Incidence of Tuberculosis and Multiple Drug Resistant TB are on the rise. The popular conception is that this disease, as old as humanity, is under control and being eradicated.
However, among certain disenfranchised and underserved populations, such as drug users, prison populations, HIV patients and refugees from high-risk countries, ripe conditions have led to a breeding ground for TB and MDR-TB. Therefore the nursing community must educate everyone they can, identify and be willing to intervene directly with underserved populations and utilize proper techniques and training.
During the first half of the 20th Century, TB was called " white plague " or "consumption" because it seemed to consume and waste a person from within, having traveled from the lungs to other parts of the body. It is a hardy organism spread in aerosol form by coughing, laughing or sneezing. A person can be a carrier, test positive but be non-contagious. They are not be considered to have TB the disease (Selekman 2006). A combination of at least four “front line” anti-TB drugs is used to prevent resistance to the organism (Kidder, 2003). Failing that, subsequent MDR-TB is treated with other more expensive drugs. Just as important as treatment are some nursing strategies that can be very effective at interrupting the spread of the disease.
Nurses must work hard to educate and dispel the many myths that surround TB. The majority of people believe it has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. Effective education by nurses could overcome barriers such as fear and language and cultural differences. One commonly held belief that is true, is that high-risk groups including inmates, homeless, drug users and certain groups of immigrants are more at risk of contracting TB (Boutotte, 2000).
The second nursing strategy is to identify underserved populations and not only go to the source but be prepared to be flexible in implementing nursing interventions. Prisons and jails are a breeding ground for TB due to overcrowding. In addition there are other circumstances that a nurse should know about that contribute to the non-compliance of therapy. In the US, prisons in California and New York have had epidemics of resistant TB. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005). In the prisons of Siberia, which are lacking in proper nutrition and appallingly overcrowded, there is a caste system, with Mafia-like bosses, middlemen and abused under castes, who may be beaten if they don’t hand up the valuable drugs to the bosses (Schwalbe, 2002). Of course Mycobacterium tuberculosis does not differentiate between murderers or petty thieves; nor prison guards and their families. It is equally important for the health of the general population that nurses seek out other disenfranchised groups such as the homeless, drug users and immigrants from certain high risk countries.
Fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. The only way to obtain compliance is to actually observe each dose administered (known as DOTS-Directly Observed Treatment Short-Course (Kidder, 2003). Compliance in following the drug regimen to its completion is even more difficult when the patient is transient, literally, such as drug users and the homeless population. Further, there is little incentive to continue the therapy when symptoms disperse and more immediate daily needs take prescedence. Dr. Paul Farmer showed that it was necessary to provide assistance with food and shelter to get better results while he worked With TB patients in Haiti (Kidder, 2003). While it requires extra work to bridge cultural, societal and physical barriers, studies also show a direct correlation to the amount of the care provider’s training and the success of implementing prevention and curative strategies (Khan, et.al, 2006).
What training and special protective measures are required by nurses to implement the third nursing strategy? First there are the basics; nurses should be actively on the lookout for patients with signs and symptoms of TB, particularly in high incidence settings. “Nurses should consider a patient to be highly infectious if he has a productive cough, pulmonary cavitation on a chest X-ray, hoarseness, laryngitis, and acid-fast bacillis (AFB) on a sputum smear, and he is not on an anti-tuberculosis drug regimen” (ICN TB Guidelines, 2004). In most cases, it is reportable to a state agency if there is a strong suspicion of infection. The suspected patient should be isolated and started on anti tuberculin drugs before confirmation of lab work. Instruct the patient to cover coughs and sneezes with a tissue or even to wear a mask. It is important that the tuberculosis (Mantoux / PPD) skin test be used as opposed to the older “Tine” test (four pin pricks), which has been deemed unreliable. Chest x-rays are often ordered as a follow-up. This illustrates the need for specialized training and indeed it is possible to become a TB specialist nurse. The work includes contact tracing to find the original carrier and screening close contacts. Being sensitive is also important as the patient may feel responsible for infecting others. The most important aspect of care is ensuring completion of the prescribed therapy. This may require the nursing support to be individualized and flexible.
It is not too hard to see how TB has spread beyond the breeding pools and into the general population and thus this emphasizes the importance of the nurse’s role in treatment and continuous monitoring. Underserved populations present unique challenges outside the classic nurse-patient model. However with diligence toward public education and one’s own education and training, and a little tenacity and flexibility, a nurse can make a difference with overlooked populations.
Bibliography
Boutotte, J., (2000), AFB isolation rounds: What your nurses need to know,
Nursing Management. 31(9), p 49(3), Retrieved October 11, 2007, from ProQuest database.
International Council of Nurses, (2004), TB guidelines for nurses in the care and control of tuberculosis and multi-drug resistant tuberculosis, Retrieved October 10, 2007, from http://www.icn.ch/tb/guide_chap2.htm.
Khan, K., Campbell, A., Wallington, T., Gardam, M., (2006), The impact of physician training and experience on the survival of patients with active tuberculosis, Canadian Medical Association. Journal, 175(7), p 749-753, Retrieved October 09, 2007, from ProQuest database.
Kidder, T. (2003), Mountains beyond mountains: The quest of Dr. Paul Farmer, a man who would cure the world. New York: Random House.
MacNeil, J., Lobato, M., Moore, M., (2005), An unanswered health disparity: tuberculosis among correctional inmates, 1993 through 2003, American Journal of Public Health. 95(10), p 1800-5 (6), Retrieved October 11, 2007, from ProQuest database.
Schwalbe, N., Harrington, P., (2002), HIV and tuberculosis in the former Soviet Union, The Lance, 360, p 19-20, Retrieved October 09, 2007, from ProQuest database.
Selekman, J., (2006), Changes in the screening for tuberculosis in children, Pediatric Nursing, 32(1), p. 73 (3)
New Verbiage
There are often barriers to any educational nursing intervention but specifically in the realm of teaching about Tuberculosis, several disadvantages are the misinformation that exists and the discrimination experienced. Effective education by nurses must over come myths such as the belief that TB has been eradicated, at least in the developed countries. People are often shocked when they hear the diagnosis because they believe it leaves them stigmatized and unclean. They believe that only the down & out get TB, yet people from all social strata get TB. Some believe smoking causes it, or that it is hereditary. The second disadvantage to education is the fear of immigration authorities, language and cultural barriers, financial restraints, lack of health insurance and inadequate housing are factors that are often compounded by co-infection with other disease processes such as HIV. Dr. Paul Farmer found that education about compliance was highly affected whether you had adequate shelter and food, or to put it another way when you are starving you aren’t so concerned about a missed dose even if it’s free (Kidder, 2003).
In Africa TB rates are high and effectiveness of treatment low. A lot has to do with the linking of TB to AIDS and inherit problems with teaching about that disease process. “Limited funding, governmental indifference or opposition, AIDS stigma, and social discomfort discussing sex were often cited as barriers.
It is not just enough to identify at risk populationsas a nursing invervention. The factors that make them hard to find, diagnose & treat are also factors that make them non-complainant with their treatments. Patients with or at risk for TB face discrimination, often because of its association with AIDS. Also, prison inmates homeless, drug users and immigrants from certain high risk countries are not often policy makers first priorities, if indeed, they are on the radar at all.
In Africa, the stigma of AIDS prevents people from readily seeking help until other disease processes including TB are well entrenched. Additionally wars and famine make a shambles of health care systems the populations become transient.
Prisoners face several of these problems. Often there is little staffing and little sympathy for the care of inmates. With limited resources it is hard to convince policy makers that $ and drugs should be used on this lowest caste of society. There are additional compliance/containment problems that typical nursing interventions are not geared toward. In some prisons, it was discovered that prisoners would sell their medication or deliberately swap sputum samples. Some actually wanted to be sick to stay in the much nicer conditions that the infirmary afforded with no work duty assigned. Conversely, some inmates, believing it would hinder their release dates, bought clean sputum samples, or bribed poorly paid prison medical staff (MacNeil, 2005).
Another problem is that government officials may not wish to acknowledge problems with treatment programs. Conversely government officials may have their own idea of what their own treatment program should look like and be dismissive of foreign intervention or non-profits whom they may feel are “irrelevant or even a nuisance.” (Naidoo, 2001)
Bibliography – New Research
Kelly, C., (2006) Psychological and socio - medical aspects of AIDS/HIV (Programs, resources, and needs of HIV-prevention nongovernmental organizations (NGOs) in Africa, Central/Eastern Europe and Central Asia, Latin America and the Caribbean. AIDS Care, 18(1), p. 12- 21, Retrieved from Proquest database January 30, 2008
Naidoo, K. (2001), The role of the nonprofit sector. In C. E. Koop, C. Pearson & M. Schwarz (Eds.), Critical issues in global health (pp. 406-415). San Francisco: Jossey-Bass.
Wednesday, February 6, 2008
Disadvantages to Proposed TB Nursing Strategies
Postpartum Depression
Postpartum depression (PPD) is feelings of failure, guilt, loneliness and low self esteem lasting longer than two weeks or beginning two weeks or more after delivery. 50-80% of women experience the “baby blues,” a period characterized by feelings of restlessness, anxiousness, fatigue and loneliness which usually subside by the 10th postpartum day. This condition is mild and transient (Wong, 2006). 10-15% of women experience postpartum depression, typically with the classic symptoms of depression, sadness, crying, withdrawal and sleep disorders.
The woman may fear harming her baby or have thoughts of suicide. PPD is one of the most commonly undiagnosed conditions after childbirth. Approximately 40% of cases go unnoticed. Generally this is due to the mother’s embarrassment, guilt or fear of the feelings she is having and more often than not, she will not voluntarily admit to this kind of emotional distress (Wong, 2006). Recently the public has become aware of this ailment due largely to celebrities coming forward about their experiences with PPD. This publicity is helping women suffering from PPD to understand it and seek treatment. The nurse’s role in educating patients to prevent PPD, recognizing signs and symptoms of PPD and successful care of women suffering from PPD is essential to the health of the mother and her baby.
Nurses can educate new mothers and their families to help prevent postpartum depression in a number of ways. The precise cause has not been identified but is a combination of biochemical, psychological, social and cultural factors. Changes in hormone levels, fatigue due to childbirth, demands of the newborn, feelings of loss when separated from the newborn and cultural norms regarding the mother’s behavior are just some of the contributing causes of PPD. Informing clients of the predisposing characteristics and circumstances that place them at risk is the first key step. Issues such as prenatal depression, maternal history of depression, lack of social support, life stress, child care stress, maternal blues, marital dissatisfaction and prenatal anxiety should all be considered during conversation with the mother during both prenatal and postnatal visits. Another significant aspect is that at childbirth, the focus of attention transfers from the pregnant mother to the newborn. Continuing to support and care for the mother would help to reduce depression as well as help family members recognize symptoms of PPD. Flexible, mother-focused support from community providers may decrease the prevalence of PPD (Watt, 2002). Educating the mother and family on signs and symptoms is an important tool. These include feelings of distress, not being able to identify the source of the distress, and expressing undue concern about the health of their infant or themselves. Signs and symptoms of PPD are similar to any depressive state and consist of feelings of disappointment or apathy, sadness, insomnia, headache and anger for no justifiable reason.
Postpartum depression can interfere with maternal role attainment and may result in delayed maternal infant bonding. Because of this, nurses should seek education to better recognize early signs and symptoms of PPD and should include knowledge on assessing patients who are at risk. Risk factors for PPD are increased anxiety during pregnancy, ambivalence about pregnancy, previous postpartum depression, previous mental health disorders, previous problems with premenstrual syndrome, marital discord, poor extended family support, low socioeconomic level and a history of abuse, neglect or alcoholism. Screening tools such as the Edinburgh Postnatal Depression Scale and Beck’s Postpartum Depression Checklist may be used (Creehan, 2007). A nurse who identifies and addresses these issues early on is able to assist the new mother with seeking treatment, supporting her and being empathetic to her feelings (Castine, 2007).
Nurses play a crucial role in providing interventions and treatment for postpartum depression, beginning with identification. Screening for risk factors is the first crucial step to discovering PPD. Next, assessing the mother’s mood and affect as well as the interactions between the mother and infant is critical. The mother is very vulnerable during this immediate postpartum period so the nurse must focus on showing support and caring. Informing the mother of strategies for feeling rested are napping when the baby does and letting someone else take care of the household chores. Discuss planning self care with the mother, such as taking a walk, reading a book, having a date with her significant other and spending time with friends. Encouraging the mother to share her feelings will also improve her well being. Encouraging breast feeding is an important role the nurse can play at this time. It can help the mother bond with her newborn and results in the mother feeling pleased. Crying is also beneficial to the postpartum woman. Psychologically, it is expressive, and physiologically, it rids the body of toxins and hormones (Fooladi, 2006). This can alleviate some of the depressive feelings the new mother has. The nurse can also promote support within the family by discussing the condition and ways they are able to help the new mother. The nurse can also help the mother get in touch with support groups and programs in the community that would be beneficial to her. When depressive symptoms continue beyond the “baby blues” period, it is important to assist women in seeking medical treatment. Medical management of PPD includes pharmacological intervention. Antidepressants such as Tegretol or Depakote are necessary in most cases. Psychotherapy is another important step in the treatment process and is focused on her fears and concerns regarding her new responsibilities and roles as well as monitoring for suicidal or homicidal thoughts (Wong). Possible alternative or complimentary therapies include acupuncture, acupressure, aromatherapy, herbs, healing or therapeutic touch, massage, relaxation techniques, reflexology and yoga.
Postpartum depression is a condition that is treatable, however it is commonly undiagnosed. Nurses are able to offer much support, guidance and knowledge to these mothers. Their role is essential in the education, recognition and successful care of women suffering from PPD.
A. Intervention 1: Focus on diagnosing postpartum depression
a. Disadvantage 1: It is difficult to assess for postpartum depression due to several factors.
The length of stay in the hospital after a vaginal delivery is forty eight hours and for a cesarean section it is ninety six hours. (Datar & Sood, 2006) This amount of time allows primary care providers to ensure the physical health of the mother and newborn as well as keeping the cost of childbirth reasonable. This amount of time does not, however, allow sufficient time to monitor mental health conditions. The first postpartum check-up takes place six weeks after birth during which the provider will perform a physical examination and discuss any concerns the new mother is having. Many women suffering from postpartum depression feel embarrassed and choose not to share their feelings. After the six-week check-up, the focus turns to the infant, without further follow up for the mother (Gjerdingen & Center, 2003). With so few opportunities to assess for PPD, it’s difficult to diagnose every case.
b. Disadvantage 2: Embarrassment may hold women back from sharing feelings.
Women are expecting a period of adjustment during the postpartum period and may not realize that what they are experiencing is abnormal. (Epperson, 1999) The period directly after giving birth is very new to first time mothers. There is a feeling of pressure to be a “good mother”. If and when depressive feelings come about, she doesn’t know how to handle it during a time that is supposed to be the happiest in her life. Because of this, it is less likely that she will seek professional assistance. Denial of the classic depressive symptoms of postpartum depression delays treatment and ultimately delays normal mother-child bonding as well. Due to the very few opportunities the primary care provider has to diagnose PPD, it is important that women be educated about PPD. This will likely help them understand their feelings and seek treatment.
B. Intervention 2: Continuing to support and care for the mother postpartum
a. Disadvantage 1: Taking the time to do self care
The demands of motherhood can be overwhelming, especially if there is also strain on the mother’s relationship with her significant other or their finances. Everything is new, and taking care of your own child is exciting and frightening at the same time. These women often have responsibilities they feel that they must do on their own including cooking, cleaning and caring for the infant while trying to recover from giving birth. In order to relieve everyday stresses incurred by the new mother, she must learn to perform self-care (Cheng, 2006). The new mother needs to take time for herself. Things such as resting and exercising will help with her physical health. But self-care is so much more than that. She must let her family and friends help her with household chores and remember that she doesn’t have to do everything by herself. The new mother also needs to take care of her emotional needs by having a date with her partner and spending time with friends. Getting out of the house to go for a walk can do wonders for stress. Talking about feelings with a significant other, family and friends will help the new mother identify any depressive symptoms she may be having as well as improve her emotional health overall (Cheng, 2006).
b. Disadvantage 2: Finding the time, energy, courage and resources to get involved in support groups.
New mothers are overwhelmed with their new duties and lifestyle. There are some strategies for coping with the stress that goes along with this such as asking for help, setting daily goals, and discovering new activities. There are support groups available for just about any condition and postpartum depression is no different. It is usually difficult for women to discuss their feelings, especially if they are embarrassed of those feelings. Talking about them with a group of strangers can be quite intimidating. There are many resources available on the internet, such as Postpartum Support International (http://www.postpartum.net/index.html) . Providing information about support groups during well child check-ups may help new mothers realize that support is out there and will hopefully seek it out if she is not comfortable discussing her feelings with her provider yet (Cheng, 2006).
Resources
Castine, J. & Walton, J. (2007, March 14-20). Postpartum depression negatively impacts child development. Michigan Chronicle, p. B8.
Cheng, C., Fowles, E., & Walker, L. (2006). Postpartum maternal health care in the United States: A critical review. Journal or Perinatal Education, 15(3). Retrieved February 4, 2008 from PubMedCentral database.
Creehan, P. & Simpson, K. (2007). Perinatal Nursing (3rd ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 492-512.
Epperson, C. (1999). Postpartum major depression: Detection and treatment. American Family Physician, 59(8). Retrieved February 4, 2008 from American Academy of Family Physicians News and Publications database.
Fooladi, M. (2006). Therapeutic tears and postpartum blues. Holistic Nursing Practice, 20(4), 204-. Retrieved January 3, 2007 from Expanded Academic ASAP database.
Gjerdingen, D., & Center, B. (2003). First-time prenatal to postpartum changes in health, and the relation of postpartum health to work and partner characteristics. Journal of the American Board of Family Medicine, 16. Retrieved February 4, 2008 from Journal of the American Board of Family Medicine database.
Hendrick, V. (2003). Treatment of postnatal depression: Effective interventions are available, but the condition remains underdiagnosed. British Medical Journal, 327(7422). Retrieved January 3, 2007 from PubMedCentral database.
Lieu, T., Braveman, P., Escobar, G., Fischer, A., Jensvold, N. & Capra, A. (2000). A randomized comparison of home and clinic follow-up visits after early postpartum hospital discharge. Pediatrics. 1058. Retrieved January 3, 2007 from Expanded Academic ASAP database.
Watt, S., Sword, W., Krueger, P., & Sheehan, D. (2002). A cross-sectional study of early identification of postpartum depression: Implications for primary care providers from The Ontario Mother & Infant Survey. Journal of BioMed Central Family Practice, 3. Retrieved February 20, 2007 from PubMedCentral database.
Wong, D., Perry, S., Hockenberry, M., Lowdermilk, D.L. & Wilson, D. (2006). Maternal child nursing care (3rd ed.). St.Louis: Mosby, Inc. pp. 619-621, 638-9, 674-9.
The Role of the Nurse in Postpartum Depression. (n.d.). Retrieved February 5, 2007, from http://www.awhonn.org/awhonn/?pg=873-6230-7000-4730-4770
Pediatric Oncology Nursing: Support for an Uncertain Journey
Uncertainty—this is an every day occurrence for pediatric oncology patients and their families. The fear and anxiety experienced from the time a child is diagnosed throughout their long journey of treatments and tests needs to be eased by a familiar role: nurses. Jaime Giampapa
Since the very nature of cancer creates an atmosphere of unpredictability and unfamiliarity, pediatric oncology patients and their families need support from nurses who can provide care to meet not only their physical needs, but also their psychological and at times emotional needs. Nurses can make a difference to a family dealing with this illness by providing supportive care. This can be accomplished by nurses using creatively to care for these children, educating their parents, and developing therapeutic relationships along the way.
Cancer can tear a family apart. When a child is diagnosed with cancer, the family is “suddenly placed in the position of coping with a wide array of new situations, such as painful and frightening symptoms, uncertainty of prognoses, and changes in social relationships” (Suzuki& Kato, 2003, p 159). Not only does this foreboding situation put stress on the patient, but the whole family unit, which can be catastrophic. Parents describe the diagnosis and treatment of their child afflicted with cancer as one of the most stressful times of their lives (Kerr, et al., 2007), and this stress can cause a family to become ineffective. Through this tumultuous time, it is vital for the patient and his family to come together in support, and the nurse can aid in this effort.
Firstly, a nurse needs to creatively provide care to their pediatric oncology patients. By using creativity, the nurse may reduce the anxiety experienced by the patient during treatment and procedures, while also meeting physical needs. This is also a more efficient way of providing care. For example, many pediatric oncology patients have aichmophobia (fear of needles or pointed objects). A researched method of reducing this fear is utilizing simple stress reducing medical devices, defined as medical equipment, such as winged needles and syringes, with simple visual stimulation on its surface, such as stickers demonstrated by the picture(Kettwich, et al., 2007) . By using these stress reducing measures, it “has been demonstrated to markedly suppress anxiety, fear and aversion” (Kettwich, et al., 2007, p 21), which will allow the nurse to effectively and efficiently provide care to these patients.
(Kettwich, et al., 2007, p 22-23)
Another creative method for treatment of pediatric oncology patients is beaded bracelets. The John Hunter Children’s Hospital introduced a Bravery Bead program in which patients receive beads spelling their name upon diagnosis and are awarded beads for completing treatments or procedures (Cotterell, 2005). This program provides children going through treatments to look forward to the fun reward of the beads after completion. Although research has not been conducted on how the beads have affected the children collecting them, one can conclude that the bracelets are symbolic of the journey they have traveled thus far. Nurses can play an integral role in implementing this program for their patients.
In addition to providing care to the patient, the nurse needs to be supportive of their parents. Parents are often overlooked when focusing on the patient’s needs, but the parents are dealing with feelings of anxiety and fear as well. Nurses need to recognize that parents “have to cope with the distress [of their child being diagnosed] along with their responsibilities as their child’s primary source of physical and psychosocial support” (Suzuki& Kato, 2003, p 160). If nurses help provide parents with the right tools to cope with their child’s illness, the child will most likely cope effectively as well. The most important tool, as identified by parents of pediatric oncology patients in a conducted study, was basic information about their child’s illness (Kerr, et al. 2007), which the nurse can address by answering questions parents may have about their child’s cancer. By locating some reliable resources (such as pamphlets, booklets and internet sites) for parents, as well as referring them to various support groups or information sessions, the nurse can attempt to fulfill the parent’s needs. In addition, 84% of the same “parent need” study revealed that emotional needs were also important for the nurse to address (Kerr, et al., 2007).
Finally, nurses need to develop a therapeutic relationship with the pediatric oncology patients and their families. The ideal therapeutic relationship is described as “the nurse combin[ing] the basics of everyday care with the human touch” (Hawes, 2005, p16), which allows the parents to feel their child is in the right hands. Trust is of utmost importance among the patient, his parents and his nurse. The relationship should be connected, but not to the point of over-involvement. This may be characterized as the nurse “tak[ing] on the role of ‘omnipotent rescuer’” (Hawes, 2005, p 15) in which the nurse has become controlling within the relationship overstepping necessary boundaries. Care should be shared between families, and the nursing staff in complete balance.
In conclusion, nurses can make the difference in pediatric oncology by providing complete supportive care for the patients and their parents. For years, nurses have been known as the “caring role” in our society, and nurses fill that role with pediatric oncology patients by establishing a care plan that involves a holistic approach to nursing. This can be accomplished by nurses creatively providing care to these children, educating their parents, and developing therapeutic relationships during their journey to recovery. The nurse develops a professional, but compassionate, relationship with the patient and the family to give complete care that will meet all their needs, physiological and psychological.
Intervention #1. Nurses develop therapeutic relationships with pediatric oncology patients and their families.
Disadvantage #1. Nurses can become too involved with the patients and their families.
A nurse can become the “omnipotent rescuer” for a particular family, which can develop into an unhealthy relationship for the nurse and the family involved. This relationship usually occurs when the nurse is inexperienced and does not know how to set boundaries between themselves, the patients and their families, indicating over-involvement. Common behaviors for blurred boundaries include the nurse-patient relationship transforms into social context, also the nurse can become controlling in the patient’s care at the expense of the patient. Nurses who fall into this type of therapeutic relationship need to develop boundaries to care for the patient, but not escalate the situation to the point that it is unhealthy for the pediatric oncology patient and the nurse providing the care. By learning from mistakes and listening to experiences of mentor nurses, pediatric oncology nurses can learn to develop positive therapeutic relationships (Hawes, 2005).
Disadvantage #2. Culture, ethnicity and race can reduce the effectiveness of a therapeutic relationship between the nurse and pediatric oncology patients and their family.
Some families of patients with cancer have different beliefs and practices due to their culture, ethnicity and race. This can prove to be a barrier in developing a positive therapeutic relationship with the nurses providing care. If the nurse is not thoroughly informed of the family’s individual culture, communication may be very difficult to achieve. This is especially true when the patient and their family speak a different language. In this situation, an interpreter may not always be available for the nurse to keep the family involved in their child’s care. It is often difficult to use children, family members and friends of the family to translate because this form of communication may not allow the patient’s family to speak openly about the care of their child. The barrier of communication continues if the nurse fails to incorporate traditional cultural beliefs of a family into treatment plans which can cause the family to not trust the nurse and staff to effectively care for their child. A nurse in this situation must learn to effectively communicate with the family in order to provide the optimum care for the pediatric oncology patient and develop the vital therapeutic relationship (Wong, et al., 2006).
Intervention #2. Nurses educate parents of pediatric oncology patients
Disadvantage #1. Parents are stressed due to their child’s status and may not retain the information taught.
Parents of pediatric oncology patients are not retaining the essential information taught because of their stress at the time of education and minimal opportunity to have proper education. Due to the increase in ambulatory care and short hospital stays, the available time to properly educate parents has decreased, and therefore, so has the absorption of information. Important aspects to the patient’s care, such as “the signs that should cause alarm and long-term implications of a disease” can contribute to ignorance of how to adequately care for their child (Fox, Smith, 2003). Not only is short hospital time reason for poor digestion of information, but also their stress levels are not conducive to learning. According to Fox and Smith, most parents need additional information after their child has been discharged and cannot recall the information provided at the hospital. Therefore, because of the parent’s heightened stress level, they forget the instructions about their child’s care. Nurses must use different forms of providing information, such as pamphlets and resourceful internet sites, to enforce information learned in the hospital and prevent parent confusion(Fox, Smith, 2003).
Disadvantage #2. Parents that have lower socioeconomic status and education may not be able to comprehend the education regarding their child’s illness.
When parents of pediatric oncology patients have a lower socioeconomic status and have lower levels of education, the understanding of their child’s treatment may not be fully comprehended. These parents are not able to process and make sense of the information given by nurses, and may lead to misunderstandings and confusion. This is not conducive to an acceptable ability to provide knowledgeable care to their child. Parents in this group also cannot understand distressing aspects of their child’s illness because they do not understand the process behind the cancer. Although there is not sufficient data to fully support the correlation between lower education and uncertainty, one can conclude that these two topics are related. In order to combat confusion and uncertainty in these situations, the nurse must use understandable information for these parents to comprehend, and then check their knowledge after education (Santacroce, 2002).
Resources
Cotterell, D. (2005). Beads for a brave journey. Australian Nursing Journal, 13(3), p31-32. Retrieved October 12, 2007, from Expanded Academic at http://web.ebscohost.com.
Fox, A., Smith, P. (2003) Parents and the internet. Internet journal of pediatrics & neonatology. 3(1), p 110-116.
Hawes, R. (2005). Therapeutic relationships with children and families. Paediatric Nursing, 17(6), p15-18. Retrieved October 12, 2007, from Expanded Academic at http://web.ebscohost.com.
Kerr, L., Harrison, M., Medves, J., Tranmer, J., & Fitch, M. (2007) Understanding the supportive care needs of parents of children with cancer: An approach to local needs assessment. Journal of Pediatric Oncology Nursing, 24, 279-293.
Kettwich, S., Sibbitt, Jr., W., Brandt, J., Johnson, C., Wong, C., & Bankhurst, A. (2007) Needle phobia and stress-reducing medical devises in pediatric and adult chemotherapy patients. Journal of Pediatric Oncology Nursing, 24, p 20-28.
Santacroce, S. (2002) Uncertainty, anxiety and symptoms of posttraumatic stress in parents of children recently diagnosed with cancer. Journal of pediatric oncology nursing. 19, p 104-111
Suzuki, L. & Kato, P. (2003) Psychosocial support for patients in pediatric oncology: The influences of parents, schools, peers and technology. Journal of Pediatric Oncology Nursing, 20, p 159-174.
Wong, D.L., Perry, S.E, Hockenberry, M.J., Lowdermilk, D.L., Wilson, D. (2006) Maternal child nursing care: 3rd ed. St. Louis, Missouri: Mosby Elsevier. p 1219-1220
Adolescent: Cervical Cancer & Human Papillomavirus (HPV)
The staggering rate of cervical cancer caused by the Human Papillomavirus (HPV) is chilling. Researchers are learning more about this disease and discovering successful prevention measures to fight it. Tove Finch
Having the tools for disease prevention, health care providers are often challenged by real world obstacles. Lack of public awareness regarding HPV transmission and at risk populations is limited, vaccine controversies surrounding adolescent girls becoming sexually active, and lack of routine screening increases the risk for cervical cancer each year. Targeting the at-risk population, educating HPV prevention, and advocating for cervical cancer screening are essential nursing strategies to reduce the burden of illness caused by HPV.
According to Cox and the CDC (2006), HPV is the most prevailing sexually transmitted infection responsible for cervical cancer. In the United States, 20 million people are currently infected with HPV, an additional six million people become newly diagnosed and nearly four thousand women die from cervical cancer each year (Cox, 2006). Many young women do not know that being sexually active puts them at risk for cervical cancer because HPV can develop undetected and become transmitted unknowingly (Cox, 2006). Fawcett (2007) supports this by stating, “young girls are particularly at risk because some start having sexual intercourse earlier, have higher number of partners, smoke and fail to use barrier methods of contraception” (p.2). Vaccinations to eradicate HPV are underway, but controversial issues continue over personal and religious beliefs. According to Ritchie (2006), there are varied levels of sex education because of religious and cultural beliefs. Therefore, greater preventative steps need to be taken to reduce the incidence of HPV in the younger population.
One nursing strategy on illness prevention is to target the adolescent at risk population. Providing a holistic approach to adolescent health care by including pediatric reproduction health services will benefit public health as a whole and assure access to the at risk population. Roye, Nelson, and Stanis (2003), support this by stating, “nurses should advocate for the provision of comprehensive reproduction health services in all clinical sites that provide primary care to adolescents” (p.4). This type of standardized quality health care will enable goals to eliminate health disparities among adolescents and permit early primary prevention. The national health promotion and disease prevention goals, Healthy People 2010, will also be promoted by strengthening community prevention and protecting the future health of the adolescent population from cervical cancer caused by the Human Papillomavirus, (Potter, 2005).
While targeting the adolescent at risk population, another key strategy must address educating HPV prevention and transmission. Fawcett (2007) states, “educating adolescents about protection against HPV is a vital part of adolescent health care” (p.5). Cox (2006) adds, “At present, HPV is widespread such that most sexually active individuals will be infected in their lifetime” (p.3). Society needs to change their attitude and eliminate political barriers by including an objective nursing focus on educating parents and adolescents about the prevention and transmission of HPV, thus empowering adolescents to participate in disease control. This education may include topics such as risky behaviors, the HPV vaccine, Pap screenings, condom use, and abstinence. Educating on adolescent behavior and giving informed sexual advice permits comprehensive decisions. According to Bartlett, Davis and Belyea, (2007), in any health-related interactions with an adolescent, failure to inquire about an adolescent's involvement in problem behaviors may result in lost opportunities to educate the adolescent, who may have nowhere else to gain such information. Fawcett (2007) supports this by stating, “sexual health education should be aimed at reducing the risk” (p.4). This strategy also supports Healthy People 2010 goals by promoting healthy behaviors and protecting adolescent sexual health, thereby increasing the quality and years to their life.
In addition to education and immunization, screening by Papanicolaou, (Pap) smear, is an essential strategy that contributes to early detection of cervical cancer (Fawcett, 2007). Nurses need to collect efficient patient history and advocate screening services in clinical sites that provide primary adolescent care. Cervical screenings have led to a notable decrease in cervical cancer deaths in the middle age population and adolescents alike (Roye, Nelson, and Stanis, 2003). If sexually active adolescents are not regularly screened for HPV they may develop cancer undetected. Fawcett supports this strategy by stating, “We believe that Pap smear screening of sexually active adolescents remains an important preventive health procedure that is clinically justifiable” (p.5).
Evidence exists showing the link between cervical cancer caused by the Human Papillomavirus and the prevalence of this disease on the adolescent population. HPV is like butter, it spreads, making HPV prevention imperative. Many parents are uncomfortable with the idea that the majority of young people are or have had sex by the time they reach early adulthood. Therefore, advocating for adolescent reproductive health services and promoting protective sexual behaviors like HPV prevention and awareness, is an essential step to lessen the burden of disease. It has only recently become a preventable infection. Every effort must be made to further eradicate cervical cancer and provide greater continuity of adolescent health care.
1. Target the At-Risk Population:
A. Failure to Address Adolescent Reproductive Health Issues:
Even though the number of sexual health clinics has increased, it remains difficult to persuade young women to use them. Many young women are sexually active, but very few visit a clinic for advice or treatment. This may be due to feelings of embarrassment or the lack of awareness of the services available. According to Fawcett, nearly half of American teenagers had engaged in sexual intercourse before graduation which suggests that many young people appear oblivious to health promotion messages (2007). Health care providers, such as pediatricians, are often uncomfortable addressing reproductive health issues with adolescent patients and many will fail to do so (Roye, Nelson, & Stanis 2003). Therefore, important adolescent reproductive health information is being overlooked and not getting through from family members or health professionals alike.
B. Lower Socioeconomic Barriers:
Cervical cancer disproportionately affects women of lower socioeconomic status, poor access to health care, and for those who are uninsured (CDC, 2006). Cultural and socioeconomic barriers to cervical cancer screenings have contributed to a distinct health disparity among African American women nation wide. African American women represent a medically underserved population, therefore more likely to be diagnosed with cancer at a later stage when the chance of survival is limited. Additionally, increased rates of cervical cancer have also been found in women in lower socioeconomic groups who may have limited access to basic health care needs. Moore and Seybold (2007) state, “The overall cervical cancer death rate among African American women is six times that among white women” (p.1). The HPV vaccine is new to the market and is not currently covered by most health care plans. While some insurance companies may cover the vaccine costs, others may not. Due to the lag-time after a vaccine is recommended and before it is covered by health plans many young females will miss the opportunity for prevention. The problem of establishing a safety net care for low-income uninsured and underinsured people is national in scope as the number of uninsured has risen past 43 million (Shapiro, Thompson, & Calhoun, 2006).
2. Educating HPV Prevention and Transmission
A. Personal and Cultural Beliefs:
As with any new immunization, controversy exists regarding the ethical use of the HPV vaccine. While it could be argued that routine vaccinations would decrease the numbers of cervical cancer deaths, many may believe that mandatory vaccine programs, currently being proposed in some states, infringe on parental rights to make wise health care decisions for their children. Additionally, some parents believe the HPV vaccine or seeking adolescent reproductive health services promotes sexual promiscuity. Parents are concerned that by consenting to the vaccine they are giving their child unspoken permission to become sexually active. Likewise, groups that promote abstinence until marriage worry that this vaccination will send a message to young women that sexual activity is safe and will undermine the abstinence message (Moore & Seybold, 2007).
B. Lack of Efficacy Data:
According to the CDC, the duration of protection from the HPV vaccine is unclear, however it is believed the vaccine is effective for at least five years (2006). Dawar, Deeks, & Dobson state that, “There are knowledge gaps, especially about the long-term efficacy, this is not unusual at the outset of any new vaccine” (p.7). In 2006 the HPV vaccine became available to the public and so far no adverse effects have been reported and a detailed post-licensure safety monitoring plan is currently in place. Nearly 100% of the study participants developed antibodies after given the HPV vaccination, but at this time there is no data available as to how long the effects of the drug will last or any long term adverse effects directly related to this drug might be.
References:
Bartlett, R., Holditch-Davis, D., & Belyea, M. (2007). Problem behaviors in adolescents. Pediatric Nursing 33(1), 13. Retrieved October 22, 2007 from Proquest database.
Cox, J. (2006). Epidemiology and natural history of HPV. Journal of Family Practice 15(11), 7. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Dawar, M., Deeks, S., & Dobson, S. (2007). Human papillomavirus vaccines launch a new era in cervical cancer prevention. Canadian Medical Association Journal. 177(5), 456. Retrieved February 4, 2007 from Proquest database.
Fawcett, E. (2007). Cervical screening for under 25’s – evaluating the evidence. Journal of Community Nursing, 21(2), 4. Retrieved October 10, 2007 from Proquest database.
Giarratano, G., Carter, C., (2003). Partners in health: Changing cancer screening disparity among underserved african american women. Journal of Multicultural Nursing and Health. 9(1), 40. Retrieved October 22, 2007 from Proquest database.
Moore, S., Seybold, V. (2007). HPV vaccine. Clinician Reviews. 17(1), 35. Retrieved April 14, 2007 from Expanded Academic ASAP database.
Potter, P., Perry, A., (2005). Fundamentals of nursing, 6th edition. (pp.90-91). St. Louis, Missouri: Mosby.
Ritchie, G. (2006). Strategies to promote sexual health. Nursing Standard. 20(48), 35-40. Retrieved October 23, 2007 from PubMed Central database.
Roye, C., Nelson, J., & Stanis, P. (2003). Evidence of the need for cervical cancer screening in adolescents. Pediatric Nursing, 29(3), 224. Retrieved October 10, 2007 from Proquest database.
Shapiro, L., Thompson, D., & Calhoun, E., (2006). Sustaining a safety net breast and cervical cancer detection program. Journal of Health Care for the Poor and Underserved. 17(2), 20. Retrieved October 22, 2007 from Proquest database.
Reducing Medication Errors With Technology
Providing patient safety is one of the primary responsibilities within the nursing profession. Medication errors not only threaten the patient, they threaten the nursing profession. Tim Lupton
Providing patient safety is one of the primary responsibilities within the nursing profession. Medication errors not only threaten the patient, they threaten the nursing profession. Roy Simpson (2005) brings to light that nurses are associated with more patient deaths and injuries than any other healthcare profession. This is related to the total time spent with the patient, a shortage in the workforce and weaknesses in operational practices and protocols (Simpson, 2005). Today’s nurse needs to be able to navigate through these obstacles and rely on other resources beyond the “five rights”. Bar code and point-of-care technologies contribute to verification of the five rights, improve workflow and allow for communication between different disciplines. Studies, such as those by Paoletti, Suess, Lesko, Feroli, Kennel, Mahler and Saunders (2007), show a substantial reduction in medication errors in clinical settings that have employed such technology. Information technology provides the means by which a nurse can reduce medication errors, insure patient safety and safeguard the nursing profession in today’s clinical setting.
The nursing shortage has a direct impact on medication errors in the clinical setting. The shortage has led to longer hours and frequent shifts resulting in additional stress and fatigue. As a result, nurses have been associated with an increase in medication errors within the clinical setting (Simpson, 2005). The five rights of right dose, route, drug, time and patient are dependent on the nurse’s ability to identify inaccuracies at the patient bedside. This system becomes compromised when the user is drained and unfocused. Bar code and point of care technology addresses the human error factor by automating the five rights (Wolf, 2007). The process involves scanning the identifying bar codes of the nurse, patient and the medication to be administered. Information is processed through various software systems accessing the patient’s medical profile and comparing it to physician orders and pharmacy protocol. A contradiction of any of the five rights results in an alert, prompting the nurse to further investigate before administering the medication and preventing a possible error.
As technology grows so has the capability of the nurse to go beyond the five rights. Enhancements are capable of alerting nurses to medications that are contraindicated due to vital signs, allergies and/or lab values. This is especially beneficial when giving cardio glycosides and electrolyte supplements. Indicators can caution nurses when using high-risk drugs, such as insulin and heparin, preventing lethal dosing. Errors associated with look-alike/sound-alike drugs can be avoided with customized comments and warnings (Grissinger & Globus, 2004). Information technology allows healthcare providers to customize systems to address the specific needs and barriers of the clinical setting.
In addition to notifying the nurse of potential problems, point of care technology broadens a nurse’s knowledge base by allowing access to the most up to date information at the patient’s bedside (Simpson, 2005). Medicine is constantly advancing and medications are constantly being introduced, updated or, in some cases, taken off the market. Systems can access data regarding new medications, medication/herbal supplement reactions, and signs and symptoms of adverse reactions. This allows nurses to make more informed decisions, faster, resulting in better patient care (Simpson, 2005).
Errors in charting have contributed to the rise medication errors and patient injuries. Patient care and medication administration is dependant on the accuracy, detail and up to date documentation by all team members. Staffing shortages and unpredictable workflow often require nurses to chart at the end of their shift increasing the potential for error (Simpson, 2005). Bar code, point of care technology allows for the nurses to electronically chart patient care and medication administration in real time at the patients bedside. This reduces the risk of errors associated with handwriting, omission and transcription (Paoletti, et al., 2007). Additionally, the time that is spent charting during a shift (which is projected to consume 13%-28% of a nurses total shift) can be focused back toward direct patient care (Braswell & Duggar, 2006).
Data collected from bar code, point of care technology allows nursing managers and pharmacist to generate reports identifying factors that can lead to medication errors. Nurse managers are able to track compliance and address training or other issues as necessary (Braswell & Duggar, 2006, p.14). Pharmacist can use the data to identify opportunities for improvement in storage strategies for medications in nursing-unit decentralized cabinets, separation of look-alike products and formulation differences within the pharmacy department (Paoletti et al., 2007, p 540). The ability to identify the origin of error is the first step and a proactive resource in bringing about positive change. This results in opening lines of communications between the disciplines in the effort to resolve obstacles that might result in error.
The need to incorporate information technology in the clinical setting can be observed in the Paoletti et al. (2007) study at Lancaster General Hospital. Medical observers reported 188 errors related to medication administration prior to the implementation of electronic medical administration records and bar-code medication administration. The errors included wrong time, wrong technique, wrong dose, extra dose, wrong medication and wrong formulation. It was found that errors were more likely to occur at the point of medication administration because safety nets relied on nurses to remember, identify and resolve discrepancies at bedside (Paoletti et al., 2007, p.538). Moreover, of the 188 errors observed, none of them were reported or identified by staff members. Paoletti et al. (2007) assert that the reporting of errors is dependant on the willingness of the provider to file a report. Many of theses errors may be unknowingly committed or go unnoticed by the provider. One can therefore conclude that the prevalence of medication errors is much higher and a greater threat than once understood.
Facilities that have implemented information technology into their medication administration protocol have seen positive results. Lancaster General Hospital had a 54% reduction in medication errors after implementation (Paoletti et al., 2007). Braswell and Duggar (2006) report that the Spartanburg Regional Health System had error rate reductions as high as 78% after implementing bar code, point of care technology systems. Paoletti et al. (2007) write that subsequent to implementation reports were generated identifying possible and prevented errors. Nursing managers were able to use the data to implement training programs to address areas of opportunity. Pharmacy and nursing communication and collaboration during the implementation phase resulted in improved interdepartmental relationships. The commitment to a safer environment has not only been appreciated by patients and nurses, but has served as a recruiting tool for new nurses.
In summary, information technology has a place at the patient’s bedside and within the nursing profession. As the number of qualified nurses begins to diminish, the reliance on technology becomes greater. Wolf (2007) declares that errors will be reduced with the assistance of technology. Technology complements the way a nurse works by supporting the five rights, improving workflow and enhancing communication. The end result is a safer environment for both the patient and the nursing profession.
a. Intervention #1 Bar-coded medication administration
i. Disadvantage 1. Automation of the five rights leads to a decline in nursing diligence.
In its efforts to make the process safer, the administration of medication with the use of bar code technology can lead to a reliance on the system alone (McDonald, 2006). A nurse must still rely on his or hers knowledge base as the primary source for decision-making. With the demands put on today’s nurse (in terms of staffing issues, patient to nurse ratios and high patient demands), nurses are more tempted to look for shortcuts. Bar coding systems are set in place to support the current protocol of addressing the five rights before administrating medication to a patient. McDonald (2006) asserts that systems can create new kinds of errors if not accompanied by well-designed, well-implemented crosscheck processes and a culture of safety.
McDonald, C. (2006, April 4) Computerization can create safety hazards: a bar-coding near miss. Annals of Internal Medicine, 144(7), 510-516. Retrieved February 1, 2008 from Academic Search Premier database.
ii. Disadvantage 2. Hardware and software systems associated with bar coded medication administration are susceptible to technical issues.
Bar-coded medication administration and its users rely on a wireless apparatus capable of connecting to the main system. When hardware and software systems are unable to communicate, the system, as a whole, becomes ineffective. Elizabeth Mims, nurse consultant for the Veterans Health Administration National Bar Code Medication Administration Joint Program Office, noted that problems with wireless transmission can occur due to steel beams in older buildings, rooms with lead shielding, and closed doors (Traynor, 2004). Additional issues include slow response/download times, equipment problems, missing armbands, and illegible barcodes (Heinen, 2003). Technical issues, and the lack to overcome them, can be costly, frustrate users, disturb workflow, and jeopardize patient safety.
Heinn, M., Coyle, G., & Hamilton, A. (2003, October). Barcoding makes its mark on daily practice. Nursing Management, 34(10), 18-20. Retrieved February 1, 2008 from Academic Search Premier database.
Traynor, K. (2004, October 1). Details matter in beside barcode scanning. American Journal of Health-System Pharmacy, 61(19), 1987-1988. Retrieved February 1, 2008 from Academic Search Premier database.
b. Intervention 2. Point of care technology and electronic patient charting
i. Disadvantage 1. Although point of care technologies and electronic patient charting can provide great benefits, it is also susceptible to infringement on ones medical condition and/or history. Leah Curtin (2005) stresses that the information contained in these databases offers enormous opportunities for prejudice and financial gain. A patient’s medical record, both past and present, is vulnerable to anyone with ability to bypass the safeguards put in place to protect those records (Curtin, 2005). A patients right to confidentiality, and the process put in place by HIPPA to protect that confidentiality, can all be threatened as information is more readily available to a larger number of people. As Curtin (2005, p 352) asserts, healthcare informatics involves healthcare, ethics and informatics – and its practioners must, for the public’s good, be bound by additional ethical, moral and legal responsibilities.
Curtin, L. (2005, October). Ethics in nursing administration. Ethics in informatics: the intersection of nursing, ethics, and information technology. Nursing Administration Quarterly, 29(4), 349-352. Retrieved February 1, 2008 from CINAHL database.
ii. Disadvantage 2. Access to patients charts and medical history is dependant on the compatibility of the system being used.
It was thought that the information that maintained electronic patient charting and patient data would be easily accessible. Philip Darbyshire (2004) states that this basic function of systems being able to “talk to each other” has been one if its shortcomings. Clinicians will see little benefit in a system which cannot communicate with an existing one in his or her hospital or integrate with other important or patient care programs (Darbyshire, 2004).. Many clinics, some within the same healthcare system, are unable to communicate and integrate information on the same patient. Information entered in point of care systems and electronic patient charts can only be useful if obtainable.
Darbyshire, P. (2004). ‘Rage against the machine?’: nurses’ and midwives experiences of using computerized patient information systems for clinical information. Journal of Clinical Nursing, 13(1), 17-25. . Retrieved February 1, 2008 from CINAHL database.
References
Braswell, A., & Duggar, S. (2006, October). The new look of beside technology. Nursing Management, 37, 14-32. Retrieved November 7, 2007, from Academic Search Premier database.
Grissinger, M., & Globus, N. (2004, January). How technology affects your risk of medication errors. Nursing, 34(1), 36-42. Retrieved October 31, 2007, from CINAHL database.
Paoletti, R., Suess, T., Lesko, M., Feroli, A., Kennel, J., Mahler, M., et al., (2007, March 1). Using bar-code technology and medication observation methodology for a safer medication administration. American Journal of Health-System Pharmacy, 64(5), 536-543. Retrieved November 3, 2007, from CINAHL database.
Simpson, R. (2005, January). Patient and nurse safety. Nursing Administration Quarterly, 29(1), 97-101. Retrieved November 3, 2007, from CINAHL database.
Wolf, Z. (April, 2007). Pursuing safe medication use and the promise of technology. MEDSURG Nursing, 16(2), 92-100. Retrieved November 3, 2007, from CINAHL
Database.
Best Practices for Pain Management in Cancer Patients
No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Ideally the goal is to equip nurses with the capability of providing consistent, improved pain management for all patients. Holly Cope
Best Practices for Pain Management in Cancer Patients
No cancer patient should needlessly suffer due to inadequacies in pain management. Nurses should continually strive to improve pain relief for cancer patients. Ideally the goal is to equip nurses with the capability of providing consistent, improved pain management for all patients. Throughout this paper, best nursing practices for pain management in cancer patients will be illustrated.
There is no question that cancer causes pain, and constant, unrelieved pain, can be torturous. Unrelieved pain has profound effects, including decreased quality of life, impaired functionality, and reduced productivity (Woodward, 2005, p.261). Several sources address the process of developing pain management programs using various improvement strategies. These combined sources acknowledge the effects of unrelieved pain, while shedding light on how improvement practices should be implemented. Through the course of this paper, three aspects of pain management will be examined: nurse assessment, documentation and patient education. Identification of key processes and barriers for effective pain management is paramount to improving pain relief (Woodward, 2005 p. 263). Every nurse that cares for a cancer patient should be asking, “Is there more that can be done to alleviate this patient’s pain?” By creating a pain management program, nurses are taking proactive measures in their patient care as well as creating an allowance for patients to be involved in their own healthcare. However none of this can be put into practice if nurses themselves are not instituting proper pain assessment. The first step in improving pain for cancer patients is to have proper, thorough and consistent nurse assessment of pain.
Support for this is given through research showing that poor staff assessment and reassessment practices impede pain relief for patients (Idell, Grant, &Kirk, 2007, p.661). Nursing efforts geared towards proper assessment are essential to maintaining successful pain management planning. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates not only pain assessment in all patients but also pain reassessment in response to interventions. Unfortunately, compliance with JCAHO standards remains problematic for many institutions (Idell, et al., 2007). However, barriers that impede proper assessment can be removed.
Research indicates that by increasing the frequency with which a patient’s pain is evaluated, interventions to reduce pain are implemented earlier. Analyzing nurse competency regarding assessment practices, and providing a team leader that holds nurses accountable has proven to be effective in increasing compliance with JCAHO standards (Idell, Grant, & Kirk, 2007, p. 662). Enhancing nurse availability and accessibility to assessment tools via a unit based educator that oversees all activities to ensure consistent implementation of said tools, has also increased compliance within institutions (Woodward, 2005, p.265). When pain assessment for all patients becomes consistent, management of pain increases and patient pain is better relieved.
Assessment can also be effectively executed with the implementation of pain management rounds. These rounds would include nurses evaluating each patient’s pain level and pain frequency trends on set days of the week. Those patients with pain would then be discussed by the interdisciplinary team and proper changes made to their pain management regimen if appropriate. Studies have shown that institutions using this assessment format have 70% of patients reporting being very satisfied with nurses’ treatment of their pain. Prior to the initiation of this assessment program, no patients rated themselves as very satisfied (Sterman, Gauker, & Krieger, 2003, p.860).
Documentation is a key factor in creating an effective pain program to aid in the relief of cancer pain for patients. An example of problematic documentation is explained in Woodward’s article. While conducting chart reviews, discrepancies in pain level documentation were revealed. The patient’s numerical pain rating was documented 60% of the time before medicating while only 12% of the time was a patient’s pain reevaluated and documented within 2 hours after a pain medication was administered (Woodward, 2005, p.263). These statistics illustrate that without proper documentation there is no record of patient care and therefore no way of addressing how to improve said care. Improper or zero documentation will result in inconsistent pain management (Sterman, Gauker, & Krieger, 2003, p. 859).
Lack of documenting a patient’s pain level is in direct opposition to best nursing practices. Various strategies to attend to this problem include the creation of better suited accountability measures for nurses, as well as the standardization of both basic and ongoing pain education for all members of the nursing care team relevant to their scope of practice (Woodward, 2005, p.265). With proper documentation, a patient’s pain level can be tracked and their pain treated without delay. Continuous accountability for documenting and follow up care pertaining to said documentation is a key element in successful pain management (Idell, Grant, & Kirk, 2007, p. 670).
Aside from nursing assessment and documentation, patient education plays a vital role in pain management. One valuable tool involves patients tracking their daily pain progress. Nurses can teach patients how to develop and use a pain management diary. The diary will provide the nurse with valuable information about their patient’s pain issues. Studies have stated the importance of patients documenting daily accounts of their pain level, the medications taken to relieve their pain and their response to the medications (Kim et al., 2004, p.1138). This strategy, coupled with nursing documentation, will provide nurses with more information with which to treat their patient’s pain.
One way to enhance a patient education strategy is through a tool called the Pain Experience Scale. This is a scale that measures patient’s knowledge regarding cancer pain management. These surveys are then evaluated to determine an effective patient education program. Most patient education programs focus on these basic principles: personalized pain management, how to better communicate with healthcare providers, and how to contact a provider. After experimentation with education programs such as these, patients demonstrated a 12% increase in knowledge when compared to patients who had not undergone such programs (Kim, et. al., 2004, 1138).
By determining where a patient’s knowledge deficit exists, a nurse will be better equipped to educate on cancer pain. A nurse can then expand and reinforce a patient’s knowledge base with information designed to facilitate pain relief (Kim, et al., 2004, p. 1142). Through education, patients are encouraged to be involved in their own pain management (Woodward, 2005, p. 261). The patient has expert knowledge about their pain level. A nurse has the obligation to teach and listen to the patient regarding what the patient is feeling and how specific interventions are working to relieve pain (Sterman, Gauker & Krieger, 2003, p.861). Patients need to be taught to use their voice in order to enable the nursing staff to better help alleviate their pain.
In summary, the overall goal for developing a pain management program is to provide consistent, improved pain management for cancer patients. This goal has been shown to be attainable through the best nursing practices of assessment, documentation and patient education. These three key elements are interrelated and work together to provide nurses with the assurance that they are doing everything in their power to alleviate their patient’s pain.
References
Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.
Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.
Idell, C., Grant, M., & Kirk, C. (2007, May). Alignment of pain reassessment practices and national comprehensive cancer network guidelines. Oncology Nursing Forum, 34(3), 661-671. Retrieved October 30, 2007 from CINAHL database.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.
Sterman, E., Gauker, S., & Krieger, J. (2003, September-October). A comprehensive approach to improving cancer pain management and patient satisfaction. Oncology Nursing Forum, 30(5), 857 – 864. Retrieved October 28, 2007 from CINAHL database.
Woodward, D. (2005, July-September). Developing a pain management program through continuous improvement strategies. Journal of Nursing Care Quality, 20(3), 261-267. Retrieved October 10, 2007 from CINAHL database.
a. Intervention 1: Instituting proper pain assessment is critical to cancer pain management
i. Disadvantage 1: Thorough education regarding proper pain assessment may not be readily available to many nurses.
Knowledge deficits in pain assessment practices among nurses are some of the most common contributing factors to under treatment of cancer pain in adults. Many health care institutions rely solely on the education the nurse received in school and provide no additional training. Proper Assessment is a key factor in pain management but lack of education for nursing staff will undermine this critical intervention. Common assumption is that all nurses have the same baseline knowledge about pain. Nurses have varied experiences in education and pain management.
Michales, T., Hubbartt, E., Carroll, S., Hudson-Barr, D. (2007, July-September). Evaluating an educational approach to improve pain assessment in hospitalized patients. Journal of Nursing Care Quality, 22(3), 260-265. Retrieved February 3, 2008 from CINAHL database.
ii. Disadvantage 2: Some patients may not be able to participate in the assessment process.
Every patient is different and assessing pain varies from patient to patient.Assessment of pain in patients with impaired communication due to the severity or progression of their cancer or even cognitive impairment, represents one of the most significant challenges in pain management. Nurses have difficulty knowing when these patients are in pain and when they are experiencing pain relief. This makes the patient vulnerable to under and over treatment.
Harper, K., Bell, S. (2006, August). A pain assessment tool for patients with limited communication ability. Nursing Standard, 20(51), 40-44. Retrieved February 2, 2008 from CINAHL database.
b. Intervention 2: Patient education plays a vital role in pain management
i. Disadvantage 1: Patients may not have the willingness or desire to participate in their pain relief plan depending on the severity of their cancer.
Patient education and participation is important in order to help the nurse better treat a patient’s pain, but should not replace the nurse’s role of providing a plan of care for pain relief. Unfortunately, not all patients want to participate in this aspect of their care. Some are too sick and just want their pain relieved, while others look to the nurse to provide the expert care. Patients may participate in a pain control plan if they are not consumed with illness and pain. Studies have indicated that many patients want to be taken care of when faced with a terminal illness and are not focused on learning about their pain. Many patients just want their pain relieved by the nurse that is providing care for them.
Kim, J., Dodd, M., West, C., Paul, S., Facione, N., & Schumacher, et al. (2004, November). The PRO-SELF pain control program improves patients’ knowledge of cancer pain management. Oncology Nursing Forum, 31(6), 1137-1143. Retrieved November 1, 2007 from CINAHL database.
ii. Disadvantage 2: Nursing staff may put too much responsibility on the patient to report their pain issues.
Nurses may rely too heavily on the patient to report their need for pain relief. By putting an emphasis on educating the patient regarding their pain, some nurses may depend entirely on the patient to tell them what they need. There needs to be a balance and partnership between the patient and the nurse that is providing care. Educational interventions to modify patient’s attitudes and misbeliefs, coupled with consistent nursing follow through, contribute to improved pain management in patients living with cancer. Nurses should not put the burden of pain relief on the patient and many will.
Aubin, M., Vezina, L., Parent, R., Fillion, L., Allard, P., & Bergeron, R., et al. (2006, November). Impact of an educational program on pain management in patients with cancer living at home. Oncology Nursing Forum, 33(6), 1183-1188. Retrieved February 1, 2008 from CINAHL database.
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Alice Dodge "Weighing in on Disease Prevention"
Weighing in on Disease Prevention By: Alice Dodge
Proper diet and exercise, which are often lacking from the majority of Americans lives, are the two greatest things that can be done to reduce the incidence of chronic disease and many types of cancer. This paper will focus on the prevalence of disease, some contributing factors and what nurses can do to improve the occurrence of healthy habits and positive outcomes.
The Centers for Disease Control and Prevention state that sixty percent of Americans do not engage in exercise at a level that gets any health benefits (CDC, 2007). The Boston Haitian Reporter adds that seventeen to twenty-three million Americans have diabetes (Jackson, 2006), and the American Cancer Society claims that two thirds of Americans are either overweight or obese (ACS, 2006). The National Academies which report findings to congress state that thirty-eight percent of all deaths are due to avoidable factors such as: tobacco use, poor nutrition, physical inactivity and alcohol consumption (nationalacademies.org, 2007). The American Cancer Society also states that one third of all cancer deaths can be attributed to lack of weight control or obesity, lack of proper nutrition, and physical inactivity and that one third more are from tobacco use or exposure. The lack of proper nutrition in American diets and sedentary lifestyles are killing Americans from somewhat preventable diseases. The nurse can promote wellness in these clients by giving them encouragement, education and providing oneself as a good role model.
The first strategy that nurses can implement is to teach on the prevalence of disease and to identify those at risk. According to a Finnish Diabetes Prevention Study, twenty-five percent of the Finnish are obese (Absetz, 2007). Through this study they showed that a large sample of clients with prediabetes were able to reduce the incidence of the diabetes progressing into type two diabetes mellitus by fifty-eight percent if the subjects were able to maintain four of the five goals listed here.
1. Less than thirty percent of total energy intake from fat.
2. Less than ten percent of total energy intake from saturated fat.
3. At least fifteen grams of fiber per one thousand kilocalories.
4. At least four hours of moderately intense physical activity per week.
5. Attaining more than a five percent weight reduction.
This study that came out this year clearly states the importance of proper diet, maintaining a healthy weight and physical activity in the role of diabetes prevention. Nurses can reference studies to provide data to interested clients hereby reinforcing the potentially enormous lifelong benefits of diet modification and increased exercise. A Fifty-eight percent chance of not progressing to type II diabetes mellitus is a strong case for behavior modification and which can offer some hope to the pre-diabetes client. With the increases in diabetes rates this is one area in which nurses can influence the lives of many people. As nurses it is one of our key responsibilities to educate the client when appropriate, while providing encouragement, which may be just what the client needed to begin their transition. We will now look at how diabetes is only one of the many areas in which the nurses can provide help in disease prevention.
The American Cancer Society reports the incidences of many cancers can be reduced by smoking cessation, alcohol intake reduction, and proper nutrition which include lots of fruit, vegetables, fiber, whole grains, good oils and less red meat. Achieving or maintaining a proper weight for body build and height, and increased levels of physical activity are factors as well. For example, smoking cessation reduces the incidence of kidney, bladder, and oral, esophageal, pancreatic and of course lung cancer. Reducing your alcohol to none or one drink per day for women and two drinks per day for men can reduce the incidence of oral, esophageal, breast, liver and colon cancers. Proper nutrition has been associated with a reduction of the incidences of oral, esophageal, colon, prostate, lung, stomach, endometrial, and pancreatic cancer. Proper weight maintenance is associated with fewer cases of oral, esophageal, kidney, breast, colon, stomach, pancreatic, endometrial, and prostate cancer. Increasing physical activity to thirty minutes of moderate exercise per day or more can reduce the rates of breast, endometrial, prostate and pancreatic cancers. The cancer link to each of these modifiable factors is a strong one, which shows directly how you can reduce the incidences by cutting out one or more of the associated behaviors. One strategy is for the nurse to inform the client about the risks associated with their specific behaviors and using the American Cancer Society’s information can help reinforce your teachings.
Nurses can clearly make an impact in the lives of clients by promoting and demonstrating lifestyle changes. A few ways to help are: Planned walks with the client during recovery and ideas on how they can easily incorporate extra physical activity in their daily lives. Taking the stairs, parking furthest from the entrance in parking lots, and taking a brisk thirty-minute walks are great ways to start. Pursuing and obtaining ones own healthy dietary habits, increasing your own physical activity level, and maintaining your own healthy weight are ways you can influence the clients and others around you by being positive proof that it can be done. You may just live a longer healthier life because of it!
In addition to the steps, which the nurse can take to promote wellness in the client on a one to one personal level, it is important to try and become involved in policy change to have a bigger impact. Becoming involved in the community on a local level and perhaps representing them with your state and federal governments are two ways which you can affect change on their behalf. Fighting to increase funding for schools, so they can reduce their dependence on profits from sweetened sodas, snacks and franchised fast food in the cafeterias could help reduce the obesity levels of school aged children and adolescents. One can follow the lead of New York City in removing harmful trans-fatty acids from the food chain that could show an overall improvement in the cardiovascular health of that region. Clients of low socioeconomic background need to have access to inexpensive fresh fruits and vegetables as well as whole grains, lean red meats and fish. It is important to compete in this area with the attractive low prices and convenience of fast food meals that can, in excess, promote weight gain, as these foods tend to be calorie dense but nutritionally poor. The nurse’s role in wellness promotion can be achieved on a one to one level of educating the client, as well as achieving policy change to enable the client to make the healthy choice by having them readily available. Remember that the lack of proper nutrition in American diets and sedentary lifestyles are killing Americans from somewhat preventable diseases. Let us be the nursing generation that changes these ominous trends for our own health and for the health of our country.
References:
1. (2006). American Cancer Society, A Cancer Journal for Clinicians, 56, 254-281 retrieved October 10, 2007 from ProQuest.
2. Absetz, P., Valve, R., Oldenberg, B., Heinonen, H., etal. (2007). Type two diabetes prevention in the “real world”: one-year results of the GOAL implementation trial. Diabetes Care, 30(10), 2465-2471 retrieved October 10, 2007 from ProQuest.
3. Jackson, S., (2006). Nutrition key to management & prevention of diabetes. Boston Haitian Reporter, 6(4), 13 retrieved October 10, 2007 from ProQuest.
4. Centers for Disease Control; United States Department of Health and Human Services http://cdc.gov/ retrieved October 10, 2007 from the World Wide Web.
5. The National Academies http:/www.nationalacademies.org/ retrieved October 10, 2007 from the World Wide Web.
Interventions for Weighing in on Disease Prevention:
a. Increase activity level: set a goal and slowly work to achieve it. (30 minutes aerobic exercise per day, like brisk walking)
i. Psychological barriers to achieving an increase in physical activity
1. Some general barriers brought up women in one study were: professional obligations, injuries, weather, illness, psychosocial factors, and personal obligations (Journal of Holistic Nursing). Some psychosocial issues mentioned by some women when they found barriers to maintaining an exercise program were: fear of pain, fear of safety, lack of places, inadequate instruction, lack of family support, older weight, overweight, threat of embarrassment, multiple role expectations, poverty status, cost and lack of time (Journal of Holistic Nursing).
2. Mary A Nies, Carrie L Motyka. Journal of Holistic Nursing. Springfield: Mar 2006. Vol. 24, Iss. 1; pg. 7
ii. Physical barriers to achieving an increase in physical activity
1. In an Australian study, adults reported size was a barrier to physical activity, with women reporting more so than men. 22.6% of the obese stated that their physical size, or obesity was a barrier to obtaining physical activity.
2. Kylie Ball, David Crawford, Neville Owen. Australian and New Zealand Journal of Public Health. Canberra: Jun 2000. Vol. 24, Iss. 3; pg. 331, 3 pgs
b. Increasing the amount of healthy foods into the diet (fruits, vegetables, fish, nuts, sources of fat, processed foods, trans fats, refined sugars, etc.)
i. Socioeconomic barriers to consuming a healthier diet.
1. Some of the greatest challenges to obtaining a healthy diet are issues of poverty and other socioeconomic factors. The costs of some foods, mainly energy-dense foods, which may be higher in added fats, added sugars, and are high in processed grains, are much lower than the healthier alternatives such as: fresh fruits and vegetables, as well as fish and lean meats (Nutrition Today). Positive relationships were shown between most nutrients and income in a Canadian study (Ricciuto, Tarasuk). In a piece in USA TODAY, researchers showed a comparison of the availability of fresh fruits and vegetables in poorer black neighborhoods versus wealthier predominantly white areas revealed these statistics: 21 vegetable choices and 13 fruit choices, as opposed to the 38 vegetable choices and 26 fruits in the higher socioeconomic white areas. These are obvious barriers as they also mentioned quality differences; nobody wants to eat a pithy apple, if given the choice.
2. Laurie E Ricciuto, Valerie S Tarasuk. Social Science & Medicine. Oxford: Jan 2007. Vol. 64, Iss. 1; pg. 186
ii. Media barriers to consuming a healthier diet
1. The media can be a barrier for teaching children and parents good eating habits. Of the television ads aimed at children, greater than 50% are for sweetened breakfast cereals, candy, sodas, and fast food (U of C, Berkeley). Other ways, in which the media encourages the consumption of these decidedly unhealthy foods, are their promotion of these foods with popular sports figures and cartoon or movie characters (U of C, Berkeley). Food advertising budgets range from 75% of budgets going to television ads and 95% of the fast food advertising going to television advertising (U of C, Berkeley). As children average seeing one food ad for every 5 minutes of viewed television time, they are constantly being urged to consume an unhealthy diet (U of C, Berkeley).
2. Center for Weight and Health, UNIVERSITY OF CALIFORNIA, BERKELEY 3 www.cnr.berkeley.edu/cwh
References:
1. 1. Mary A Nies, Carrie L Motyka. Journal of Holistic Nursing. Springfield: Mar 2006. Vol. 24, Iss. 1; pg. 7
2. Kylie Ball, David Crawford, Neville Owen. Australian and New Zealand Journal of Public Health. Canberra: Jun 2000. Vol. 24, Iss. 3; pg. 331, 3 pgs
3. Laurie E Ricciuto, Valerie S Tarasuk. Social Science & Medicine. Oxford: Jan 2007. Vol. 64, Iss. 1; pg. 186
4. Center for Weight and Health, UNIVERSITY OF CALIFORNIA, BERKELEY 3 www.cnr.berkeley.edu/cwh
Autoethnography and Mental Health Nursing
It is no secret that it takes a special kind of person to be a mental health nurse. Qualities and abilities such as well-developed self-awareness, acceptance of self and others’ feelings, an understanding of the complexity of the human experience, an ability to accept ambiguity and uncertainty, willingness to take responsibility for self, and provision of trust and respect are crucial for the effective psychiatric mental health nurse (Foster, McAllister & O’Brien, 2006).
But how does one integrate all these qualities effectively in practice? How does one become an effective mental health nurse? Foster, McAllister & O’Brien, 2006, state that autoethnography is the answer. According to them, autoethnography, the study of "self" should be an integral part of every mental health nurse's practice to ensure the highest level of care.
Little research has been written on the topic of autoethnography, and its use. Foster, McAllister & O’Brien, 2006, in their article “Extending the Boundaries: Autoethnography as an Emergent Method in Mental Health Research” talk about the use of autoethnography as a new approach to caring for the mentally ill, as well as a research method, with the emphasis on mental health nursing research.
The same authors, in an article published in December 2006, talk about the experiences of a doctoral student whose mother is mentally ill, and the process through which she used autoethnography to generate new research in the field, and relate to other mentally ill patients.
Other articles such as “Nursing Student Attitudes to Psychiatric Nursing and Psychiatric Disorders in New Zealand” (Surgenor, Dunn & Horn, 2005) and “A Survey of Mental Health Nurses’ Experiences of Stalking” (Ashmore, Jones & Jackson, 2006) talk about the different experiences that nurses have with mental health patients. These articles show how different interactions with mental health patients change nurses’ attitudes, and the way that they interact with their patients thereafter.
It is a well known fact that attitudes, beliefs, values, life experiences and even religious practices greatly impact nurses’ ability to care. In most areas of nursing practice, attitudes and beliefs are mostly positive. When it comes to mental health however, these attitudes and beliefs become less positive. This in turn, negatively impacts the level of care that mental health patients receive.
Research by Reed & Fitzgerald, 2005, found that attitudes were linked to issues that influence nurses’ ability to provide care. Many nurses suggested mental health care was not their role. One of the most prevailing feelings however was fear, which caused avoidance. James & Cowman, 2007, identified attitudes towards clients with bipolar disorder to be less then favorable. The authors recognize that mental health patients are more difficult to care for than other patients. As a result, these patients receive care that is inadequate.
Autoethnography has been defined as “the study of self” (Foster, McAllister & O’Brien, 2006). A process through which a nurse looks at herself and identifies her own attitudes, beliefs and values about mental health, and issues that are involved in mental health nursing in order to improve her care of the mentally ill. This way, psychiatric mental health nursing is seen as being directed by the nurse’s own characteristics, working together with the client to create a therapeutic relationship and to improve or maintain the client’s health.
In order for the nurse to effectively interact with the client, the nurse needs to first be able to understand that her character has been constructed by a set of experiences that is different from the patient’s. Social constructivism is a perspective that maintains that people develop a sense of what is real through conversation with, and observations of others (Foster, McAllister & O’Brien, 2006). This means that whatever the nurse holds to be real, might not be real for the patient, because his experiences have been different. Thus, a nurse cannot impose her perception of reality onto the patient because of her different experiences. A nurse cannot be therapeutic until she realizes that what is real, and what makes sense to her, might not be real, or not make sense to a patient. Autoethnography works by having the nurse look at what her reality is, takes note of what the patients’ reality is, and only then, can the nurse make a final judgment.
“Psychiatric mental health nursing research literature also recognizes the importance of the quality of engagement between nurse and the client as being integral to the nurses effective use of self” (Foster, McAllister & O’Brien, 2006). The way that a nurse interacts with the patient, and the quality of their relationship, is crucial for a therapeutic environment. Foster, McAllister & O’Brien, 2006, also state that clients themselves have reported that provision of respect, security, confirmation, and companionship are some of the most valuable aspects of the nurse-client relationship. How can nurses provide these to the patients, when the nurses are afraid of the patients, avoid the patients and or believe that it is not their role to take care of these patients? It is impossible for the nurse to provide security, when they themselves are scared. It is impossible for the nurse to provide companionship to these patients, when the nurse avoids them. If the nurse cannot effectively talk to, listen to, and empathize with the patient, there is no therapeutic relationship.
Using autoethnography, the nurse first needs to understand that she dislikes these patients, is afraid of these patients, and avoids these patients. The nurse than must think and identify the reasons for these behaviors. Why is it that the nurse fears and avoids these patients? Then she must remedy the problem. By doing so, the nurse no longer fears and avoids the patient, and becomes a nurse who can develop a healthy therapeutic relationship with the patient.
Autoethnography is the process through which nurses evaluate their own attitudes and beliefs towards mental health. This way they can correct any misconceptions or false beliefs about mental health patients they might have. In this manner they can provide the best care possible. It is a process which should be applied by every nurse that has a mental health patient in her care.
INTERVENTION 1
The nurse will identify her own thoughts, feelings and perceptions about the mentally ill client and the disease process that can interfere with the quality of care provided and set them aside while caring for the mentally ill client.
Disadvantage 1
Knowledge deficit
Knowledge deficit is a big problem in mental health nursing. Many research studies have concluded that most nurses are undereducated about how to care for mentally ill patients. Because of the limited amount of education, nurses rely on their own beliefs, perceptions and values when setting standards in their care for the mentally ill clients (Reed & Fitzgerald, 2005). A lot of nurses have their preset beliefs that mentally ill patients are difficult to take care of, assaultive and non cooperative and simply hard to take care of. A lot of times nurses attribute these qualities to all mentally ill patients (Reed & Fitzgerald, 2005). It is hard for them to understand that this is not necessarily true and that she needs to set these feelings aside. Because of the lack of education in caring for these clients, these nurses make further mistakes in their care which in turn reinforces their false beliefs. The nurse goes on attribute these qualities to the patient’s condition and does not perceive them as their own beliefs and perceptions. This makes it even harder for the nurse to implement this nursing intervention while caring for the mentally ill client.
Disadvantage 2
Pt. discrimination/dislike.
Dislike and discrimination of mentally ill clients has been thoroughly studied and documented. Most of the time, this attitude stems as a result of the choices the patients make. Choices which make it more difficult for the nurse to provide care (Reed & Fitzgerald, 2005). Mentally ill clients can become easily agitated, non cooperative, resistive and paranoid (Reed & Fitzgerald, 2005). They also make poor choices and judgment calls. In most cased hygiene standards are usually very low also. This leads the nurse to develop a sense of dislike towards these patients. This attitude makes the nurse more reluctant to identify her own attitude as a barrier in quality care. As a result, there is a further increase in the nurses' anxiety, dislike and avoidance of the patients. This type of attitude also increases the use of medical and mechanical restraints which can be very detrimental to the patient.
Intervention 2
The nurse will sit with the mentally ill pt. for at least 20 minutes to listen to the pt’s “story”, identify the pt’s belief system, thoughts, perceptions and degree of cooperativeness to help nurse better understand patient and increase comfort level with patient.
Disadvantage 1
FEAR.
Fear is the biggest barrier in providing quality care for the mentally ill patient. The nurses are worried about their physical safety and the safety of other coworkers on the ward. They also feel vulnerable professionally, ethically and legally about the action they might have to take to avoid harm if such action should be necessary (Reed & Fitzgerald, 2005). This can cause a gap in between the nurse and the patient. As a result, the nurse can end up avoiding the patient, keep their distance and take shortcuts when interviewing them. For communication to be effective in the nurse/mentally ill client relationship, the nurse has to show empathy, warmth, respect, patience and trustworthiness (Foster, McAllister & O’Brien, 2006). When the nurse fears these patients, she can’t show any of these qualities to these patients, thus making it hard to implement this intervention.
Disadvantage 2
NEGATIVE PAST EXPERIENCES.
Past experiences with mentally ill clients can either strengthen or ruin the perception of these clients to the nurse. Negative experiences heavily influence the nurses’ perception of these patients, the care they deserve, and even the nurses own perspective on her ability to provide care for these patients (Ashmore, Jones & Jackson, 2006). Nurses who had negative experiences with mentally ill clients experienced an increase in their level of anxiety, increased feelings of unhappiness and anger. They also said they felt less relaxed, outgoing, happy and competent in their care (Ashmore, Jones & Jackson, 2006). The same article stated that 37.5 percent of nurses who had a stalking experience ignored the patient afterwards, 14.3 percent of nurses yelled at the person, and 19.6 percent pleaded the person to stop (Ashmore, Jones & Jackson, 2006). Experiences as such, can make the nurse avoid a situation where she has to sit and talk with the mentally ill client. She will also be reluctant to develop nursing interventions in which the nurse has to spend time with the patient. This can make the relationship even worse and have a negative outcome on the plan of care.
References:
Ashmore R., Jones J., Jackson A. & Smoyak S. (2006, March). A survey of mental health nurses’ experiences of stalking. Journal of Psychiatric and Mental Health Nursing, 13, 562-569. Retrieved November 1, 2007 from CINAHL database.
Foster K., McAllister M. & O’Brien L. (2005 December). Coming to autoethnography: A mental health nurse’s experience. International Journal of Qualitative Methods, 1-13. Retrieved November 1, 2007 from CINAHL database.
Foster K., McAllister M. & O’Brien L. (2006, March). Extending the boundries: Autoethnography as an emergent method in mental health nursing research. International Journal of Mental Health Nursing,15, 44-53. Retrieved October 4, 2007 from CINAHL database.
James P. & Cowman S. (2007 October). Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 670-678. Retrieved November 1, 2007 from CINAHL database.
Reed F. & Fitzgerald L. (2005, December). The mixed attitudes of nurse’s to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14, 249-257. Retrieved November 1, 2007 from CINAHL database.
Surgenor, L., Dunn, J. & Horn, J. (2005, June). Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand. International Journal of Mental Health Nursing, 14, 103-108. Retrieved October 20, 2007 from CINAHL database.