the nursing staff prove to be essential components of managing oral mucositis in cancer patients.
In order for nurses to properly manage oral mucositis they must first be knowledgeable about the pathophysiology. The oral mucosa is composed of rapidly-dividing epithelial cells, which are replaced approximately every two weeks from stem cells of the submucosa. Therefore, the integrity of the mucosa is dependent on the continuous reproduction of the submucosal stem cells (Cawley & Benson, 2005, p. 585).
Cawley and Benson (2005) use Sonis’ model to describe the five phases that occur with the process of oral mucositis. It begins with phase one (0-2 days), initiation, when epithelial cells are damaged by the effects of radiotherapy and chemotherapy. Next, phase two (2-3 days), upregulation and message generation, occurs. It involves increased tissue injury and cell death by inflammatory cytokines. Clinically, patients may begin to present with erythema as the mucosa starts to thin. Then, the third phase is signaling and amplification (2-10 days) in which there is cell damage below the mucosal layer. Next is ulceration (10-15 days), the fourth and most clinically observable phase. Ulcers appear deep (extends from epithelium into the submucosa) and are irregularly-shaped. The ulcers are often coated with a pseudomembrane of fibrinous exudate, which is ideal for bacterial colonization. Furthermore, nurses should recognize that nerve endings are exposed at this point. Thus, patients begin to experience pain during this phase. The final phase, phase five is healing (14-21 days). Cell proliferation begins and new tissue layers form. Although healing occurs, patients will continue to have an increased risk for developing oral mucositis because cells below the surface are permanently damaged.
Furthermore, nurses must be knowledgeable about the risk factors associated with the development of oral mucositis. This will help nurses identify high-risk patients, allow nurses to promote oral health care in high-risk patients, and assist nurses in prioritizing their care (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15; Sadler et al., 2003, p. 30). There are treatment related risk factors including chemotherapy, radiotherapy, and bone marrow transplantation (Cawley & Benson, 2005, p. 585). In addition, patient-related risk factors include age, periodontal disease and oral health, diet, tobacco and alcohol use, medications, oxygen therapy, and changes in breathing (Eilers, 2004, p. 15). Young children are at risk due to their higher epithelial cell proliferation rate, and their higher rate of hematologic malignancies which produces prolonged and intensive myelosuppression; older individuals are at risk due to physiologic declines in renal function and healing capabilities (Eilers, 2004, p. 15). Periodontal disease and alterations in oral health impair the permeability of the oral mucosa, reduces oral pH, causes tooth decay and gingivitis, and increases infection rates (Eilers, 2004, p. 15). Nurses should encourage patients to complete a comprehensive dental evaluation prior to receiving their cancer treatment (Sadler et al., 2003, p. 30). Moreover, diet is another factor that places patients at risk. Excessive sugar consumption or inadequate protein and calories in the diet contribute to tooth decay and irritation of the oral mucosa, which prolongs healing time (Eilers, 2004, p. 15). Patients should be counseled about the effects of their diet so they can actively minimize their risk. Furthermore, tobacco and alcohol use exacerbates periodontal disease and irritates and alters the oral mucosa (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15). Medications that may cause xerostomia (e.g. opioids, antidepressants, antihypertensives, antihistamines, diuretics, sedatives, phenothiazines) also promote periodontal disease and create a favorable environment for bacterial and fungal overgrowth (Eilers, 2004, p. 15). Lastly, patients who are subjected to oxygen therapy and/or have changes in their breathing (e.g. tachypnea and mouth breathing) are at an increased risk for developing mucositis because of the dry environment created in the oral cavity (Eilers, 2004, p. 15).
In addition to knowledge, nurses require proper assessment skills and tools to adequately manage oral mucositis. It is essential for nurses to incorporate thorough and ongoing assessment and monitoring throughout the treatment period so that interventions can be modified accordingly (Eilers, 2004, p. 14; Sadler et al., 2003, p. 31). Assessment of the oral cavity should begin before cancer treatment. Nurses play a key role in teaching patients the rationale and benefits of ongoing assessments. During nursing assessments, a thorough examination of the oral cavity should be implemented with appropriate lighting (Eilers, 2004, p. 17). Oral cavity assessments should include visualization of the lips, tongue, gingivae, and all other surfaces within the cavity; palpation of visible lesions; and evaluation of function (Eilers, 2004, p. 17). Interaction with patients for subjective assessment data is also important (Eilers, 2004, p. 17). Nurses should inquire about problems that patients may be experiencing, and they should also inquire about patients’ opinions about current interventions. If current interventions are dissatisfying to patients, or if patients do not understand how to adequately provide self-care, it can cause delays in the healing process and/or may cause the patient to discontinue treatment. Moreover, nurses must accurately document all observable findings gathered from each assessment. Observable findings in the oral cavity that could indicate impending complications include color changes, moisture changes, change in mucosal integrity, and edema of the lips and tongue (Eilers, 2004, p. 17).
Following this further, nurses must utilize proper assessment tools. It is critical for all nurses involved with a patient to use the same assessment tool and to be properly trained in using the assessment tool (Cawley & Benson, 2005, p. 587; Potting et al., 2005, p. 233). An ideal tool to evaluate the oral cavity should be: reliable, valid, objective, and usable in all clinical and research situations (Cawley & Benson, 2005, p. 586; Potting, Blijlevens, Donnelly, Feuth, & Van Achterberg, 2005, p. 229). Some of the instruments utilized in practice for scoring oral mucositis include the Oral Assessment Guide (OAG), Oral Mucositis Assessment Scale, Oral Exam Guide, World Health Organization Scale, and the National Cancer Institute Common Toxicity Criteria Scale for Mucositis and Stomatitis (Cawley & Benson, 2005, p. 587; Potting et al.; 2005, p. 229). Potting et al. (2005) argue that current instruments lack inter-rater reliability, practicality, and usability in daily nursing practice. Thus, Potting et al. (2005) developed a new instrument called the Nijmegen Nursing Mucositis Scoring System (NNMSS), which was tested and found to have favorable results. The goal of developing the NNMSS was to create an assessment instrument that was reliable, valid, and usable in daily nursing practice (Potting et al., 2005, p. 233). The NNMSS measures both objective (erythema, oedema, lesions) and subjective (pain, dryness of mouth, viscosity of saliva) characteristics of the oral cavity (Potting et al., 2005, p. 232). The NNMSS is still a newly developed instrument that needs further testing, but proves to be a promising assessment tool for the future.
The final component nurses should incorporate in their management of oral mucositis is the delivery of adequate evidence-based care. Nursing implementation of an oral care protocol is the key to preventing or minimizing oral mucositis and its complications (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 15). For patients who undergo cancer therapies, good oral hygiene is the most basic element in the oral care protocol (Cawley & Benson, 2005, p. 588; Eilers, 2004, p. 16). Nurses should always include patient teaching of how and when to care for the mouth to promote self-care. Nurses need to educate patients on topics such as toothbrushes (use soft-bristled/foam brushes, brush at lease twice daily, when to replace ); daily flossing; mouth rinses (avoid alcohol-based mouthwash); foods to avoid (coarse, spicy, acidic, alcohol, extremely hot or cold); ways to deal with dry mouth (rinses, sugar-free candy/gum, increase fluid intake); denture-care instructions (remove when performing oral care, avoid use except when eating, importance of regular cleaning); products to use for dry lips (water-based moisturizers); and how to examine and note changes in their oral cavity (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 16).
In addition to oral care protocol, there are various treatment therapies to manage oral mucositis (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). A common therapy to prevent and treat oral mucositis is mouth rinses (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). It helps to clean the debris, keep the oral cavity soft and moist, and offers pain relief (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18). Recommended rinsing solutions include 0.9% saline solution, sodium bicarbonate, and a 0.9%/sodium bicarbonate mixture (Eilers, 2004, p. 18). There are also some rinses that can offer pain relief such as Magic mouthwash (lidocaine, diphenhydramine, magnesium or aluminum hydroxide), and Gelcair Bioadherent Oral Gel (polyvinylpyrrolidone, sodium hyaluronate, and glycyrrhetinic acid) (Cawley & Benson, 2005, p. 589). Nurses must teach patients about various rinses and instruct patients on its proper use.
Another treatment for oral mucositis is cryotherapy (Eilers, 2004, p. 18; Nikoletti, Hyde, Shaw, Myers, Kristjanson, 2005, p. 751). Cryotherapy is based on the principle of vasoconstriction, which reduces epithelial exposure (Eilers, 2004, p. 18). It is an ideal treatment for patients who receive a bolus of chemotherapy (especially with 5-fluorouracil), but it is not practical for those receiving prolonged chemotherapy infusions (Eilers, 2004, p. 18). Nikoletti et al. (2005) conducted a study of cryotherapy, using ice chips, and found that it significantly reduces the effects of oral mucositis.
Furthermore, mucosal protectants, growth factors, antiseptic agents, anti-inflammatory agents, and topical analgesics are other therapeutic agents available (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 19-20). Mucosal protectants promote mucosal healing and cell regeneration (Eilers, 2004, p. 18). According to Eilers (2004), growth factors assist with the regeneration and healing of the oral mucosa (p. 21). In addition, recombinant human keratinocyte growth factor is instrumental in treating mucositis because, it stimulates the replication and maturation of epithelial cells (Cawley & Benson, 2005, p. 589).
To conclude, it is crucial for nurses to be self-directed in seeking knowledge deficits, updating their knowledge base and skills, and utilizing evidence-based interventions to provide optimal patient care and effective management of oral mucositis. Knowledge enables nurses to anticipate the occurrence of oral mucositis and be proactive in the management of its process (Cawley & Benson, 2005, p. 585). Although visual signs of mucositis typically only appear after seven to ten days of treatment initiation, damage begins the day of treatment (Cawley & Benson, 2005, p. 585-586). Initiating patient care prior to therapeutic cancer regimens will minimize the debilitating effects of oral mucositis. Furthermore, adequately maintaining or minimizing oral mucositis will increase the likelihood for completion of therapy and improve patient outcome.
a. Intervention 1- Proper Oral Assessment
i. Disadvantage 1- Current assessment tools lack inter-rater reliability, practicality, and usability in daily nursing practice.
Some of the common scoring instruments used for the assessment of the oral cavity in cancer patients lack validity, reliability, and/or usability (Cawley & Benson, 2005, p. 586; Potting et al., 2005, p.228). A few current scoring instruments used in practice include the Oral Cavity Assessment Form (OCAF), the Oral Assessment Guide (OAG), the Oral Mucositis Index (OMI), and the Western Consortium for Cancer Nursing Research Stomatitis Staging System (WCCNR). Potting et al. (2005) revealed that some instruments base their validity on consensus statements from cooperative groups or a small number of experts in the field, and that only a few instruments were evaluated for reliability during the study of the instrument. In addition, Potting et al. (2005) state that some instruments require the assessment of several items or symptoms on specific locations in the oral cavity, which require patients with severe pain to open their mouths for prolonged periods. Various instruments require different tools to correctly inspect the oral cavity, which can be too complicated for daily nursing practice and requires a significant amount of training to be used accurately (Potting et al., 2005, p. 231). Moreover, some of the scoring instruments were developed for various purposes and from the perspective of a specialized field (e.g., dentistry, radiotherapy, oncology) (Jaroneski, 2006, p. 1086; Potting et al., 2005, p. 229). Most of these instruments focused on evaluating a particular intervention and were not developed with an emphasis on inter-rater reliability because they were only used by a few researchers (Potting et al., 2005, p.229). The lack of inter-rater reliability in these instruments is incompatible with daily nursing practice, which requires a reliable and validated instrument that offers consistency with the changing of staff during every shift (Potting et al., 2005, p. 229).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006, July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
ii. Disadvantage 2- Lack of universal standards of practice regarding oral care for cancer patients.
According to Jaroneski (2006) there are no universal standards of oral care for patients with cancer. Moreover, Eilers (2004) notes that not only are standards of oral care used inconsistently in patients who undergo cancer therapy, but standards of oral care do no even exist in many institutions. Literature regarding the frequency of performing oral assessment is inconsistent, and experts fail to agree upon the use of assessment tools in the management of oral mucositis (Jaroneski, 2006, p. 1089). Current clinical guidelines, and evidence-based guidelines developed by organizations such as the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology, for the prevention and treatment of cancer therapy fail to address the use of grading scales in the assessment phase (Jaroneski, 2006, p. 1089). Chemotherapy and biotherapy guidelines and recommendations by the Oncology Nursing Society addresses the use of an assessment tool, but does not provide a specific protocol for its use (Jaroneski, 2006, p. 1089). The lack of standards of practice in the use of assessment tools and in the frequency of performing oral assessments leads to the use of inconsistent assessment tool, inadequate documentation, and absent or inconsistent oral evaluations. Adequate and proper assessment of oral mucositis is necessary to guide clinical practice for positive outcomes.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
b. Intervention 2- Delivery of adequate evidenced-based care.
i. Disadvantage 1- Knowledge gaps in the pathophysiology of oral mucositis, and identification of at-risk patients.
Oncology nurses must be aware of and become familiar with the current five-stage model of mucositis developed by Sonis. A review of Sonis’ five-stage model is included above. An understanding of this model can help guide clinical practice for more positive outcomes (Cawley & Benson, 2005, p. 586; Jaroneski, 2006, p. 1089). Nurses who are knowledgeable about the five stages can better anticipate the occurrence of oral mucositis and can better manage oral mucositis by incorporating proactive care, patient education, and treatment of complications in their care. Before Sonis’ research, mucositis was believed to be a result of epithelial damage caused by radiotherapy and chemotherapy (Cawley & Benson, 2005, p. 585). Sonis’ research has helped us better understand the process of oral mucositis, which targets the submucosa, as opposed to the previously believed epithelium (Cawley & Benson, 2005, p. 585).
In addition to being knowledgeable about the pathophysiology, nurses should also be able to identify at-risk populations. This knowledge will help nurses reduce patients’ risk, implement early interventions, and provide supportive care to patients who are at-risk from suffering the effects of cancer therapy (Cawley & Benson, 2005, p. 584). Cawley & Benson (2005) acknowledge differing views based on age as a risk factor, which includes both the older populations and the younger populations. Other risk factors that nurses should be aware of include gender (women more likely than men to develop oral mucositis), certain chemotherapeutic agents (5-FU, etoposide, methotraxate, antimetabolites, cyclophosphamide, bulsulfan), medications (opioids, antidepressants, phenothiazines, antihypertensives, antihistamines, diuretics, sedative), tobacco and alcohol use/abuse, oxygen therapy, poor oral health or periodontal disease, diet (high sugar intake, protein/calorie malnutrition), changes in breathing (tachypnea, mouth breathing) (Cawley & Benson, 2005, p. 585; Eilers, 2004, p. 15).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Jaroneski, L.A. (2006, November). The importance of assessment rating scales for chemotherapy-induced oral mucositis. Oncology Nursing Forum, 33(6), 1085-1090. Retrieved February 4, 2008 from CINAHL database.
ii. Disadvantage 2- Lack of an efficacious management strategy.
According to Eilers (2004) there is a widespread interest in the prevention and treatment of mucositis, but limited progress toward finding an efficacious management strategy. Eilers (2004) states that there are a few well-designed studies demonstrating the effectiveness of various treatments, but the studies are inconsistent. Thus, different institutions are using diverse regimens and are forced to make incomplete informed treatment decisions (Eilers, 2004, p. 17). In addition, although there are a variety of agents available for reducing the severity of mucositis, oral complications remain a significant source of morbidity for patients who undergo cancer therapy (Eilers, 2004, p. 17). Current treatment strategies are targeted at providing symptomatic relief, reducing the severity of mucositis, and using systemic agents that work against multiple targets (Cawley & Benson, 2005, p. 589; Eilers, 2004, p. 18).
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
References
Cawley, M., & Benson, L. (2005, October). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592. Retrieved October 18, 2007 from CINAHL database.
Eilers, J. (2004, April). Nursing interventions and supportive care for the prevention and treatment of oral mucositis associated with cancer treatment. Oncology Nursing Forum, 31(4), 13-23. Retrieved October 18, 2007 from CINAHL database.
Nikoletti, S., Hyde, S., Shaw, T., Myers, H., & Kristjanson, L. (2005, July). Comparison of plain ice and flavoured ice for preventing oral mucositis associated with the use of 5 fluorouracil. Journal of Clinical Nursing14(6), 750-753. Retrieved October 18, 2007 from CINAHL database.
Potting, C.M.J., Blijevens, N.A.M., Donnelly, J.P., Feuth, T., & Van Achterberg, T. (2006 July). A scoring system for the assessment of oral mucositis in daily nursing practice. European Journal of Cancer Care 15(3), 228-234. Retrieved October 18, 2007 from CINAHL database.
Sadler, G., Stoudt, A., Fullerton, J., Oberle-Edwards, L., Nguyen, Q., & Epstein, J. (2003, February). Managing the oral sequelae of cancer therapy. MEDSURG Nursing, 12(1), 28-36. Retrieved October 18, 2007 from CINAHL database.
Monday, February 4, 2008
Managing Oral Mucositis
Draft for Research Paper by M. Dempsey
Measles, also known as rubeola, is a highly contagious, airborne disease transmitted by infected people. Most people live in parts of the world where vaccinations and immunity are a way of life.
. In six countries, including the United States, measles deaths are at near zero today (Otten, Okwo-Bele, Kezaala, & Brellick, 2003). Still, many people around the world do not have access to these vaccinations, and are therefore susceptible to many diseases that have nearly been eradicated in first world countries, such as the United States. The World Health Organization recognized a need to create a new vaccination program to immunize African children and adults against the number one killer of preventable disease in their country, measles. As a united front, the World Health Organization, The American Red Cross, The United Nations Foundation, The Bill Gates Foundation, and The United States Center for Disease Control and Prevention created The Measles Initiative, as a solution for the measles epidemic in effected regions of the world. The Measles Initiative was put in motion to prevent unnecessary deaths of innocent children and adults by the simple use of a $1.00 vaccination. In addition to saving lives, this global vaccination program will help stop the spread of a highly contagious disease, in hopes of eradicating the measles virus for good.
The measles vaccine has been in use for forty years, but it was not until 1974 that global measles vaccination programs were put into effect (Wolfson, 2007). These programs have since been categorized into three phases. The first phase began in 1974, with high hopes of introducing routine measles vaccinations to almost every country in the world. UNICEF then led a universal childhood vaccination program that started the second phase. The second phase started in the 1990’s and continued to 1999 with the administration of one vaccination at 9 months old to children in 47 countries (Elliman & Bedford, 2007). The second phase found failure when school age children were found to contract the disease, due to not responding well to the vaccination at 9 months old. It was in 1999, when the WHO, UNICEF, The Bill Gates Foundation, and The American Red Cross united to create The Measles Initiative to vaccinate children age 9 months to 14 years old. The third phase would involve two vaccinations, at least three years apart, with scientific research showing that two vaccines are more effective than one (Elliman & Bedford, 2007).
The partnership of each group involved in The Measles Initiative is crucial because each group bears a different responsibility. The WHO designs the policies and health guidelines for each country to ensure proper, safe steps are taken during immunization campaigns. UNICEF is the only organization allowed to import the vaccine into most developing countries and has a sophisticated logistics capacity as well as great stature in the country. The CDC provides funding and the technical and scientific information to the campaign. The UN Foundation provides a substantial amount of funding as well as the financial mechanisms necessary to move funds between agencies and to countries. The American Red Cross provides funding and has the network of Red Cross volunteers to do the work, ensuring each child has a chance to be vaccinated. The Bill Gates Foundation provides funding (Measles Initiative, 2006).
With all of these groups coming together, the vaccination of over 80 million children started in Sub-Saharan Africa, an area of the world that was responsible for over half of the worlds measles deaths, causing 45% of vaccine preventable deaths (Otten, Okwo-Bele, Kezaala, & Brellik, 2003). The Measles Initiative would continue all over the world and wherever there was a need, there would be a vaccine against measles. The Measles Initiative set a goal to cut global measles deaths by 90% by 2010 (Measles Initiative, 2006).
In 2005 Otten, Kezaala, Fall, Maresha, Caimes, & Eggers (2005) found that between December, 2000- June of 2003, the average decline in the number of reported cases was 91%. The total estimated deaths averted in 2003 were 90,043. The initiative has been wildly successful and is still in progress. In 2005 the number of reported measles-related deaths around the world was at 345,000, which is a 60% decrease from 1999’s reported number of deaths of 873,000 (Irby, 2005). In continuing with this success, The Red Cross wants to ensure that The Measles Initiative steadily moves across the globe to vulnerable regions like Asia, where measles deaths are the highest outside of Sub-Saharan Africa and to smaller countries such as Pakistan, and Uzbekistan. With theses programs, health workers provide not only measles vaccines, but also insecticide-treated nets for malaria prevention, vitamin A, de-worming medication and polio vaccines (Irby, 2005).
The follow up campaigns have proven to be successful all over the world. And it has even been suggested that receiving the measles vaccine could act as a non-specific immune boost to give added protection against other diseases, but further research is needed to confirm this (Salama, Mcfarland, & Mulholland, 2003). There is still a need to continue with vaccination campaigns in Africa. Between 2003-2005, citizens of Mozambique were ravaged with a measles outbreak. There were 1,676 confirmed cases in just three years (Nshimirimana, et all, 2006). This was from failure to vaccinate enough of the population to prevent the endemic proving the absolute importance that even those in remote areas of the world must be vaccinated due to the virus’s airborne ability to infect. In 2004 and 2005, there were several large outbreaks in the European Region. The outbreaks in Romania and the Ukraine were the source of measles outbreaks in a number of EU countries, countries in which the government had reported that measles were under control (Spika, 2006). This exemplifies that measles can still effect vulnerable and non-vulnerable populations alike.
The necessity to eradicate vaccine-preventable diseases is overwhelming. Many of these diseases are highly contagious and there are no walls to protect us from the infected. Everyday people travel from region to region carrying unknown diseases. Diseases, such as measles, are capable of wiping out at-risk populations where treatment and medications are remote. We are fortunate to have access to vaccines that our bodies respond to with immunity. The measles vaccine, when given in two doses, is nearly 100% effective against the virus, but whether we can totally eradicate the virus with global vaccination is debatable. Eradication is possible due to the fact the virus in monotypic and unable to mutate (Spika, 2006). The lack of an animal reservoir and the fact that this is an acute, not chronic, illness makes eradication possible. The problem still remains that measles is a highly contagious disease, making it necessary to vaccinate every child, including those in remote areas of the world (Spika, 2006).
With continuing measles vaccination programs and with the united support of major health organizations such as UNICEF, the WHO, The American Red Cross, and the CDC, eradicating measles becomes more of a possibility every time a child is vaccinated. The measles vaccination has been shown to save tens of thousands of lives and the need to vaccinate against measles will continue until the final goal of measles eradication is met.
a. Intervention 1 Immunize every child in Africa against Measles
i. Disadvantage 1 It is extremely unlikely that every child in Sub-Saharan Africa will be found by members of the Measles Initiative due to the topography of the country
1. Sub-Saharan Africa’s climate and topography make it extremely difficult to account for its total population. “Despite colonialism, African remains powerfully itself, moulded by its hard environment.” The problems of finding those in need of medical care are usually compounded by a collapse in basic infrastructure; broken roads and bridges, and continued insecurity. It is difficult to maneuver through the terrain to find tribal groups that are “hidden” from society. The measles initiative would like to vaccinate every child in Africa, but this seems unlikely due to the fact that there are people unaccounted for in a country that is divided by desert, mountains, vast forest and war.
Otten, J. The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.
ii. Disadvantage 2 There is knowledge deficit amongst some of Africa’s population that the immunization is necessary.
1. Many people In Africa are more concerned with short-term survival than minded to take risks for long-term development. Tribal people in the Congo region live in a warring county, their primary concern is to survive the day. These people have more eminent concerns such as what they are going to eat and drink for the day rather than the need for vaccinations. Knowledge deficit is a problem because they are surviving, but their children are dying from diseases like measles, that could have been prevented from a simple vaccine. It is important to teach the need of vaccinations not only individually but also globally as measles cannot be eradicated unless every individual is immune.
Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database
b. Intervention 2 Give a booster shot of the measles vaccine to the same children at least three years apart from the time it was first given,
i. Disadvantage 1 Record keeping if Africa is modest due to the socioeconomic status of certain rural parts of the country.
1. Immunization records have been lost or never documented due to the fact that there is little access to computers where most records are stored safely. Paper charting has been lost. especially in tribes where travel is a way of life. This problem has led to errors in documentation of school age children who have or have not received a second booster shot to discourage a measles outbreak during early education. The booster shot is necessary to prevent further outbreaks and spread of such a highly contagious disease. As the child gets older, vaccination records have become more and more obscure, This potentiates the need to vaccinate school age children against measles and other threatening diseased where there are either no documents of incorrect document of the child’s past medical history. In Sub-Saharan Africa, there are few computers and even fewer dollars to provide accurate accounts of medical history.
.Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health, 3(1), 47-52. Retrieved February 4, 2008, from Research Library database..
ii. Disadvantage 2 African tribes travel due to political unrest, making it difficult to find the children who are in need of a booster shot.
1. Political unrest and a warring state have caused people to leave their homes and communities. . Some of these people go into hiding to escape the consequences of war. This makes it extremely difficult to find those children in need of a second measles shot as well as other vacciinations. The reality of this has shown that the measles epidemic is still a problem in Africa because school age children need a booster to keep them immune from the disease. Aid workers cannot find these displaced children to give them the immunization that are necessary.
Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18(850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. References
Alan R. Lifson, Dzung Thai, Kaying Hang. (2001). Lack of Immunization Documentation in Minnesota Refugees: Challenges for Refugee Preventive Health Care. Journal of Immigrant Health, 3(1), 47-52. Retrieved February 4, 2008, from Research Library database. (Document ID: 352546391)
Carlson, L. (2007, March). Immunization update: neonates to adolescents. Nurse Practitioner, 32(3), 49-57.
Fitzpatrick, M. (2007, May 24). An End to the MMR guilt trip for blameless parents. Community Care, Community Care 1674, 23.
Nshimirimana, D., Masresha, B.G., & Maumbe, T. . (2006, September 22). Effects of measles-control activities--African region, 1999-2005 MMWR: Morbidity & Mortality Weekly Reportt
55, 1017-1021.
Otten, M. W., Okwo-Bele, J. M., & Kazaala, R. (2003, May 15). Impact of Alternative Approaches to Accelerated Measles Control: Experience in the African Region. Journal of Infectious Diseases 187, 36-43.
.Richard Dowden (2005, March). To save Africa we must listen to it. New Statesman, 18(850), 18-20. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 810330381).
Tim Cullinan, James Welsh. (2001). The problems of medical relief agencies. The Lancet, 357(9257), 713-4. Retrieved February 4, 2008, from Platinum Full Text Periodicals database. (Document ID: 69559122).
The suffering of millions. (2003, June). New African,(419), 59. Retrieved February 4, 2008, from Platinum Full Text Periodicals database.
Adolescent HIV Prevention and Education
Sexually active young people in the United States are at persistent risk for HIV infection. This risk is especially notable for youth of minority races and ethnicities. Continual prevention outreach and education efforts are required in order for adolescents to receive clear and accurate information. Approximately 4,842cases of HIV are diagnosed yearly among people ages 15-24 years (Eaton et al., 2006). With this rate of HIV infections among adolescents it is clear that additional efforts are required as new generations replace the generations that benefited from earlier prevention strategies. Adolescents are receiving mixed messages regarding HIV due to the medications that are now available and longer life expectancy of those living with the disease. Nurses working with adolescents can be pivotal in reaching youth before high-risk behaviors are established by identifying high risk adolescent populations, promoting education, and eliminating barriers to testing.
The Centers for Disease Control and Prevention (CDC) has conducted biennial Youth Risk Behavior Surveillance (YRBS) studies since 1991 in order to identify priority risk behaviors among youth. The results for the YRBS are obtained from students in grades 9-12 who participate in national, state, or local surveys. Of the students surveyed, 46.8% had engaged in sexual intercourse at least once in their life (Eaton et al., 2006). Male students were consistently ranked higher in risk taking behaviors than female students. Minority students (African American and Hispanic) predominately had more risk behaviors than Caucasian males or Caucasian females. These behaviors included multiple sexual partners, unprotected intercourse, and injection drug use (Eaton et al., 2006). Although most students receive some form of preventative health care annually, few discuss STD, HIV, or pregnancy prevention at those visits (Burstein, Lowry, Klein, & Santelli, 2003).
Understanding and identifying adolescent populations that are statistically at higher risk for HIV is a key strategy for nurses. Beedy-Morrison, Nelson, and Volpe (2005) provide evidence that Caucasian adolescent girls engage in higher HIV risk behaviors and receive less HIV testing compared with African American adolescent girls. Although HIV prevalence is higher among African American adolescents, the authors emphasize the implications the result of this study has on health care professionals. According to the findings, if Caucasian girls are more likely to engage in risky sexual behaviors and yet are less likely to be tested, there may be many undiagnosed HIV cases. In addition to the undetected HIV cases, the information health care professionals utilize to identify high risk groups may be inaccurate. Authors Goodenow, Netherland, and Szalacha (2002) found significantly high rates of HIV risk behaviors among bisexual adolescents. A study conducted in Seattle and British Columbia supports the previous research but also found a higher likelihood of HIV risk behaviors among sexually abused students in all sexual orientation categories (Saewyc et al., 2006). Nurses must promote greater community awareness of at-risk adolescents and seek to educate those populations. Education can occur through street outreach, pamphlets with referrals, posters, and classes where youth are located such as the YMCA or Boys and Girls Clubs of America.
Another key strategy for nursing professionals is to provide reality based education. HIV education should include “skills in negotiation, conflict resolution, critical thinking, decision-making and communication, which improves their self-confidence and ability to make informed choices such as postponing sex until they are mature enough to protect themselves from HIV, other STIs and unwanted pregnancies” (Unicef, 2002, p.26). Rew, Whittaker, Taylor-Seehafer, and Smith (2005) suggest that nurses must make sure confidentiality boundaries are established in order to build trust. Adolescents are more receptive to nurses that are open and direct and move from less sensitive topics to more sensitive topics during an assessment. Nurses must assist youth in establishing clear goals for preventing HIV and focus on specific health behaviors related to those goals. Adolescents need to be encouraged to talk with their parents and delay sexual intercourse. If delaying sexual intercourse is not an option adolescents must be taught about the risks and effective contraception methods that will protect against pregnancy, STD’s, and HIV.
An additional strategy nurses need to utilize is to eliminate barriers to sexual health promotion in order to provide effective HIV education. Barriers such as embarrassment, worries about confidentiality, previously bad experiences, and access problems can prevent an adolescent from seeking care. Lindberg, Lewis-Spruill, and Crownover (2006) found that African American adolescents “viewed available healthcare systems as formidable and unwelcoming and healthcare providers as judgmental and disrespectful” (p.85). The adolescents pointed to lack of privacy, having to discuss the problem with multiple personnel including the receptionists, and long waiting times as major barriers. In order to target adolescents, they need a place where they can receive competent care in a relaxing, private, and adolescent focused environment. A teen health clinic with a non-medical environment and open staff is one solution to this problem. Other options include private entrances for teens or a prescribing nurse available at schools.
Currently, we do not yet have a cure or vaccine to prevent HIV. This disease is still winning the war but there is an arsenal of weapons at our command. Nurses must have the know-how and the ability to utilize the resources available. The key to making a difference for adolescents is the adoption of successful HIV prevention interventions, paired with ongoing evaluation of their effectiveness in reducing risky behaviors or increasing safer behaviors. The key strategies addressed provide a foundation to prevent adolescent HIV infection rates. However, many more strategies will be required in order to find success. Young people need the tools to protect themselves from HIV infection and it is going to require a community collaborative effort.
Intervention I- Provide Reality Based Education
Disadvantage I- Limited and Inconsistent HIV Education
HIV prevention work cannot take place without certain ‘tools’ – things that can be used by those at risk of HIV to prevent infection. Ongoing discrimination against HIV positive people and a high number of annual infections suggest that AIDS education in the US is not as effective or as widespread as it could be. A 2006 survey for example found that 10% of Americans thought that there were drugs that could cure HIV, and 29% thought HIV could be transmitted through kissing. Although comprehensive sex education in schools is generally considered the best context in which to teach about AIDS, only around 60% of teachers report using a comprehensive (or abstinence-plus) system. About 34% teach strict abstinence-only programs, while at least 6% teach absolutely nothing at all. The exact content of what is taught can also vary considerably, and many have reported that even in schools where comprehensive education is theoretically taught, a lot of important information can be missed out or glossed over.
UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf
Disadvantage II – Outside Variables Can Affect HIV Curriculum Success
Important factors other than curriculum characteristics may dramatically affect their success. In general, at least three groups of factors may affect whether a curriculum-based program produce behavior change: 1) the characteristics of the curriculum and its implementation; 2) the needs, deficits (and assets) of the youth being served by the program; and 3) the characteristics of the youths’ environment, especially the prominence of AIDS, other STDs or teen pregnancy. In some communities in the United States where few young people hear messages to delay sex until older and where HIV is a salient issue, programs that encourage young people to delay sex in order to avoid HIV may be effective, whereas they might not be effective in other communities where youth already hear those messages or where HIV is not a salient issue.
Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth: Their impact and important characteristics. Family Health International, 1-76. Retrieved from www.etr.org on January 28, 2008
Intervention II – Eliminating Barriers to HIV Prevention Education
Disadvantage I – Health Care Access and Poverty Prevent Youth From Seeking Care
Studies have found that young people face a host of barriers to health care, including limited access to transportation, lack of confidentiality and youth-friendly service delivery environments, fear about seeking care, and lack of information about services available. Nearly 1 in 4 African Americans and 1 in 5 Hispanics live in poverty. The socioeconomic problems associated with poverty, including lack of access to high-quality health care, can directly or indirectly increase the risk for HIV infection.
Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.
Disadvantage II- Less Effort to Reaching “Other” At-Risk Populations
There is a need to pay more attention to the needs of specific groups of young people like young parents, young lesbian, gay and bisexual people, as well as those who may be out of touch with services and schools and socially vulnerable, like young refugees and asylum-seekers, young people in care, young people in prisons, and also those living on the street. Young people who drop out of school are more likely to become sexually active at younger ages and to fail to use contraception.
Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.
References
Beedy-Morrison, D., Nelson, L.E., & Volpe, E. (2005). HIV risk behaviors and testing rates in adolescent girls: Evidence to guide clinical practice. Pediatric Nursing, 31(6), 508-513. Retrieved January 14, 2007 from Expanded Academic ASAP database.
Burstein, G.R., Lowry, R., Klein, J.D., & Santelli, J.S. (2003). Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics, 111(5), 996-1002. Retrieved January 3, 2007, from Expanded Academic ASAP database.
Eaton, D.K., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Harris, W.A., & et al. (2006). Youth risk behavior surveillance-United States 2005. Morbidity and Mortality Weekly Report, 55(SS-5), 1-112. Retrieved January 31, 2007, from http://www.cdc.gov/mmwr
Goodenow, C., Netherland, J., & Szalacha, L. (2002). AIDS-related risk among adolescent males who have sex with males, females, or both: Evidence from a statewide survey. American Journal of Public Health, 92(2), 203-210. Retrieved January 9, 2007, from PubMed central database.
Kirby, D., Laris, B.A., & Rolleri, L. (2006). Sex and HIV education programs for youth:Their impact and important characteristics. Family Health International, 1-76Retrieved from www.etr.org on January 28, 2008.
Lindberg, C., Lewis-Spruill, C., Crownover, R. (2006). Barriers to sexual and reproductive health care: Urban male adolescents speak out. Issues in Comprehensive Pediatric Nursing, 29(2), 73-88. Retrieved October 2, 2007, from EBSCO Research database.
Rew, L., Whittaker, T.A., Taylor-Seehafer, M.A., & Smith, L.R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19. Retrieved October 2, 2007, from EBSCO Research database.
Saewyc, E., Pooh, C., Murphy, A., Skay, C., Richens, K., Reis, E. (2006). Sexual orientation, sexual abuse, and HIV risk behaviors among adolescents in the pacific northwest. American Journal of Public Health, 96(6), 1104-1110. Retrieved October 2, 2007, from EBSCO Research database.
UNICEF (2002). Young people and HIV/AIDS: Opportunity in crisis. New York, NY: Author. Retrieved October 2, 2007, from http://www.unicef.org/publications/files/pub_youngpeople_hivaids_en.pdf
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Medication Errors
Maggy Eldridge
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs.
Cause and Prevention: Medication Errors
Administration of medications is an important nursing function and one that if not properly carried out, can lead to a host of problems for the patient and nurse. It is estimated that over 1.5 million preventable medication errors occur annually in the United States (Neal, 2006), leading to death, patient disability, increased length of hospital stays and costs. According to Abudato (2004), medical errors (including medication administration errors and others) kill approximately 44,000 people yearly costing hospitals up to $30 billion annually. Medication errors can result in consequences for both the patient and the nurse; death for the patient and legal troubles for the nurse. By following some basic strategies, nurses play an important role in the reduction of such errors. These strategies include following established safety procedures, utilizing team communication to ensure safety, and using technology to reduce errors.
There are many factors that contribute to medication errors resulting in consequences to both patient and nurse. Factors that can contribute to errors include illegible handwritten drug orders, confusing drug names, and the use of nonstandard or unclear abbreviations (Neal, 2006). For the patient, the effect of drug errors can range from no side effects to death. For the nurse who commits a medication error the consequences can range from additional training and supervision to lawsuits and revocation of licensure. Medication errors can occur at any stage in the process of delivering medications to patients, from the originating prescriber to the pharmacy, but the majority of medication errors occur during administration.
Adherence to established safety procedures by all healthcare professionals can help to reduce medication errors. Errors occurring during the administration process are likely due to one of the steps of the five rights of medication administration being omitted: the right patient, medication, dose, route, and time, with the most frequent errors resulting from omission, wrong dose, and wrong medication (Davidhizar & Lonzer, 2003). Factors that can exacerbate errors include problems with the drug distribution system, inadequate staffing levels, environmental factors (e.g., distraction), nurses working in unfamiliar units, and not following standard policy and procedure. According to Davidhizar and Lonzer (2003), the following strategies are useful in addressing safety issues that revolve around medication errors: 1) reporting and analyzing errors using a multidisciplinary approach; 2) providing adequate staffing and training; 3) establishing and monitoring policies and procedures to ensure effectiveness and safety; and 4) all members of the healthcare team should have an awareness of how medication errors occur and be conscientious when administering medications. Attention to safe drug administration and safety guidelines is of particular importance in efforts to reduce medication errors and increase patient safety; it is an issue that is of concern across the various healthcare disciplines and nurses are essentially the final check and balance in the system.
Communication is a key function for nurses in providing safe and effective healthcare to their patients, and includes communicating effectively with patients and other healthcare team members. Abudato (2004) states that 90% of errors that occur within the healthcare industry are due to communication that breaks down at the nurse-physician level. Often, dysfunctional communication patterns between professionals in healthcare entities results from the organizational structure which determines how professionals interact with each other, who has the power (individual and group), and the cultural norms of the organization. RN’s are accountable to provide safe care to the point of questioning physician orders in order to fulfill the role of patient advocate. This can lead to dysfunctional communication because it represents a challenge to the authority and power of the physician, especially those who feel that they are where the “buck stops” when deciding what is and is not appropriate patient care (Arford, 2005).
Johns Hopkins has adopted a three-step model that focuses on assertiveness as a strategy for communication. This model advocates that when nurses communicate it is appropriate to use the first name of the person they are addressing in order to get their attention. The model further stresses that it is important to not only present the problem, but also present a solution and seek agreement to what has been proposed. Finally, the model suggests that if satisfactory resolution is not attained, move the problem up to the next level of authority (Abudato, 2004). Organizational structure often dictates the way communications occur and it is important to remember that no matter the situation, mutual respect must be maintained. Effective communication among all team members is an important aspect of delivering appropriate patient care and advocating for the patient, and is an area where things can often go wrong.
There is no substitute for common sense and diligence, but technological advances may be of use in helping to prevent medication errors. Technological measures include automated medication dispensing machines, computerized IV administration, and the bar coding of both patients and drugs. A research study conducted among a select group of nursing students at a suburban New York university was designed to answer the question: Does the use of PDAs (personal digital assistants) with drug and medication calculation software improve the accuracy and efficiency of medication administration (Greenfield, 2007)? Results of this study upheld the hypothesis that the use of PDAs and medical software did, overall, improve the accuracy and efficiency of medication administration. The author of the study recommends that all nursing students be required to have PDAs with drug and calculation software on them. There is evidence to suggest that use of technology is helpful in reducing medication errors, nonetheless, a strong human component remains and does not replace the need for carefulness and good judgment.
Medication errors represent a serious issue for the healthcare community as a whole. Errors can result for a variety of reasons; however, the majority of errors occur during administration of the medications. Because the nurse is the final link in the process of administering medications, it is the responsibility of the nurse to ensure accurate delivery of medications to patients. Strategies that the nurse can use to accomplish this include attention to policies and procedures, effective communication with other healthcare team members, and using available technological resources to complement other safeguards and individual competence.
a. Staffing and reporting
i. Staffing
1. Because of the high acuity of patients in the hospital setting today, with nurses possibly discharging and admitting several patients within a shift, adequate staffing levels are critical to providing safe patient care. With repeated interruptions nurses may find it difficult to establish and maintain a routine that may be critical to the delivery of appropriate and timely medications. In addition to disruptions in the work flow, the complexity of the work performed by nurses as they balance their workload along with managing the goals of the organization and goals of patient care, contributes to the problem.
2. Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
i. Reporting of errors
1. Reporting of errors relies on voluntary reporting. Traditionally, the nursing profession has operated based on a culture of fear and blame that focuses on individual culpability rather than looking at problems from a system-wide perspective. There can also be some ambiguity with regards to what actually constitutes a medication error (e.g., is late delivery of a dose a medication error?) and there is often reluctance to report errors that do not result in patient harm. Often nurses feel that reporting medication errors will be personally and professional damaging and are also reluctant to report errors made by others such as physicians, pharmacists and other nurses.
2. Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
j. Communication & organizational structure
i. Interpersonal communication
1. Historically, health care has been organized in a hierarchical fashion with physicians at the top of the hierarchy and seen as the authority when it comes to patient care. This type of culture has become so ingrained in our health care system that we don’t even question it. According to Abudato (2004), the acceptance of this culture can result in physicians subconsciously ignoring important information provided by nurses because they view them as subordinate. When this type of response is the norm, nurses may feel irrelevant and stop communicating, which only serves to further dysfunctional communication styles and may have an impact on the quality of patient care, including medication administration.
2. Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
ii. Organizational structure
1. While each nurse should have accountability in delivering safe and competent care including medication administration, often the organization itself leads to problems. It is the organization that provides the context in which nurses and physicians communicate because it directs the behavioral norms and determines how nurses and physicians communicate with each other. Conflict can arise in the context of nurses performing their roles as independent practitioners which can result in dysfunctional nurse-physician communication when individual authorities are challenged. Organizations often do not provide environments that are conducive to fostering teamwork and collaborative communication between nurses and physicians.
2. Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
References
Abudato, S. (2004, September). Making the communication connection: To minimize miscommunication with colleagues and patients, get assertive. Nursing Management 35(9), pp. 33-35. Retrieved from ProQuest on October 24, 2007.
Aebersold, M., Kalish, B.J. (May/June 2006). Overcoming barriers to patient safety. Nursing Economics 24(3), pp. 143-155. Retrieved from ProQuest on February 2, 2008.
Arford, P.H. (2005, March-April). Nurse-physician communication: An organizational accountability. Nursing Economics 23(2), pp. 72-77. Retrieved from Expanded Academic ASAP on April 6, 2007.
Davidhizar, R., Lonser, G. (2003, July-September). Strategies to decrease medication errors. Health Care Manager 22(3), pp. 211-218. Retrieved from Expanded Academic ASAP on April 6, 2007.
Greenfield, S. (2007, March). Medication error reduction and the use of PDA technology. Journal of Nursing Education 46(3), pp.127-131. Retrieved from ProQuest on April 6, 2007.
Groves, M., Pafford, L., Stetina, P. (June 2005). Managing medication errors – a qualitative study. MEDSURG Nursing 14(3), pp 174-178. Retrieved from Expanded Academic ASAP on April 6, 2007.
Harrington, S., Lilley, L., and Snyder, J. (2007). Pharmacology and the nursing process (5th ed.). St. Louis: Elsevier Saunders.
Neal, T. (2006, September 19). Preventing medication errors. The Seattle Times. Downloaded from seattletimes.nwsource.com on April 6, 2007.