Nurse-managed primary care delivery clinics

Health care presently is an ever-changing environment for all Americans, including the veteran population. New and innovative approaches to health care must include goals that maximize quality care, improve access and cost effectiveness, facilitate patient satisfaction, and optimize the functional status of patients. Recognizing the opportunities in this challenging environment, advanced practice nurses are stepping forward as competent primary care providers who can meet these goals. This article describes the establishment of primary care clinics run by advanced practice nurses in the US Department of Veterans Affairs Upper Midwest Healthcare Network, in the states of Minnesota, North Dakota, and South Dakota.     

Healthy buildings: impact on nurses and nursing practice

Mounting evidence indicates that buildings can be a significant cause of human illness and environmental degradation. According to the United States (US) Environmental Protection Agency, indoor air pollution is one of the top five environmental risks to public health in the US. This may be related, to a large extent, to the fact that US citizens spend as much as 95% of their time indoors. Health care leaders, designers, and architects, recognizing the connection between health and the buildings in which much time is spent, are engaging in sustainable design and construction for healthy, 'green' buildings. The purpose of this article is to assist nurses in understanding the impact that unhealthy buildings can have on nurses and nursing practice and to provide tools and resources to assist nurses in transforming the health care industry with the goal of creating healing environments and reducing the negative environmental impact of the health care industry. First definitions, current initiatives, and motivations related to sustainable designs will be presented. Next sustainable health care design strategies, such as site planning, clean transportation, water conservation, healthy materials selection, indoor environmental quality, and also the benefits of sustainable design will be discussed. The article will conclude by sharing a variety of resources nurses can use to create healing environments in health care settings.     

Taking steps to control costs in the OR

Hospitals continue to be challenged by rising expenses in an environment of moderate reimbursements. Health care costs have increasingly come under scrutiny and, with the advent of health care reform, will continue to be scrutinized. Perioperative nurses play a key role in evaluating product safety, effectiveness and efficiency, environmental concerns, and cost and how these factors affect patient care. Cost-saving opportunities that a hospital product evaluation committee can consider include choosing less expensive but equivalent supplies, comparing the expenses associated with disposable versus reusable products, limiting the use of custom supplies, determining ways to reduce linen use, and changing practices to eliminate products that are found to have little clinical value. Adopting effective product evaluation and purchasing practices can lead to reduced costs without affecting the quality of patient care.     

Environmentally safe health care agencies: nursing's responsibility, Nightingale's Legacy

Florence Nightingale and subsequent nurse scholars have written about the impact of the environment on human health. Nightingale described, and staked out, the nurse's role in optimizing environments for healing. Since Nightingale's time numerous scholars have documented that environmental conditions play a major role in the health of individuals and populations. As nurses become more informed about the environment as a determinant of human health, they will be able to advocate more effectively for environmental conditions that promote health. This article provides both theoretical and practical perspectives to integrate environmental concerns into nursing practice. It recommends specific actions nurses can undertake to improve the environment within the health care setting. In particular the article provides a historical review of an environmental focus in nursing, discusses ways to manage both upstream waste and downstream waste (solid, biohazard, and hazardous chemical wastes) so as to decrease environmental pollution, and recommends specific nursing actions to promote a healthy environment within our health care agencies.     

Medication errors in the emergency department: a systems approach to minimizing risk

Adverse drug events caused by medication errors represent a common cause of patient injury in the practice of medicine. Many medication errors are preventable and hence particularly tragic when they occur, often with serious consequences. The enormous increase in the number of available drugs on the market makes it all but impossible for physicians, nurses, and pharmacists to possess the knowledge base necessary for fail-safe medication practice. Indeed, the greatest single systemic factor associated with medication errors is a deficiency in the knowledge requisite to the safe use of drugs. It is vital that physicians, nurses, and pharmacists have at their immediate disposal up-to-date drug references. Patients presenting for care in EDs are usually unfamiliar to their EPs and nurses, and the unique patient factors affecting medication response and toxicity are obscured. An appropriate history, physical examination, and diagnostic workup will assist EPs, nurses, and pharmacists in selecting the safest and most optimum therapeutic regimen for each patient. EDs deliver care "24/7" and are open when valuable information resources, such as hospital pharmacists and previously treating physicians, may not be available for consultation. A systems approach to the complex problem of medication errors will help emergency clinicians eliminate preventable adverse drug events and achieve a goal of a zero-defects system, in which medication errors are a thing of the past. New developments in information technology and the advent of electronic medical records with computerized physician order entry, ward-based clinical pharmacists, and standardized bar codes promise substantial reductions in the incidence of medication errors and adverse drug events. ED patients expect and deserve nothing less than the safest possible emergency medicine service.     

Drug disposal among hospice home care nurses: a pilot study of current practice and attitudes

ContextIt is the role of the hospice home care nurse to dispose of unused medications after a patient’s death. However, the methods of disposal, the nurses’ attitudes, and beliefs regarding the environmental and health effects of disposal practices, as well as the knowledge of applicable federal guidelines, are unknown.ObjectivesThe purpose of the study was to explore the drug disposal practices of Michigan hospice home care nurses and the related attitudes and beliefs.MethodsA Web-based survey was administered to a convenience sample (n = 138) of hospice home care nurses.ResultsNearly half of the respondents reported disposing of 11 or more doses per patient. Nurses most commonly disposed of the drugs by mixing them with a noxious substance and considered this method both acceptable and safe. However, more than half (55%) reported that they dispose to sewerage always or often, and nurses were concerned about legal and environmental issues around drug disposal. Most nurses reported that returning medications to the hospice office was unsafe or extremely unsafe.ConclusionFindings from this study suggest further education, practice, and research directions.     

Oncology nursing: Finding the balance in a changing health care system.

Health care restructuring has resulted in significant changes in the workload and work environment for oncology nurses. While recent studies describe the impact of these changes on the general nursing workforce in several countries, there have been no published studies that have focused on worklife issues of Canadian oncology nurses. Therefore, a qualitative study was conducted to gain insight about how oncology nursing has changed over the past decade and how Canadian oncology nurses are managing these changes. Analysis of telephone interviews with 51 practising oncology nurses employed across Canada revealed three major themes. The first theme, "health care milieu", portrayed a picture of the cancer care environment and patient and professional changes that occurred over the past decade. The second theme, "conflicting demands", reflects how the elements of change and social forces have challenged professional oncology nursing practice. The third theme, "finding the way", describes the patterns of behaviour that nurses used to manage the changing health care environment and make meaning out of nurses' work in cancer care. Overall, the findings portray a picture of Canadian oncology nurses in "survival mode". They face many workplace challenges, but are able to keep going "for now" because they find ways to balance their responsibilities on a daily basis and because they know and believe that their specialized nursing knowledge and skills make a difference in patient care.     

Patient education and consumer medicine information: a study of provision by Queensland rural and remote area Registered Nurses

Aims and objectives. The aim of the larger study was to ascertain the medication practices of registered and enrolled nurses in rural and remote areas of Queensland after the introduction of the Health (Drugs and Poisons) Regulation. This paper reports on the findings of the role of registered nurses and their confidence in the ability to provide information on medications in a way that the client understands; the frequency of the provision of information to clients prior to discharge; and the frequency of Indigenous Health Workers or interpreters for people without English as a first language. Background. Queensland employs approximately 17% of the Australian registered nurse workforce. In 1996 Queensland changed the Health (Drugs and Poisons) Regulation to allow specific registered nurses, who had undertaken approved postgraduate education and training programmes, to become endorsed for an expanded medication practice role. In particular, it allowed endorsed nurses to administer and supply (but not prescribe) drugs listed in a drug formulary to certain clients using protocols. It was not clear, however, whether the changes to the Regulation reflected the scope of practice, thereby providing adequate legal protection for the nurse. Design. During 2001–02 an exploration of the medication practices of rural and remote area nurses was conducted by the use of a cross‐sectional postal survey. Phase 1 of the study used a facility audit to ascertain facility medication practices and phase 2 of the study used a postal survey to ascertain nurses’ medication practices. Method. All nurses employed in rural and remote health facilities in Queensland were eligible to participate in the study. The nurse registering authority's (the Queensland Nursing Council) register was used to generate a non‐proportional stratified random sample. Of the 1999 questionnaires sent, there were 668 respondents. Of these, 520 were registered nurses. Results. The data indicated that there was a difference between endorsed and unendorsed registered nurses’ medication practice. In particular, it was apparent that endorsed registered nurses were more likely to believe they could explain the side‐effects of medication to clients in a way the patient understood; provided medication education to clients on discharge; and used Indigenous Health Workers or interpreters to explain medications to those clients for whom English was not a first language. However, it was apparent that <50% of all Registered Nurses were providing client medication education or using Indigenous Health Workers or interpreters. Conclusion. It is apparent that the changes to the Regulation have ensured that Registered Nurses who have undergone postgraduate education to enhance their medication practice are more likely to provide client education and consumer medication information. However, the results suggest that the majority of registered nurses in Queensland, whilst believing they have sufficient knowledge of pharmacology to provide client education, often do not provide appropriate medication advice to clients, particularly on discharge from the acute setting. Relevance to clinical practice. It is well recognized that the provision of medication education to clients has several benefits to both the client and the health care system. The lack of client medication education indicated in this study compromises patient's safety as well as their compliance with their medication regime.     

Medication errors: ethical implications

Errors in health care are receiving much attention today, although committing such errors is not a new phenomenon. Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors. Although many types of errors can and do occur in the health care setting, this article focuses on a discussion of medication errors and related ethical implications. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. Nurses' appropriate ethical responses to medication errors need to be supported. Changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring.     

Healthy choices: transforming our hospitals into environmentally healthy and safe places

While it is commonly understood that the quality of the air we breath and the water we drink can impact our health, it is often more difficult to recognize that our choices of the health care products, along with the way we dispose of them, and the chemicals we spray on our foods or use to clean and disinfect may actually compromise the environment and consequently our health. This article will guide nurses and other health care professionals as they transform our hospitals into environmentally healthy and safe places by helping them adhere to environmentally preferable purchasing policies, follow environmentally conscious waste management strategies, decrease use of chemical pollutants, promote use of healthy foods, and provide leadership in environmental stewardship.     

Evaluation of contextual influences on the medication administration practice of paediatric nurses

Title. Evaluation of contextual influences on the medication administration practice of paediatric nurses. Aim. This paper is a report of a study conducted to explore the impact of preidentified contextual themes (related to work environment and socialization) on nursing medication practice. Background. Medication administration is a complex aspect of paediatric nursing and an important component of day‐to‐day nursing practice. Many attempts are being made to improve patient safety, but many errors remain. Identifying and understanding factors that influence medication administration errors are of utmost importance. Method. A cross‐sectional survey was conducted with a sample of 278 paediatric nurses from the emergency department, intensive care unit and medical and surgical wards of an Australian tertiary paediatric hospital in 2004. The response rate was 67%. Result. Contextual influences were important in determining how closely medication policy was followed. Completed questionnaires were returned by 185 nurses (67%). Younger nurses aged <34 years thought that their medication administration practice could be influenced by the person with whom they checked the drugs (P = 0·001), and that there were daily circumstances when it was acceptable not to adhere strictly to medication policy (P < 0·001), including choosing between following policy and acting in the best interests of the child (P = 0·002). Senior nurses agreed that senior staff dictate acceptable levels of medication policy adherence through role modelling (P = 0·01). Less experienced nurses reported greater confidence with computer literacy (P < 0·001). Conclusions. Organizations need to employ multidisciplinary education programmes to promote universal understanding of, and adherence to, medication policies. Skill mix should be closely monitored to ensure adequate support for new and junior staff.     

Continuous quality improvement project: decreasing the potential for the development in the inpatient setting of drug resistance by improving nursing practice for HAART administration.

HIV/AIDS patients' dissatisfaction with highly active antiretroviral therapy (HAART) medication administration in the inpatient setting was the impetus for a continuous quality improvement (CQI) project. The purpose of the CQI project was to initiate a change in nursing practice for HAART medication administration. The goal of the project was to decrease the potential for development of drug resistance in the inpatient setting related to nonadherence with food requirements for drug administration and to incomplete or "missed" doses of prescribed HAART. A secondary goal was to increase the provision of patient education on HAART medications by nurses. The interdisciplinary CQI team found that medication administration in the inpatient setting involved more than nurses simply "passing meds." Inpatient medication administration was a complex process involving a variety of hospital systems, departments, and traditions, all of which had an impact on patient care. The article describes the CQI methodology that was used for the project and how each step of the project was planned and implemented. Specific problems related to administering HAART in the hospital setting are listed as areas for needed nursing research.     

Impact of bar-code medication administration on nursing activity patterns and usage experience in Taiwan

As medication safety is a foremost goal of patient safety, the adoption of bar-code medication administration can help nurses ensure safe medication administration. The aims of the study were to explore the impact on nursing activity patterns of using this device and to understand the nurses' usage of this technology. The data collection was conducted in a medical center in northern Taiwan using work sampling observation and qualitative interviews. A total of 4940 observations were conducted on two groups of nurses who did or did not use the device, and six nurses were interviewed using a semistructured interview guide. The results showed that the nurses who used this device spent less time on medication-related activities and more on indirect care and unit-related activities, especially on the day and night shifts. Three themes were identified from the follow-up interviews: facilitating nursing workflow, improving medication safety, and encountering operational difficulties. Although the technology use could divert the nurses' practice patterns from medication-related activities to indirect care and unit-related activities, their direct care was not compromised. In addition, although the bar-code medication administration use could improve workflow and patient safety, hardware sufficiency and system functionality deserve more attention in the technology adoption process.     

A training package for primary care nurses in conducting medication reviews: their views and the resultant outputs

Aims. To ascertain nurses’ views about training in and undertaking of medication reviews and to analyse documented pharmaceutical care issues (PCI) and outputs from nurse reviews. Background. Primary‐care nurses in the UK are increasingly expected to contribute effectively to chronic disease management for example by undertaking medication reviews. There are concerns that nurse education is inadequate for these new roles. Little research is published about nurse medication reviews. A pilot study in one Scottish medical practice demonstrated that, after training in systematic medication review, practice‐based nurses could identify medication‐related problems. The training, consisting of reading material, including self‐assessment questions and a training event, was subsequently offered to all practice‐based nurses in the Community Health Partnership (CHP); participants then undertook six reviews to achieve CHP accreditation. Design. Survey of participant nurses and analysis of completed documentation from reviews. Methods. A self‐completion, postal questionnaire distributed three months post‐training. Analysis of documentation from reviews for PCI and outputs. Results. Eighty‐one nurses were offered training: 64 (79%) participated; 38 (59%) returned questionnaires. Low confidence levels before training (0, very confident; 6, 16% confident) rose afterwards (8, 21% very confident; 19, 50% confident). Thirty‐two (84%) nurses indicated the training had completely or mostly met their needs. A total of 120 nurse reviews were analysed and 188 PCI documented, mean 1·6/patient, with 117 outputs, mean 1·0/patient. Twenty‐seven outputs (23%) involved prescribed medicine changes. Conclusions. A pharmacist‐supported training package in medication reviews for primary‐care nurses is feasible and generally welcome. The training met the needs of most respondents although concerns were expressed regarding time pressures and knowledge base for extended roles. Relevance to clinical practice. Medication reviews are vitally important for both patients and the NHS; this approach may be useful for nurse prescribers and non‐prescribers alike although concerns expressed will require attention.     

Positioning impact on the surgical patient

The operating room is unknown territory to most health care providers. It frequently brings up thoughts of blood, strange smells, and cold temperatures. Many nursing programs have scheduled little, if any, time in this environment for students. As a result, few nurses who practice outside of this specialized area understand the patient care events that occur in the operating room. Those who have selected the operating room for their work environment know that it is a somewhat isolated period in the perioperative experience. This article provides insight into this area of patient care and a greater understanding of how patients are positioned, the physiologic impact of these positions, and some consequences that may impact the postoperative care of these patients.     

Emphasizing terminal care as district nursing work: a helpful strategy in a purchasing environment?

This paper describes how within a study on the experiences of district nurses since the introduction of general practitioner purchasing, participants were encouraged to describe and define the district nursing service. The identification of terminal care by district nurses and others as a significant and defining example of district nursing work is explored and the possible reasons for its emphasis over other aspects of patient care. The extent to which terminal care was used within contract and purchasing discussions to aid general practitioner understanding of district nursing work and achieve extra funding is described. The paper concludes by questioning the extent to which terminal care is a helpful and accurate representation of what district nursing work entails, and the implications there may be in emphasizing one aspect of care within a purchasing environment.