Simulation software: engineer processes before reengineering

People make decisions all the time using intuition. But what happens when you are asked: "Are you sure your predictions are accurate? How much will a mistake cost? What are the risks associated with this change?" Once a new process is engineered, it is difficult to analyze what would have been different if other options had been chosen. Simulating a process can help senior clinical officers solve complex patient flow problems and avoid wasted efforts. Simulation software can give you the data you need to make decisions. The author introduces concepts, methodologies, and applications of computer aided simulation to illustrate their use in making decisions to improve workflow design.     

Family affairs

It's no secret that your job is stressful, forcing you to deal with tragedy and death on a regular basis. You've become good at what you do because you pay attention to details and care about people. Most of the EMS providers I've known dedicate untold hours to their work, usually in addition to the regular jobs they hold. Their communities need them to be ready at a moment's notice when the pager sounds. Someone is in crisis. A life may hang in the balance-a life they may save. But what about the family that's left behind as you run out the door-yet again? How do your spouse/significant other and kids cope with whatever emotional state you're in when you return home? While your stress may be evident, their distress may be overlooked. What price do they pay to live with you? These questions were addressed during several workshops my colleagues and I conducted for EMS providers and their families. Many of the problems and frustrations identified in this article were shared by EMTs' family members who attended.     

Reflective Action—Strategies for Solving Client-Nurse Partnerships in Primary Care

In this grounded theory study, which addressed the research question, ‘What strategies do nurses use to form client-nurse partnerships,’ a variety of data sources were used. The first data set consisted of participant observation, and reports of focus groups formed as part of the ‘First International Conference on Nursing Theory and Primary Health Care’ at Massey University, New Zealand which was attended by an international group of 80 nurses in 1990. As an adjunct to the formal presentations, members of the focus groups addressed four questions: a) Is a nurse-client partnership viable in primary care? b) What do you plan to do to promote this partnership? c) What do you think others should do? and d) What is the next step? Reports from these focus groups, pooled with questionnaires (n = 17) and informal interviews completed this data set. The central process that described participants' perceptions of the viability of nurse-client partnerships was named reflective action. Ethical questions arose and were placed along a continuum of viability. A second data set consisted of interviews with, and selected literature by, Canadian nurses on partnerships in primary care. The perceptions of this international study group are seen as adding to our knowledge of barriers to nurse-client partnerships in primary care, and strategies for transcending these barriers.     

What makes your day? A study of the quality of worklife of OR nurses

From data obtained in this study, the weak or negligible influences on the quality of worklife of OR nurses are: Organizational Structure Leadership, and Organizational Learning. Things that matter to OR nurses and that influence their quality of worklife are: Collaborative Decision-Making, Multiskilled Workers, Change, Organizational Culture, Locus of Control; and the most important influence of all- Teamwork. So, now when the question is asked "What Makes Your Day?" The answer is clear--at the end of the day, it all boils down to the most fundamental of all answers--People! People are involved in collaborative decision-making, multiskilled workers, change, organizational culture, locus of control, and teamwork. These People include the OR nurse, who is involved in collaborative decision-making and all the other items that affect your daily work environment. The people you collaborate with, the people you interact with in the organization, and the people that make up the team--you and everyone around you are responsible for that magic ingredient--Teamwork. What you say, what you do, and how you behave makes all the difference in the daily worklife of your colleagues. Each and every comment and interaction contributes to the efficiency and effectiveness of the team. Each and every day from this day forward, remember this--remember how important your role is in building a strong and effective team. At the recent AORN Congress, Joan Rivers shared a favourite saying with us: "The past is history, The future a mystery, Today is a gift from God, that is why it is called the present." Today is all that we really have--let us make the best of each and every day as we continue to respect and value each member of the team. Teamwork--our building block of the future--yours, mine, and every other member of the surgical team. Each member can make an enormous contribution--we only need to believe that the "best is yet to be--the best resides in me". Yes, we can do our part in making our workplace a good one. But we can only do so much. It's time for governments, administrators, and managers to examine the work environment, to identify the kinds of things that motivate nurses to get up in the morning and go to work, and what makes that workplace pleasant enough that they are happy to stay there. We are hearing about nursing shortages across Canada and the United States. Recruitment and retention strategies are returning to hospitals. Besides "sign-on" bonuses, it is time for governments and administrators to examine the culture of the workplace. Questions that must be answered: Are nurses included in decisions made? Do nurses have what they need to work with? Are they given a reasonable workload? Are nurses part of a team that values them and their unique contribution to patient care? In the words of Senator Lucie Pépin (1999): "We must turn our anger first, into passion, then into action. A hostile or unpleasant workplace must not be tolerated!" With confidence we must be assertive as we look to improve our work environment. Yes, we can do our part, but now it is time for the other stakeholders to pay attention!     

Sharing responsibility for home care of the indigent

What should you do with indigent patients who are ready for discharge but cannot afford the home care services they need? Should you extend their hospital stay? Discharge them and hope for the best? Search for a community agency that will care for them at no cost? To address this dilemma, one hospital developed a health care consortium for the purpose of guaranteeing home care to indigent patients, regardless of their ability to pay.     

Carpal tunnel syndrome and vitamin B6

QUESTION: A 42-year-old woman with carpal tunnel syndrome tells you she has started taking a vitamin B6 supplement to relieve her symptoms. Her work in an automotive parts department involves both lifting moderately heavy packages and typing at a computer terminal. What does the research indicate about vitamin B6 as a treatment option, and what health issues should you discuss with this patient? ANSWER: Although its effectiveness is controversial, vitamin B6 is often used as a conservative and adjunct therapy in treatment of carpal tunnel syndrome. Many patients attempt to treat their symptoms with vitamin B6 on their own. Vitamin B6 at less than 200 mg daily is not likely to cause any adverse effects, but patients should be monitored for changes in symptoms, particularly when high doses are taken over long periods.     

What to do if you're exposed to a bloodborne pathogen

What happens when the healthcare worker is the one needing care? Occupational exposure to a bloodborne pathogen is a known risk for healthcare workers but one that we are often ill prepared to handle. Each healthcare worker must know what the risks are and how to immediately access specialized care. This article will outline what you should expect and do if you are exposed.     

Ethical inquiry and the concept of research

The place of scholarly research in nursing has not been well studied. Ethical inquiry, as scholarly research, has been included in this neglect. The concept of ethics research is defended and new research approaches to ethics are outlined. Forms of ethics research identified are scholarly, empirical, and dual mode. Questions considered are: Is ethics research research? What are the forms of ethics research? What is the role of empiricism in ethics research? And what is the relationship of ethics research to the moral concerns of nursing? Ethics research explores the basic moral norms undergirding nursing research, practice, and education.     

Decision-making theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives

Jefford E, Fahy K, Sundin D. International Journal of Nursing Practice 2011; 17 : 246–253 Decision‐Making Theories and their usefulness to the midwifery profession both in terms of midwifery practice and the education of midwives What are the strengths and limitations of existing Decision‐Making Theories as a basis for guiding best practice clinical decision‐making within a framework of midwifery philosophy? Each theory is compared in relation with how well they provide a teachable framework for midwifery clinical reasoning that is consistent with midwifery philosophy. Hypothetico‐Deductive Theory, from which medical clinical reasoning is based; intuitive decision‐making; Dual Processing Theory; The International Confederation of Midwives Clinical Decision‐Making Framework; Australian Nursing and Midwifery Council Midwifery Practice Decisions Flowchart and Midwifery Practice. Best practice midwifery clinical Decision‐Making Theory needs to give guidance about: (i) effective use of cognitive reasoning processes; (ii) how to include contextual and emotional factors; (iii) how to include the interests of the baby as an integral part of the woman; (iv) decision‐making in partnership with woman; and (v) how to recognize/respond to clinical situations outside the midwife's legal/personal scope of practice. No existing Decision‐Making Theory meets the needs of midwifery. Medical clinical reasoning has a good contribution to make in terms of cognitive reasoning processes. Two limitations of medical clinical reasoning are its reductionistic focus and privileging of reason to the exclusion of emotional and contextual factors. Hypothetico‐deductive clinical reasoning is a necessary but insufficient condition for best practice clinical decision‐making in midwifery.     

So you want to be an Out of Hours emergency nurse!

So, what is Assessment? One definition is that ‘assessment is a way of finding out if learning has taken place. It enables you, the assessor, to ascertain if your learner has gained the required skills and knowledge, needed at a given point, towards a course or qualification.’     

Is in-vitro fertilization for older women ethical? A personal perspective

Fertility treatments raise a range of social and ethical issues regarding self-identity for family, sexual intimacy, and the interests and welfare of potential children. Eggs and sperm are combined to produce fertilized eggs. These eggs are then implanted as embryos and grow into viable fetuses, which are carried by the original mother or a surrogate mother. This artificial form of conception can challenge religious values and family structures. In-vitro fertilization (IVF) can be considered either as a medical miracle or playing with divinity. What obligation do medical professionals have to infertile women and to what extent? The bioethical dilemma of IVF use encompasses different moral issues for all involved in the process. Ethical issues address respect for personal autonomy, access and care, and the duty of the health care provider to be compassionate to persons whose actions and moral values may be different from their own. Health care providers need to impart empathy, understanding and sensitivity towards this unique type of patient population. The conflict for those treating patients who are trying to conceive by IVF includes respect for personal autonomy, nonmaleficence, justice, utility and the ethics of care. As a registered nurse in a postpartum hospital unit, I have seen antepartum and postpartum women involved with this new technology. I have worked with mothers and their partners as they experience different levels of anxiety and hope for the future. There is an underlying psychosocial connection with patients who undergo IVF treatments. The purpose of this article is to explore the ethical use of IVF on older women. Is this type of biotechnolgy being applied for the right reasons and for the best patient population?     

Government 103: what happened to the great idea?

A similar analysis relates to bloodborne pathogens legislation, clinical laboratory reimbursement regulations, and Title VII support for health professions education. What ultimately happens to a great idea depends on our nurture and protection, meanwhile the efforts of others may subjugate its purpose. Failure to nurture the idea means it may have a previously undreamed-of effect. This commentary on the consequences of political action supports hard work, action, and vigilance. The framers intended that the system be energized, not paralyzed by multiple checks, balances, controls and remedies. George III wasn't big on any of these in the 18th century, so they now exist for the protection of us all. That they may seem obtuse is but one more reason for a vibrant participatory body politic, players on all sides who care to take the time to know the issues and our current boundaries. ASCLS has understood this, has taken up the gauntlet and has advocated for our field and its effect on patients in need of clinical laboratory tests for longer and with more success that any entity in US history. What part can you play in the knowing and the doing?     

Management of thrombocytopenia in bone marrow failure: a review

The clinical course of many neoplastic and primary bone marrow diseases will result in cytopenias secondary to bone marrow failure or infiltration. Acute and chronic leukemias, the myelodysplastic syndromes (MDS), aplastic anemia, breast and prostate cancer, as well as other hematologic and solid tumors, all may lead to chronic, severe cytopenias. Management of anemia and neutropenia are well described in the medical literature. Less well detailed are management approaches for patients with chronic thrombocytopenia, with or without active bleeding. Severe thrombocytopenia presents many difficult management choices for caregivers, patients and their families, especially near the end of life. The use of platelet transfusions in this patient population presents complex issues; platelets are logistically more difficult to transfuse than red cells and carry risks including acute febrile episodes, alloimmunization, and infection. In this review, we discuss the association of chronic thrombocytopenia to serious bleeding and the role of various prophylactic and therapeutic interventions available to palliative care and hospice providers. Specifically, this review examines the following issues: What is the morbidity and mortality from chronic thrombocytopenia in the setting of cancer or other bone marrow failure states? Is there a role for prophylactic platelet transfusions in the palliative care setting, and if so, with what frequency of monitoring, and at what transfusion threshold? What is the impact of alloimmunization and how can it be minimized? What treatments are available besides, or in addition to, platelet transfusions for acute bleeding episodes?     

The ethical dilemmas

This column has posed the issues and identified resources that home care nurses can use in an attempt to resolve the moral, social, economic, and professional factors that are confronted each day. Ethical dilemmas have been presented. The editor and I invite you to share your success (or lack of it) in resolving the issues you have experienced in caring for your patients. We look forward to hearing from you in an effort to benefit from your experiences.     

Suicide at the age of retirement]

Canadian statistics show an increase in the number of suicides by newly retired pensioners in Quebec. Quebec and Ontario mortality rates by suicide of persons between the ages of 67 and 69, are second only to those of Manitoba. After investigating the health care field of the Mauricie and Outaouais regions, a group of researchers were able to identify suicidal behaviors. Based on their report, this article--written by one of the researchers--answers questions such as: What happens to people when they reach retirement age? What makes new pensioners vulnerable to suicide? Is their suicide preventable? What is the best nursing intervention? This article presents an alarming situation where nurses will need to implement elements of prevention. The idea that the first month of retirement is critical for a pensioner, is well spelled out. Nurses have an important role to play in teaching these persons how to live differently and to value their new lifestyle. Counselling suggestions for nurses include: establish a climate of confidence; evaluate whether or not they are an immediate suicide risk; find the best time to communicate so that you are certain they are hearing you; talk to them about death without moralizing; try to help them find solutions to overcome their crisis; let them talk about their desire to commit suicide and show that you understand their suffering. Help them to accept that there are no miracle solutions. What answers there are must be worked out and not bought on the market.     

Principles of cancer screening for clinicians.

This chapter has outlined some principles of tumor growth, test characteristics, and the evaluation of screening technologies. We have emphasized that test specificity is the critical parameter in the evaluation of technologies because it is the healthy people who will suffer the most from the adverse effects of screening. We have also emphasized that the efficacy of a test is best evaluated by examining mortality reductions in comparable populations. The purpose has been to assist clinicians with their interpretation of the literature. Busy clinicians may not always have the time or inclination to do this themselves. In those cases they need to examine how organizations who make recommendations are coming to their conclusions because it is physicians, not organizations that will do the screening. In particular, it is important to ask the following: (1) Were criteria followed to justify the recommendations being made? (2) If so, what were they, and can the organization demonstrate that they are being met? (3) What perspectives and biases do the organizations bring to the judgments they inevitably have to make? (4) Do you share those perspectives? and (5) When the recommendation is adopted, can you guarantee that it will "first do no harm."     

Nurses who become the parent of the patient

How often have you received a nursing report on a pediatrics unit and heard or overheard, "The Mom (Dad) is a nurse and drove me crazy all day?" Or perhaps your own child has been hospitalized and you remember feeling frustration and anger when you think about the experience. What are the dynamics involved in these two situations? What do we as caring professionals really understand about the emotions involved? What emotions might we feel if our own child needs hospitalization? The following anecdotal dialogue was written by two professional nurses whose lives were unexpectedly disrupted when their babies each needed hospitalization. Together, involved in the care of one child they found their emotions and professional beliefs interwoven in such a manner as to make this article possible.     

Primary health care: what does it mean for nurses?

What health systems need, according to many nursing groups, is primary health care (PHC). But what is PHC and how can it be practised in hospitals where most nurses work? How will nurses benefit from PHC if it is successful? And what are the barriers that must be met to implement this radical concept?     

You did what? Clinical errors in EMS

It was late and you were exhausted. You ran a call that didn't go the way you would have liked. Errors occurred. What actions do you take when your partner is making mistakes? When do you step in? Do you step in? What if there's more to the errors than you realize? This article provides guidelines for EMS personnel to consider when dealing with a scenario that contains clinical errors. Although not an all-inclusive list, the examples and solutions may be beneficial to providers, including rookies and veterans.