Why we are here

We have this thing, my husband and I. I protest that life is hectic and timing is impossible and that I am not 'feeling' that I am ready for the trip from the east coast. He talks me up and tells me how I will feel once the conference starts and I meet up with nurses from all over the country and begin networking. But my presentation isn't quite perfect. It will be, he coaxes. I have so much to do. You need to recharge your professional batteries he reminds me.

It takes little time to feel the energy of AACN's NTI. From the flight attendants giving a 'shout out' to the nurses on the plane, or the LED sign welcoming AACN Nurses to Denver or walking into the conference center and picking up your materials working out your schedules for the week.

It is day one of NTI2014.

On the phone he reminds me why am I here. And I have to admit he was right. Recharge and renew.

Why are you here? What will you learn? What will you take away?

Today we Step Forward in Denver together for NTI 2014.

Not a physician, not a nurse...what?

APRN Advanced Practice Registered Nurse
ACNPC Acute Care Nurse Practitioner-Certified
CCNS Certified Clinical Nurse Specialist
CEN Certified Emergency Nurse 
Are you following the pattern?  I could go on...
These are examples of just some of the many certifications for nurses in specialized areas of care. And please excuse the underlying snarky tone as I am not feeling so "happy" after this past Certified Nurse Day.

Disclaimer: I am very proud to be a nurse and promote clinical excellence through certification - this is not a swipe at certification  or certified nurses!

So let me set the scene. I primarily work as an ACNP specifically as a Hospitalist and part time as a CNS. I also work as nursing faculty at a local university. During this past certified nurses day a unit clerk asked in general to anyone in earshot is it CNA day? (meaning certified nursing assistants day)  I spoke up and said no, it's certified nurses day - a day to recognize nurses that have obtained specialty certification, I gave him examples of my certifications and the clerk pointed to a list on a wall and said I was not on the list and finished with "well you're a doctor". "Umm, well actually I'm not. I did not go to medical school. Well you're not a nurse anymore," was the reply. Wow! I was not prepared for that. As it turned out this person was not alone in this perception.

Interestingly, I am no longer considered part of the nursing staff but not "part" of the medical staff. I have to abide by the medical staff by laws. I am not allowed to eat meals in the medical staff lounge or get free meals in the cafeteria. I am part of the "Allied Health Staff" which includes NPs, PAs, CNRAs,  & CMWs; we all pay dues. But we have no leadership. No meetings. No organization. No lounge. And we are not welcome at either nursing meetings or medical staff meetings.

So if I'm not physician and not a nurse, what am I? I know that I am not the only nurse practitioner or clinical nurse specialist that has been experienced something similar? Please don't get me wrong, I have a great working relationship with most of the medical and nursing staff members and I love my both of APRN positions. And most of all I LOVE being a nurse.

I continue to educate the staff on my evolving roles (I started out as a staff nurse and worked my way through school and various positions).  And to either our determent or benefit, I think we [nurses] will continue to educate others on what we do at every level as we continue to diversify our roles in healthcare.

I know I am not a physician. I do not pretend to be. I am an acute care NURSE practitioner and clinical NURSE specialist and I believe that I offer my patients something my physician counterparts do not. I am proud of my roots and my education and experience...and most of all my certifications. All of them!

Put one foot in front of the other...

I have to admit that is what I first thought of when the President-elect new theme was unveiled. Then I gave it more thought..Dare to Step Forward...nice. The themes fit very well. Of course all of the themes fit well...these are very smart woman and NURSES!

It was a week a firsts for me. My first trip to Boston. My first time sightseeing in a city by myself and see the path of great Patriots. My first time presenting at NTI. A week of stepping out of my comfort zone and into something bigger. I can hear all the past themes running through my head.

We are once again reminded that we, as individuals not to mention as unified group can do great things. Each one of us. We all matter. We deserve to be happy. And we must rest. Wow...powerful stuff.

In the weeks before I left for Boston, I was struggling with whether or not I still wanted to go and if I had it in me to present at NTI in the API track (step forward). Whether I wanted to travel to a city that had suffered a brutal, cowardly attack (together, stronger, bolder). Whether I wanted to go essentially alone, save my colleagues and friends from my AACN Chapter. I was so wrong...I not only wanted to go, I needed to go (dare to).

I learned so much - not just about clinical practice and being an advanced practice nurse but about myself (act with intention)

There are so many things that left an impression on me. So much that touched me and is pushing me to work harder and to do more (stand tall)

So the big questions is how will you Step Forward this year?

One foot in front of the other

The NTI countdown begins

So we are just days away from undoubtedly the largest gathering of nurses - the AACN's NTI conference in Boston, MA.

I have to admit, I have been slow to get excited for this conference; especially since the bombing occurred. Glued to the TV for days as the events of the attack unfolded, I was shocked and horrified and angry that yet again a senseless tragedy occurred on American soil. Relief poured over me when details emerged and the suspects were caught.

As many of my nursing colleagues have thought about I'm sure, I have prayed for not just the victims but the numerous nurses, paramedics, physicians, and other healthcare providers impacted by this act of terrorism. No doubt we will hear more this week from these frontline providers that worked tireless to save lives.

This is my first time presenting at NTI. Part of me is terrified. But I am starting to feel a tiny bit of excitement build deep within me...I am after all presenting on something I feel very patient about.

Over the past week or so I have given much thought about this trip to Boston...specifically NTI. I was reminded by someone very dear to me that it is a time to recharge my nursing batteries with many strong and powerful nurses. He's right. Nurses are strong and overcome crises and struggles everyday to care for patients and ensure the best possible outcomes. We are passionate and forward moving.

It turns out that Boston is a great place for NTI this year. Nurses and other providers always rise to the occasion and remain strong and resolute. So has Boston.

Yeah, I think I'm ready.

Boston Strong                                 Nurses Strong

Patient safety lessons from Starbuck's

Anyone who knows me, would agree that saying I like coffee is an understatement. In fact, coffee is truly one of my life's pleasures. Right up there with anything chocolate and the beach. A good cup-a-joe, anytime of the day - hot or iced, frappuccino or espresso, I'm guaranteed to love it.

So what does my love of coffee, Starbuck's and healthcare have in common? Probably very little at first glance; besides the fact that coffee is the fuel of healthcare providers and clinicians everywhere...we may be able to learn something from the highly rated java-giants.

A typical shift day for me begins with a trip to the local Starbuck's for my usual special latte for one last jolt of caffeine to get through my unpredictable day. No matter what time I visit, I am always greeted by a friendly voice in the drive-thru that identifies themselves first and says something like "Good morning or welcome, my name is so-and-so, how may I help you today?" WOW! It always impresses me...really. Every day. All the time. No matter the person taking my order. I respond the same...."Good Morning! (It's contagious you know) I'll have...I won't bore you with my special coffee needs" And here's the best part...wait for it.....the friendly barista READs BACK & VERIFIES my ORDER! (RBVO) Ta-Da! Yes, they verify what they heard you say. Amazing. And if it is wrong they correct it on the spot and you get the wrong drink in addition to the corrected order. Now granted, no one is going to die or be injured with the wrong coffee-drink, but that is not the point.

In our clinical practice settings we give and receive orders or diagnostic results or other patient-related communication all the time and it is extremely easy to misinterpret or transcribe them incorrectly. The difference is, we can't take back the wrong treatment, medication or diagnostic result and it can most definitely harm the patient. I give telephones quite frequently and I am surprised at how many times they are not read back & verified. I often ask them to repeat the order back to me or I repeat it myself.

If Starbuck's thinks it is important enough to Read, Back & Verify your Order (RBVO) shouldn't it be important enough to us where the stakes are much higher? Incidentally, those of use that work in the acute care (hospital setting) know that CMS and The Joint Commission already think so...this was a National Patient Safety Goal for many years; it is now part of the Provision of Care Standards and yes a hospital can actually be penalized for not demonstrating evidence that a verbal or telephone order was RBV.

Startbuck's greets their customers with kindness and reads back their orders to maintain a high level of customer service and satisfaction, not because people will die. Clinicians and providers at every level should make reading back and verifying communications a natural part of their practice and a priority for patient safety.

Hard pill to swallow???

For many Americans sweet dreams are not obtainable. They complain of poor sleep everyday - or more appropriately every night. The elderly are much more likely to report sleep problems. Due to a myriad of reasons, most physiologic sleep is altered and they find themselves up at night when they should be getting restorative sleep. For that reason the use of sleep aids has increased...and so have the consequences. Many drugs leave patients with 'hangover' effects impairing judgment and physical mobility long into the daylight hours after taking these prescription sleep aids - especially long-acting formulas. For the elderly this can be especially dangerous leading to increased risk for severe injuries related to falls, mismanagement of medications and other accidents. Some hospitals have reduced the use of such medications in hopes of reducing confusion, falls and other sequelae (especially in the elderly). In the hospital setting, patients often do not recover from untoward events. 

Cascade Iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline. It often results in a poor outcomes for the patient or inability to return to pre-illness level of functioning and is preventable. Many of these events are precipitated by medications - either a new medication, too many medications (polypharmacy) drug-drug interactions, over-sedation, so on and so on...
As for the use of sleep aids, especially in the acute care setting, it cannot be overstated - we must be vigilant and cautious when utilizing these or any medications in the elderly patient. Having an a lower dose option may be helpful, however we should really be considering alternatives rather than adding one more pill to the the medication soup

See the following:
Wall Street Journal: Citing Dangers, FDA Requires Lower Doses for Certain Insomnia Drugs http://online.wsj.com/article/SB10001424127887324081704578233652166139618.html?mod=dist_smartbrief 
National Sleep Foundation: http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia

History taking getting too personal?

Whether or not you support the constitutional right to bear arms and what you believe the right to free speech covers, there is a definitely a controversy brewing in Florida over the "Gag Law."  A recent ruling states that Florida "cannot enforce a law that prohibits physicians from asking patients whether they own a gun because it infringes on their First Amendment right to free speech." The National Rifle 

Association (NRA) helped lobby for the law believing the second amendment was at risk and stating that the information obtained by healthcare providers would go into individuals' permanent health records. Physician groups argue they are trying to protect children and that assessing whether there is a gun in the home is necessary to provide education on gun safety, similar to bike and car safety. Other groups disagree. But what about adult patients? 

The question then becomes what information is necessary for healthcare providers? How is some of this and other social information used in relation to patients' overall health care? Some argue that some information should not be kept in their permanent medical record and do not understand the relevance. 

Would it be appropriate to assess a person with profound depression risk for suicide? Part of that assessment would include assessing for a plan, access to methods and ability to carry it out.  How about a patient that has substance abuse issues - is it appropriate to ask about the use of drugs and alcohol? Sexual orientation, partners? You get the point...

As an ACNP I understand the concept of history taking but I also understand the need for being respectful of sensitive information. Of course many patient's do not share everything with healthcare providers out of fear, or stereotyping or some sort of recourse. Will this situation in Florida have the effect they are looking for - preventing unintentional firearm accidents? I'm not sure. But I do know that constitutional rights are polarizing topics and it seems that most sit on one side or the other. Regardless of your personal beliefs on firearms or free speech, when it comes to caring for patients, the patient must remain central in order to be a true advocate.

Florida 'Gag Law' on Physician Gun Queries Blocked for Good

Roundup: Doctors entitled to free speech, too

Burning out: Combating compassion fatigue & moral distress

Most of know that feeling as being "burned out." When you fell like you cannot do your job another shift let alone the rest of your working days. The irony is that we became healthcare providers (nurses, medics, physicians, etc) because we wanted to care for others. To make a difference. We knew our work was that of service and that some days it would be hard. And although television often portrays healthcare as glamorous and adrenaline-producing every moment of every day, we know the real truth.

Compassion fatigue is defined as a loss of compassion and caring over time. It is a condition that is hallmarked by emotional, physical and spiritual exhaustion that occurs from caring for and internalizing the suffering of others. Compassion fatigue is also referred to as secondary post-traumatic stress disorder. Nurses have a propensity to carry on the burdens and problems of others - their patients, coworkers, families, and friends which may leave them exhausted and feeling empty. (I recommend reading Bertice Berry's Blog, especially Day 145: Seeing Miracles)

Moral distress is another term often used related to burn out, however often there is an ethical component or dilemma associated. Nurses frequently find themselves in the middle of conflicts involving patient care issues, especially related to end-of-life or futility of care. This produces a great deal of stress for the nurse whom often has no outlet.   

We have all seen it - burned out coworkers call out more, are late to work, have no interest in most of what they do, chronic fatigue, decreased productivity, high turnover, workplace injuries, reduced satisfaction in work and home, and even more patient complaints. Not to mention patient safety events; if our head is not in the game so to speak how can we be sure we are not going to make a serious error or failure to rescue or prevent harm to a patient.

There are many reasons that nurses become burned out with their jobs. High patient acuity, staffing issues, conflicting values and expectations for time between work and other life responsibilities and difficult or devastating patient situations.We talk about it. We say, "Oh, I'm so burned out, I just don't care anymore." Yet we do little to nothing about it. At work we barely support each other; often because we are so busy ourselves and consumed with our own tasks and crises. Helping and supporting each other through difficult situations and even the everyday ones has to be a priority. It is wearing us out and creating an undercurrent of distress and hostility and resentment. Having formal systems in place to help us deal with difficult emotions is important not only for the staff member involved but all other staff, and more importantly for the patient. 

At home we do even less. We set no priorities of care for ourselves. Do not allow ourselves to grieve a loss at work or at home. We do not give ourselves permission to really care for ourselves in a healthy way - sleep and eat well, exercise, rest and relax, read a good book, play and so on.

I have posted some very good resources on moral distress, compassion fatigue and burn out. I strongly encourage you to read them and develop resources in your workplace to combat this insidious foe to our job satisfaction and personal happiness.

Addressing Moral Distress: An Important Step toward a Healthy Work Environment

Six Ways to Deal With Compassion Fatigue and Burnout, Kendra Mims, ENA Connection (Mar 2012)

How do I deal with compassion fatigue?

6 Ways Nurses Can Beat Compassion Fatigue

Safe Practices: Preventing Needlestick Injuries

Dr Mary Foley

I recently had the privilege to learn more about the Safe in Common campaign, an exciting healthcare initiative that is promoting safe work environments free from needlestick injuries from one of the leading health worker safety advocates, Dr. Mary Foley. Below is our interview. Please read and consider taking the pledge for preventing needlestick injuries and creating safe work environments.

(Kelly) What has been your experience with the general "culture" or perception by nurses and other healthcare professionals regarding needlestick safety?

(Dr Foley) In my experience, healthcare workers are focused on patient care.  They are aware of needlestick risks, but they keep their worries about occupational injury in the background, so they can focus on giving the best care they can.  That presents some danger to healthcare workers.  Doctors, nurses, aids, lab technicians, housekeeping, and maintenance personnel are all at risk when sharps devices and delivery systems are not designed for maximum protection.

(Kelly) Can you estimate the cost in lost wages or medical care annually related to needlestick injuries?  What is the emotional cost?

(Dr Foley) There is an emotional cost to the ever-present threat of an injury, which is there even if a healthcare worker manages to keep the concerns "controlled", so they can focus on patient care. 

When a worker is exposed to a contaminated device, there is an immediate sense of panic, since this could be an infected device.  In spite of that fear, or maybe because of it, almost half of all injured workers fail to report their injury—which puts them at risk for no coverage if they become ill.

Injured workers talk about the tension in their personal and family lives as they wait for test results which are conducted over 6 or more months to determine if the worker is infected.  Some healthcare personnel are encouraged to take prophylactic medications, some of which are difficult to tolerate.  

The preferred future: reduce accidental injuries with better devices, proper training, and a culture of safety.

(Kelly) Can individual nurses make a difference?

(Dr Foley) Individuals can make a difference. Care for the caregivers begins with self care—being as knowledgeable as possible about protecting patients and oneself.  But many of the improvements in health care settings will require collective action by policy makers, device makers, occupational health specialists, managers, and staff.

(Kelly) What can we all do to offer our support?

(Dr Foley) The Safe in Common campaign was launched in May, and we already have thousands of pledges of support.  Just as importantly, the subject of sharp injury prevention is active again, over 10 years after the passage of the Needlestick Safety and Prevention Act.  There have been some improvements in some rates of injuries, but there are still too many occupational injuries from sharps, and now, many of those occur when staff uses "safety" devices. Clearly, the devices in use are not adequately protecting staff, and more work must be done.

Spread the word (thank you for writing about this), share the pledge, advocate for educational content and conference programming that informs and advocates for better protection.

(Kelly) Can you provide any statistics / facts about the frequency and gravity of needlestick injuries?

(Dr Foley) Virtually all healthcare personnel are at risk of harm from occupational exposures such as needlestick injuries. The Center for Disease Control notes that nurses sustain approximately half of all needlestick injuries, while physicians, housekeeping and maintenance staff, technicians, and administrators are also harmed.

The U.S. Occupational Safety and Health Administration (OSHA) estimates 5.6 million workers in the U.S. healthcare industry are at risk of occupational exposure to bloodborne pathogens via needlestick injuries and other sharps-related injuries. OSHA further reports that each year 385,000 needlestick injuries and other sharps-related injuries are sustained by hospital-based healthcare personnel. This equates to an average of around 1,000 sharps injuries per day in U.S. hospitals.

Including other non-acute healthcare facilities, it is estimated that between 600,000-800,000 healthcare personnel incur a needlestick injury each year in the U.S.

Forty percent of injuries occur after use and before disposal of sharp devices, 41% of injuries occur during the use of sharp devices on patients, and 15% of injuries occur during or after disposal.

(Kelly) How did you get involved advocating for needlestick safety?

(Dr Foley) As a registered nurse for more than 35 years, I was one of the first healthcare workers to combat the emerging HIV-AIDS epidemic during my work at Saint Francis Memorial Hospital in San Francisco during the 1980s. I played a key role in securing the passage in California of the first state-based laws in the U.S. mandating the use of safety medical devices. Afterwards, I joined other nursing colleagues to campaign for the adoption of the Federal Needlestick Safety and Prevention Act. Elected President of the American Nursing Association (ANA) in 2000, I was in the Oval Office of the White House when President Bill Clinton enacted the Act into law. Since, I have continued to work to improve healthcare policy, including improving the workplace, and promoting safe care for workers and patients nationally and internationally. Given my passion and knowledge of the issues, Safe In Common asked me to lead their Needlestick Safety Advocacy Tour.

(Kelly) What does Safe in Common do to protect healthcare personnel?

(Dr Foley) Safe in Common is a movement of healthcare personnel committed to making their working environment safe from the risk of needlestick injury. With the safest equipment, the best practices and the right culture, we believe all needlestick injuries can be prevented. The non-profit organization was established to enhance and save the lives of U.S. healthcare personnel at risk of harm from needlestick injuries.  First established in 2010 as an online community of healthcare professionals and other advocates committed to injection safety, Safe in Common is leading the Needlestick Safety Advocacy Tour across the U.S from March 2012 through March 2013 to engage with healthcare personnel to hear their concerns, raise their hopes and unite them together behind the creation of a workplace environment that is free from the risk of needlestick injury. 

The Tour will visit more U.S. hospitals and attend healthcare conferences across the nation during the first stage of the national campaign. At each location, Safe in Common representatives will advocate for needlestick safety, record real stories from healthcare personnel, and provide demonstrations of the latest safety-engineered medical devices that can help to deliver optimal protection to those at risk of harm.

(Kelly) What is the Safe in Common Pledge?

(Dr Foley) The pledge is the cornerstone of the NSAT: http://www.safeincommon.org/needlestick-safety-pledge.

Our goal is to have at least 100,000 healthcare personnel take the pledge as a show of support that more can be done to reduce needlestick injuries. The pledge, which can be taken online or in person wherever SIC is engaging healthcare personnel, says “A safe working environment is essential if I am to effectively serve the needs of my patients. Needlestick and sharps injuries represent one of the most serious threats to occupational safety within my facility.”

The pain and trauma that these injuries inflict upon healthcare personnel, and their loved ones, is unacceptable. The dollars lost each year in the testing and treatment of reported injuries is unacceptable. The continued use of medical equipment that fails to adequately address the safety and functional needs of healthcare workers and their patients is unacceptable.

Thank you Dr Foley for sharing this important topic with my readers. Patient safety causes often take priority over safety initiatives for ourselves. As nurses, other healthcare providers and ancillary services it is imperative to use caution and advocate for safe and healthy work environments.


Please follow the link and take the Safe in Common Pledge! 

NTI 2012 Starts with a Bang...literally!

My Day 2 was the official start to NTI which meant the first Supersession - and boy was it super! We should have known something was up when they were handing out drumsticks as we walked in the door! The 2 hours were filled with excitement and inspiration and laughter and tears! From Bertice's beautiful voice and rendition of the national anthem to Sticks of Thunder jumpstarting the crowd. 


Mary Stahl sharing heartfelt stories of nurse heroes and nurses lifting each other up in laughter. Nurses reaching for what seems to be the impossible in clinical excellence to using their seemingly small voice to advocate for the patient no matter how new they are. 


It was a magical sight I'm sure watching thousands of nurse tapping drumsticks together in unison. Close your eyes. Imagine it. We are a community of strong nurses. Together we can accomplish many things. Together our voice is bold. 


We are powerful. 

Together. Stronger. Bolder. 

Reaching out one story at a time...CodeSTEMI Series Unveiled

Lights, camera, action...CodeSTEMI series premiered at EMSToday in Baltimore, MD.

Despite sophisticated systems of care, numerous education outreach programs and the focus on being heart smart, cardio-embolic events remain the number one killers among men and women. As EMS and hospital systems across the country continue to build collaborative systems of care that aim at improving timely recognition and intervention of cardiovascular events such as STEMI and cardiac arrests, one trio is documenting the journey for various emergency medical systems across the nation. The result... an incredible documentary-style collection of real life stories of successes and challenges in developing high-performing cardiac systems of care. The first episode premiered last night at a special viewing sponsored by PhysioControl at the EMSToday Expo Showroom. The response was positive, leaving viewers anxious for more.

I encourage you to check out the first full episode: Rural STEMI System of Care: Sioux Falls

The CodeSTEMI team:

Host: Tom Bouthillet, Fire Captain/Paramedic
Executive Producer: Ted Setla
Second Camera: Chris Eldridge

CodeSTEMI TV

Nurse guilty of doing her job

Recently a nurse in Arizona was fired from a very large medical center and is "under investigation" with the State Board of Nursing for doing her job. In question is the very core of nursing practice: patient advocacy and education. Her story can be found on many nursing blogs and twitter - I have provided a link to one of the blogs below.

The nursing community is pulling together to help support her and bring media attention to her unfair situation. Read her story and you be the judge...

The Nerdy Nurse 
Arizona Nurse Has License Threatened By Doctor After Providing Patient Education