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Inside ANA Strictly Clinical Practice Matters Career Sphere Mind/Body/Spirit Leading the Way

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BEST OF THE BEST

November 2014 Special Edition www.AmericanNurseToday.com

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American Nurse Today is the official journal of theAmerican Nurses Association, 8515 Georgia Avenue,Suite 400, Silver Spring, MD 20910-3492; 800-274-4ANA. The journal is owned and published byHealthCom Media. American Nurse Today is peer re-viewed. The views and opinions expressed in the edi-torial and advertising material in this issue are those ofthe authors and advertisers and do not necessarily re-flect the opinions or recommendations of the ANA, theEditorial Advisory Board members, or the Publisher,Editors, and staff of American Nurse Today.

American Nurse Today attempts to select authorswho are knowledgeable in their fields. However, itdoes not warrant the expertise of any author, nor is itresponsible for any statements made by any author.Certain statements about the uses, dosages, efficacy,and characteristics of some drugs mentioned here re-flect the opinions or investigational experience of theauthors. Nurses should not use any procedures, med-ications, or other courses of diagnosis or treatment dis-cussed or suggested by authors without evaluating thepatients conditions and possible contraindications ordangers in use, reviewing any applicable manufactur-ers prescribing or usage information, and comparingthese with recommendations of other authorities.

Rhonda Anderson, DNSc(h), RN, FAAN, FACHEChief Executive Officer Cardon Childrens Medical Center Mesa, Ariz.

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Nancy Dunton, PhD, FAANResearch ProfessorSchool of NursingUniversity of Kansas Medical CenterKansas City

Michael L. Evans, PhD, RN, NEA-BC, FAANDean and ProfessorTexas Tech University Health Sciences Center School of NursingLubbock, Tex.

Margaret A. Fitzgerald, DNP, APRN, BC, NP-C,FAANP, CSP

President, Fitzgerald Health Education Associates,Inc.

North Andover, Mass.FNP, Adjunct Faculty, Family Practice ResidencyGreater Lawrence Family Health Center, Inc.Greater Lawrence, Mass.

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Norma M. Lang, PhD, RN, FRCN, FAANProfessor and Dean EmeritusSchool of Nursing University of PennsylvaniaPhiladelphiaWisconsin Regent Distinguished Professor and Aurora

Professor of Health Care Quality and InformaticsCollege of Nursing University of WisconsinMilwaukee

Gail Pisarcik Lenehan, EdD, RN, FAEN, FAANNurse Clinical SpecialistEmergency DepartmentMassachusetts General HospitalBoston

Julianne Morath, MS, RNChief Executive OfficerHospital Quality Institute Sacramento, Calif.

Rebecca M. Patton, MSN, RN, CNOR, FAANFormer President, American Nurses AssociationAtkinson Visiting InstructorFrances Payne Bolton School of Nursing at Case

Western Reserve UniversityCleveland, Ohio

Ginette A. Pepper, PhD, RN, FAANDirector, Hartford Center of Geriatric Nursing

ExcellenceProfessor & Helen Bamberger Colby Endowed Chair

in Gerontologic NursingAssociate Dean for Research and PhD ProgramsUniversity of Utah College of NursingSalt Lake City

Therese Richmond, PhD, FAAN, CRNPAndrea B. Laporte Endowed Term Associate

Professor of NursingUniversity of Pennsylvania School of NursingPhiladelphia

Cass Piper Sandoval, MS, RN, CNS, CCRNClinical Nurse SpecialistCardiovascular Critical Care, University of California,

San Francisco Medical CenterSan Francisco

Franklin A. Shaffer, EdD, RN, FAANChief Executive OfficerCGFNS InternationalPhiladelphia

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ProgramSchool of NursingJohns Hopkins UniversityBaltimore, Md.

May L. Wykle, PhD, RN, FGSA, FAANMarvin E. and Ruth Durr Denekas ProfessorFrances Payne Bolton School of NursingCase Western Reserve UniversityCleveland, Ohio

Susan Wysocki, WHNP-BC, FAANPPresidentiWomansHealthWashington, DC

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Editorial mission: American Nurse Today is dedicated to integrating the art and science of nursing. It provides a voice for todays nurses in all specialties and practice settings. As the official journal ofthe American Nurses Association, it serves as an important and influential voice for nurses across thecountry. We are committed to delivering authoritative research translated into practical, evidence-basedinformation to keep nurses up-to-date on best practices, help them maximize patient outcomes,advance their careers, and enhance their professional and personal growth and fulfillment.

Editor-in-ChiefLillee Smith Gelinas, MSN, RN, FAAN

System Vice President and Chief Nursing OfficerClinical Excellence Services

CHRISTUS HealthIrving, Tex.

Editorial Advisory Board

American Nurse Today Best of the Best www.AmericanNurseToday.com

Edited, designed, & printed in the USA

www.AmericanNurseToday.com November 2014 American Nurse Today Best of the Best 1

FEATURES

4 Dispelling pain myths By Lora McGuire and Pam BolyanatzErroneous assumptions about pain run counter to evidence-based best practices for managing pain.

7 Beware of oversimplifying mealtime insulin dosing for hospital patients By Julie S. Lampe Insulin administration involves a complex decision-making process. Find out how to reduce the risk of adverse outcomes in hospital patients receiving this drug.

DEPARTMENTS

2 Alcohol screening and brief intervention: A clinical solution to a vital public health issue By Nancy E. Cheal, Lela McKnight-Eily, and Mary Kate Weber Alcohol screening and brief intervention is a fast, inexpensive technique that can lower the amount a person drinks by 25% per occasion.

RAPID RESPONSE

11 A swift, decisive response to GI bleeding By Ira Gene Reynolds A patients sudden nausea, coffee-ground emesis, low blood pressure, and fast heart rate triggerinterventions to staunch acute upper GI bleeding.

THE HUMAN SIDE OF PATIENT SAFETY

12 Managing our fears to improve patient outcomes By Susan Tocco and James DeFontesIf youre afraid to speak up when you see a colleague making a serious mistake, you probablywork in an environment where you feel psychologically unsafe.

16 Stop: A strategy for dealing with difficult conversations By Kathleen Pagana When the going gets tough, the tough can use this simple and effective four-step process to confront someone about a prickly topic.

18 What to do when someone pushes your buttons By Laura L. Barry and Maureen SiroisHaving your buttons pushed is uncomfortable but unavoidable. Learn how to embrace it by digging deeper to unearth unresolved wounds.

20 What you can learn from failure By Rose O. Sherman To bounce back from a failure, analyze why it happened and learn how to use it to help yourself and others.

Mind/Body/Spirit

Strictly Clinical

Practice Matters

Leading the Way

Career Sphere

November 2014 Special Edition www.AmericanNurseToday.com

Inside ANA

RISKY OR EXCESSIVE alcohol use is common, ex-pensive, and underrecognized as a significant publichealth problem. Its also not addressed adequately inhealthcare settings. At least 38 million U.S. adultsdrink too much. Drinking too much includes bingedrinking, high weekly alcohol consumption, and anydrinking by those under age 21 or pregnant women.Risky alcohol use cost the United States $224 billionin 2006. Its the third-leading preventable cause ofdeath, contributing to a wide range of negative healthand social consequences, including motor vehiclecrashes, intimate partner violence, and fetal alcoholspectrum disorders. Over time, it can result in seriousmedical conditions, such as hypertension, gastritis,liver disease, and various cancers. Despite alarmingstatistics and serious health and societal harms,healthcare providers dont routinely talk with theirpatients about alcohol use.

Understanding how much drinking is too much isnt widely understood by the public or healthcareproviders. Most people think that drinking too muchmeans that a person is an alcoholic or alcohol de-pendent. However, data show that only about 4% ofadults are alcohol dependent and another 25% arentdependent but drink in ways that put themselves andothers at risk of harm.

Definitions of excessive drinking in the UnitedStates are shown in the graphic below. Also important,consuming more than one drink a day for women ormore than two drinks a day for men has been shownto have negative health effects. In addition to pregnantwomen and those under the legal drinking age, anyconsumption is too much for individuals who are de-pendent on alcohol or unable to control the amount ofalcohol they drink. Furthermore, alcohol is contraindi-cated with many medications. Therefore, individuals

Issues up closeAlcohol screening and brief intervention: A clinical solution to a vital public health issueWhat is risky alcohol use and why is it important to health?

By Nancy E. Cheal, PhD, RN; Lela McKnight-Eily, PhD; and Mary Kate Weber, MPH

Inside ANA

Source: CDC. www.cdc.gov/vitalsigns/alcohol-screening-counseling/infographic.html

Drinking too much includes

2 American Nurse Today Best of the Best www.AmericanNurseToday.com

taking certain prescription drugs, those who havemedical conditions that can be made worse by alco-hol, and persons driving, planning to drive, or doingother activities that require skill, alertness, and coordi-nation should limit or abstain from alcohol use.

What can be done?Alcohol screening and brief intervention (SBI) is aneffective, quick, and inexpensive clinical preventiveservice that can reduce the amount a person drinksper occasion by 25%. The U.S. Preventive ServicesTask Force (USPSTF), multiple federal agencies, andother health organizations have recommended that al-cohol SBI be implemented for all adults in primaryhealthcare settings (including pregnant women) dueto strong evidence of its effectiveness. Furthermore,in 2011 the American Nurses Association released arevised position statement supporting nonpunitive al-cohol and drug treatment for pregnant and breast-feeding women and their exposed children.

What is alcohol screening and brief intervention?Alcohol SBI is a preventive service similar to hyper-tension or tobacco screening. It identifies and pro-vides help to patients who may be drinking toomuch. It includes: a validated set of screening questions to identify

patients drinking patterns. These can be adminis-tered orally or on a form. The USPSTF recom-mends the use of the Alcohol Use DisordersIdentification Test (AUDIT, U.S. version), the briefthree-question version of this measure called theAUDIT-C, or a single-question screener for heavydrinking days (such as, How many times in thepast year have you had five or more drinks in aday [for men] or four drinks [for women]?)

a short conversation with patients who drink toomuch. Generally, a conversation of 6 to 15 minutesis effective for a brief intervention. For the smallpercentage of patients who are alcohol dependent,a referral to treatment is provided as needed. Alcohol SBI can be integrated into a routine med-

ical visit. The four key steps to keep in mind whenperforming this service are the following:1. Ask the patient about his or her drinking using a

validated screening instrument. If the patient re-ports drinking more than the levels indicated in thegraphic or the cut-offs for the screening instrument,conduct a brief intervention as described below.

2. Talk with the patient, using plain language, aboutwhat he or she thinks is good and not so goodabout their drinking.

3. Provide options by asking the patient if he or shewants to stop drinking, cut down, seek help, orcontinue with the current drinking pattern. Based

on the results of this discussion, help the patientcome up with a plan.

4. Close on good terms, regardless of the patients re-sponse.

How can nurses intervene?Nurses are trusted healthcare providers and areuniquely positioned to provide and change practicein many settings. In fact, a number of studies reportthat nurses providing alcohol SBI have had excellentresults.

To actively promote implementation of alcoholSBI, nurses can: become familiar with levels of risky drinking understand and share with others how well alco-

hol SBI works learn how to conduct alcohol SBI with patients ef-

fectively champion and support the integration of alcohol

SBI into routine primary care.

Available resources A number of excellent resources are readily availableonline on how to conduct alcohol SBI. Two helpfulresources developed by the National Institute onAlcohol Abuse and Alcoholism include HelpingPatients Who Drink Too Much: A Clinicians Guideand a booklet and website called RethinkingDrinking (http://rethinkingdrinking.niaaa.nih.gov).

Although individual nurses or other healthcare pro-fessionals should conduct alcohol SBI, implementa-tion planning for their specific healthcare settings isneeded to make it routine. The Centers for DiseaseControl and Prevention have developed step-by-stepimplementation guides for alcohol SBI in trauma cen-ters and primary care settings. These guides help anindividual or small planning team adapt alcohol SBIinto their standard practice.

Risky alcohol use is a significant and costly publichealth problem that has not been addressed ade-quately despite the availability of effective interven-tions. Alcohol SBI works to reduce excessive alcoholuse in persons who drink. Nurses can champion theroutine implementation of alcohol SBI and deliver iteffectively in a variety of settings, helping adult pa-tients reduce excessive alcohol use and influencingclinical practice to effect population-level change. O

Visit www.AmericanNurseToday.com/Archives.aspx for a list of se-

lected references.

Nancy E. Cheal is a research health scientist, Lela McKnight-Eily is anepidemiologist, and Mary Kate Weber is a public health analyst at theCenters for Disease Control and Prevention in the National Center onBirth Defects and Developmental Disabilities, Fetal Alcohol SyndromePrevention Team.


UNLESS MANAGED aggressively,

acute pain (defined as pain lasting

a few seconds to about 3 months)

may progress to chronic or persist-

ent pain. This progression stems

from central sensitization (some-

times called wind-up syndrome),

in which increased sensitivity to

unrelieved pain makes neurons

more excitable, leading to central

nervous system changes.

Continuous stimulation of peripher-

al nerves activates group C nerve

fibers, causing a progressively in-

creasing electrical response and

hyperexcitability. This can result in

chronic pain syndrome.

As healthcare professionals, we

need to manage our patients acute

pain effectively to help prevent hos-

pital readmissions necessitated by

pain and to prevent chronic pain

syndrome. To do this, we need to

separate the facts about pain from

the myths. This article dispels pain

myths using actual cases (names

have been changed) and discusses

best practices for patients with pain.

Pain myth #1: Standardanalgesic dosages are effectivefor all postoperative patientsA 48-year-old female (well call her

Susan) is admitted for intractable

back pain. Her pain rating is 9 on

a 0-to-10 scale. Comorbidities in-

clude degenerative hip disease of

the right side and multiple sclerosis.

She has had more than 10 previous

surgeries and many episodes of un-

relieved pain. For 10 years, she took

up to six hydrocodone/aceta-

minophen tablets daily. She also has

an undiagnosed anxiety disorder.

When a magnetic resonance im-

aging (MRI) scan reveals a new disc

herniation at the site of a previous

laminectomy, the physician pre-

scribes conservative treatment, in-

cluding a lumbar epidural steroid

injection, oral steroids, I.V. opioids,

and physical therapy. Nonetheless,

Susans pain persists and grows

even worse.

The physician then recommends

a microdiscectomy. After the proce-

dure, Susans postoperative course

is managed via patient-controlled

analgesia (PCA) with hydromor-

phone I.V. 0.3 mg every 8 minutes,

with a 10-minute lockout for the

first 24 hours, until she can tolerate

oral fluids. Her pain rating on PCA

therapy is 3 on a 0-to-10 scale

(3/10), and shes reluctant to have

the PCA discontinued. However, she

begins to receive extended-release

oral morphine 30 mg every 12

hours. To reduce the amount of opi-

oids, the healthcare team initiates a

multimodal pain-management regi-

men, which includes the muscle re-

laxant baclofen 10 mg P.O. every

8 hours, two lidocaine (Lidoderm)

patches applied to intact skin (12

hours, 12 hours off), and the anxi-

olytic hydroxyzine 50 mg P.O. every

6 hours as needed.

As this case study shows, stan-

dard analgesic dosages may not be

effective in postoperative patients.

Susan had persistent (chronic) pain

for many years caused by multiple

sclerosis and degenerative hip dis-

ease. Although her persistent pain

previously had been fairly well

controlled, her healthcare team is

now challenged by her acute post-

operative pain. Her history of

chronic pain may necessitate high-

er-than-standard analgesic dosages

to control postoperative pain.

Although medication is the main-

stay of acute pain management,

nonpharmacologic options should

be tried as well to ease discomfort.

Before a nonpharmacologic method

begins, explain to the patient how

the technique works based on the

gate control theory of pain. This the-

ory proposes that all pain sensations

pass through a gating or control

mechanism in the dorsal horn of the

spinal cord. When more small nerve

fibers than large nerve fibers are

stimulated, the gate opens and pain

impulses travel to the brain, where

pain is perceived. Complementary

and alternative techniques (such as

relaxation and distraction) cause

stimulation of more large nerve

fibers, which is thought to cause the

gate to close. Taking the time to ex-

plain the rationale in simple lan-

guage shows patients you care and

want to ease their discomfort.

On day 3, Susan rates her pain

as 6/10 and experiences muscle

spasms in her paraspinal muscles.

Her muscle relaxant is changed to

tizanidine 4 mg P.O. every 8 hours

as needed. Multimodal therapy in-

cludes ice applied to the surgical

site for 20 minutes every 4 hours

and physical therapy assistive de-

vices (a grabber and a walker).

Susans pain is more challenging

to manage than many other patients,

partly because of her history of mul-

tiple surgeries, opioid tolerance, and

undiagnosed anxiety disorder.

Multimodal management allows

a decrease in Susans opioid dosage.

She tolerates tizanidine better than

baclofen, so shes now more able to

Read up on the latest evidence-based best practices in pain management.

By Lora McGuire, MS, RN, and Pam Bolyanatz, MS, APN, FNP-BC


participate in physical therapy. She

states, I was always so anxious

about my pain. Now my anxiety is

lessened, and I dont need anxiety

medication because my pain is con-

trolled. At discharge, she reports a

pain rating of 3/10 and thanks the

nursing staff for the high-quality

care they provided.

Pain myth #2: Older adultsshouldnt receive chronic opioidtherapy An 88-year-old female whos not a

native English speaker is brought to

the emergency department by her

husband. The electronic medical

record indicates that Pradnaya has

had multiple readmissions due to

compression fractures and pain.

During the intake process, she is

unable to rate her pain when the

nurse asks her to, but the nurse as-

sumes shes experiencing pain

based on her compression fractures

and her obvious moaning. When

moved to the table machine for an

MRI, Pradnaya just cries and

moans. Her husband reports she

stopped taking her prescribed hy-

drocodone/acetaminophen because

it caused constipation and she hat-

ed using it. He states, "We dont

want her to take it any more."

Medication refusal is common in

older adults. If patients keep refus-

ing pain medication, theyll begin

to decline due to physical dysfunc-

tion. If your patient refuses pain

medication, realize there may be

more to the story. Perhaps he or

she cant afford the medication,

doesnt understand how to take it,

or (like Pradnaya) cant tolerate the

side effects.

So what are best practices for a

patient like Pradnaya? To address

the language barrier, use an inter-

preter to interview her and find out

why she stopped taking her pain

medication. In Pradnayas case, the

interpreter confirmed that it was

constipation.

Through the interpreter,

Pradnaya and her husband receive

education on the purpose of pain

medication as well as treatment

and prevention of side effects. In the

hierarchy of pain assessment, self-

report is the gold standard. But with

a patient like Pradnaya whos un-

able to self-report, caregivers should

keep in mind that she has a patho-

logic condition that can be expected

to cause pain. The physician de-

cides to prescribe a 24-hour anal-

gesic trial of around-the-clock oxy-

codone 5 mg P.O. every 6 hours to

determine if it reduces her pain

and improves physical function.

Opioids arent contraindicated

for older adults, but they should be

started at a low dosage and titrated

upward slowly. Many older adults

have multiple comorbidities that can

result in more serious adverse ef-

fects. Prevention and treatment of

opioid-induced constipation is man-

aged mainly by the bedside nurse

and should begin when the opioid

is started. Nurses must be proactive

about bowel function in all patients

taking opioids. Patients dont build

a tolerance to this side effect, which

significantly affects overall health.

The nurse is able to find a pain

rating scale (0-10) in Pradnayas

native language. After 24 hours of

oxycodone therapy, Pradnaya rates

her pain as 2/10. To help prevent

constipation, the nurse starts her on

senna (a nonprescription laxative)

and docusate sodium (a nonpre-

scription stool softener) twice daily.

After several days, her constipation

resolves. On discharge, she rates her

pain as 3/10 with activity. She ver-

balizes to her husband that she will

adhere to the drug regimen.

The dangers of labeling patientsas drug seekingSome healthcare professionals may

label certain patients who come in

frequently as drug seeking. But

we need to ask ourselves how such

labeling advances the patients care.

Does it truly promote the nurses

role as patient advocate? When a

coworker refers to a patient this

way, do you stop and discuss the

problems that can result from pa-

tient labelingor do you bypass

the discussion because youre busy

and wish to avoid whats likely to

be an uncomfortable conversation?

Addressing patient labeling and

misconceptions is crucial to provid-

ing the best possible care.

Because were human, we may

find it hard to care for challenging

patients. If you find yourself not be-

lieving or trusting a patient, speak

with your manager. Consider asking

that the patients care be transferred

to another nurse for that shift; al-

though not an ideal solution, this

gives the patient a better chance of

getting the best care possible. Then

further reflect on why you dont be-

lieve or trust the patient, and think

about how you can resolve your

feelings in the future. Your manager

should be happy to support you.

Best practices in painmanagementWhen appropriate, healthcare

givers should use multimodal ap-

Common nonopioid drugs used for acute painAcetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to

relieve acute pain. Acetaminophen injection (Ofirmev) typically is given as 1,000

mg by I.V. piggyback every 6 hours for 24 hours. It may be administered for another

24 hours in patients on nothing-by-mouth status.

Ketorolac, an NSAID, usually is given as 30 mg by slow I.V. push every 6 hours.

For patients older than age 65 and those with diminished renal clearance or func-

tion (creatinine clearance below 30 mL/minute), give 15 mg instead. Dont adminis-

ter this drug longer than 5 days.

Caldolor (ibuprofen in water for injection) is a newer parenteral NSAID com-

monly given as 400 to 800 mg by I.V. piggyback for 30 minutes every 6 hours.



proaches to pain management.Multimodal analgesia combines dif-ferent classes of medications thatfight pain through different mecha-nisms, which can make pain man-agement more effective. Some med-ications add analgesic effects;others work synergistically. The pa-tient can receive lower dosages ofeach medication and experiencefewer adverse effects.

Pharmacologic management ofacute pain may include: opioids nonopioid drugs, such as I.V. or

oral acetaminophen, I.V. ketoro-lac, or oral nonsteroidal anti-in-flammatory drugs (NSAIDs)

adjuvants, such as muscle relax-ants, anticonvulsants, and anti an -xiety agents. (See Common nono-pioid drugs used for acute pain.) Commonly used opioids include

morphine, hydromorphone, andfentanyl. Oral or I.V. administration(or both) are recommended.Codeine isnt recommended be-cause of genetic variances in howthis drug is metabolized and ab-sorbed. Several pharmaceuticalcompanies are working to developtests or markers that allow health-care professionals to identify themost effective analgesics for indi-vidual patients. (See Common opi-oids used for acute pain.)

Here are some other best prac-tices for pain management: Advocate for pain management

for all patients. Assess pain regularly using an

appropriate pain scale. Make pain visible in the hospi-

tal setting. For instance, advocatefor a hospital-wide campaign sopatients, families, and visitors cansee that pain control is a priority.

Avoid labeling and judging pa-tients.

Ask the patient, Is there any-thing we can do to make youmore comfortable?"

Treat pain early instead of wait-ing for it to become more severe.

Consider the patients age, cul-ture, religion, and socioeconomicstatus when developing a pain-management plan.

Assume pain is present. To eval-uate analgesic effectiveness, usea 24- to 48-hour around-the-clock analgesic trial for patientswith obvious pain.

Beware of the risk of acetamino-phen toxicity. Keep the total dai-ly dosage below 4,000 mgevenlower for older adults.

Give the lowest dosages ofNSAIDs possible for the shortestduration to avoid complications,such as peptic ulcers, GI bleed-ing, and cardiovascular disease.

Assist prescribers in choosing anappropriate analgesic for yourpatients pain levelfor example,nonopioids or tramadol for mildpain; oxycodone or hydro codonefor moderate pain; or morphine,oxycodone, hydromorphone, orfentanyl for severe pain.

If possible, give only one opi-oidpreferably a long-acting

opioid and a short-acting formu-lation of the same opioid (if oneis available). This will simplifythe regimen.

Administer adjuvant analgesics,such as anticonvulsants, musclerelaxants, and antispasmodics, asappropriate.

Use nonpharmacologic interven-tions as needed to enhance painrelief.

Regularly evaluate the effectivenessof the pain-management plan.

Nurses role

According to Ann Schreier, pastpresident of the American Societyfor Pain Management Nursing,Every nurse is a pain-managementnurse. In acute-care settings, nurs-es should empower and educatepatients and families about painand its management. Make painmanagement be a high priority.Urge your organizations leaders to make pain more visibleforinstance, with appropriate signs,whiteboards, TV monitors, andhandouts of the Pain Care Bill ofRights (from the American PainFoundation). Many hospitals havecreated pain-awareness campaignsthat feature pain teams and pain-resource nurse programs.

Our messaging should incorpo-rate appropriate and positive com-munications, such as What can wedo to make you more comfortable?As nurses, we know never to prom-ise patients that a medication orother treatment will take away allof their pain. But if we can treatpain before it gets severe, helpmake it more tolerable, and in-crease patient functioning, weregiving the best care we can. O

Visit www.AmericanNurseToday.com/Archives/

aspx for another case study illustrating a pain

myth, nonpharmacologic pain-management

options, and a list of selected references.

Lora McGuire is a clinical educator at Presence St.

Joseph Medical Center in Joliet, Illinois. Pam Bolyanatz

is an inpatient pain-management nurse practitioner

at Cadence Health Delnor Hospital in Geneva, Illinois.

Common opioids used for acute painMorphine, the gold standard, is hydrophilic. (Hydrophilic agents are absorbed more

slowly than lipophilic agents and take longer to cross the blood-brain barrier.) A

10-mg intramuscular dose is equianalgesic to a 30-mg oral dose. It can be given by

any route. Dont break or crush sustained-release formulations; instruct the patient

not to chew them.

Hydromorphone, also hydrophilic, is 80 times more potent than morphine.

A 1.5-mg intramuscular dose is equianalgesic to an oral dose of 7.5 mg. A long-

acting, once-daily hydromorphone formulation is now available.

Fentanyl is 100 times more potent than morphine. Lipophilic, its prescribed in

micrograms, not milligrams, and can be given by various routes. The transdermal

patch is used for chronic pain only.

Learn how to

make clinical

decisions more

confidently for

patients on

insulin.

By Julie S. Lampe, MSN, CNS, CNS-BC,

ADM-BC

ITS LUNCHTIME. Three of yourpatients are scheduled to receiverapid-acting insulin in addition tosliding-scale insulin. Mr. Jones, age 87, has type 2 di-

abetes. His blood glucose levelis 223 mg/dL. Hes on a clear diet.

Mrs. Smith, age 63, has type 1diabetes, a serum creatinine lev-el of 1.6 mg/dL, an inconsistentappetite, and widely varyingblood glucose levels. Her cur-rent blood glucose level is 105mg/dL.

Mr. Brown, age 58, has pneumo-nia, type 2 diabetes, and obesity;hes receiving corticosteroids. Heeats everything on his tray andasks for snacks. His lunchtimeblood glucose level is 152mg/dL. By the time youre ableto administer his insulin, he haseaten half his lunch tray.Which patient should receive in-

sulin as scheduled? Should any ofthem not receive it? Should any re-ceive scheduled insulin plus thesliding-scale dose? What shouldyou do if one of them has a nor-mal blood glucose level? Are any atrisk for hypoglycemia? What couldhappen if they eat before you canadminister insulin?

These are questions you mightask yourself every day but rarelyhave the time or resources to getthe answer. Yet to make safe clini-cal decisions, you need the re-quired knowledge base, becauseinsulin is strongly linked to med-

Beware of oversimplifyingmealtime insulin dosing

for hospitalpatients



ication errors and adverse drug

events (ADEs). The American

Hospital Association deems coordi-

nation of meals and insulin a top

priority for reducing in-hospital

ADEs.

The variety of insulin types and

their wide-ranging pharmacokinetic

properties further complicate in-

sulin use in the hospital. Whats

more, much variation exists in the

insulin regimens used to meet

blood glucose goals recommended

by regulatory bodies and profes-

sional organizations, such as The

Joint Commission and the

American Diabetes Association.

Basal-prandial insulin therapy One insulin regimen involves

basal-prandial insulin therapy. This

therapy became popular after pub-

lication of the RABBIT 2 trial in

2007, which compared stand-alone,

sliding-scale insulin therapy with a

basal-prandial insulin regimen. It

found that the latter decreased

mortality and complications with-

out significantly increasing hypo-

glycemia occurrences.

Basal-prandial insulin therapy

has three components:

long-acting insulin given once or

twice daily

rapid-acting insulin given in pre-

scribed doses with meals

correction insulin given with

meals and at bedtime. (See

Comparing short- and rapid-act-

ing insulin.)

Basal-prandial regimens may in-

volve more insulin than youre

used to giving with traditional slid-

ing-scale and stand-alone regi-

mens. This may make you hesitate,

particularly at mealtimes, when

you may be giving higher doses of

rapid-acting insulin. A clear under-

standing of the pharmacologic

principles of basal-prandial insulin

and how its prescribed will boost

your confidence.

Unlike traditional sliding-scale

regimens, which are reactive, basal-

prandial regimens address the pa-

tients insulin requirements proac-

tively. With these regimens, dosages

are calculated based on the pa-

tients weight and estimated in-

sulin sensitivity. Defined as the

patients expected response to

1 unit of insulin, insulin sensitivity

can vary widely among patients

and depends on several factors.

For instance, patients with renal

failure, advanced age, and type 1

diabetes tend to be more insulin-

sensitive. In contrast, those with

obesity, type 2 diabetes, or infec-

tions and those receiving steroids

tend to be more insulin-resistant.

Once the patients insulin sensi-

tivity is determined, a sensitivity

factor is selected and multiplied by

the patients weight in kg; the re-

sult is the total daily dosage of in-

sulin. Half of the total dosage is

given as basal insulin and the re-

mainder is divided by three and

given with meals. (See Calculating

basal-prandial insulin.)

Each part of the basal-bolus reg-

imen serves a specific purpose:

Long-acting insulin meets basal

This chart shows how to calculate total daily insulin doses, basal insulin doses, and prandial insulin doses for the three fictitious pa-

tients discussed in the article. Calculations for each patient are based on weight, insulin sensitivity factor, and pertinent comorbid

medical conditions.

Insulin Total Basal Prandialsensitivity daily insulin insulin

Patient Weight factor dose doses doses

Mr. Jones 191.8 lb (87 kg) 0.4 units/kg/day 35 units/day 18 units/day 6 units t.i.d. with meals

Mrs. Smith 119 lb (54 kg) 0.3 units/kg/day 16 units/day 8 units/day 2 units t.i.d. with meals

Mr. Brown 231 lb (105 kg) 0.5 units/kg/day 53 units/day 26 units/day 9 units t.i.d. with meals

Calculating basal-prandial insulin

This table summarizes the pharmacokinetics of rapid-acting insulin and regular insulin.

Insulin type Names Onset of action Peak effect Duration of action

Rapid-acting analog insulin Insulin aspart 5 to 15 minutes 1 to 2 hours 3 to 4 hours

Insulin glulisine

Insulin lispro

Short-acting insulin Regular insulin 30 to 45 minutes 2 to 4 hours 5 to 7 hours

Human insulin

Comparing short- and rapid-acting insulin


insulin requirements and is de-signed to match the livers con-tinuous glucose output.

The prandial rapid-acting insulincomponent covers the carbohy-drate bolus that the patient eatsat each meal.

The correction coverage ad-dresses blood glucose levels out-side the target range and isdosed on a sliding scale basedon blood glucose levels. (SeeGeneric correctional insulin

scale.)

Mealtime insulin and foodintakeMealtime boluses of rapid-actinginsulin should be given with 30 to60 g of carbohydrates. But few pa-tients count carbohydrates in thehospital. So how do you knowhow much carbohydrate a patientconsumes? Typically, hospital pa-tients on a diabetic diet receive1,800 calories per day. On an1,800-calorie diet tray, the carbohy-drate portion of one meal is about60 to 75 g. That means the patientmust eat about 50% of the trayconsistently to receive the pre-scribed prandial boluses. A patientlike Mrs. Smith, with an inconsis-tent appetite, normal blood glucoselevel, and poor renal function,needs to be evaluated at each mealto determine how much insulin togive. If she eats a full meal, youmay administer a full prandialdose; if she eats less than 50% of

her meal, call the physician forclarification. Ideally, patients likeher should have standing orders onhow to proceed when they eat lessthan 50% of a meal (if such ordersarent part of the facilitys basal-bolus order set). You might suggestthat the physician address the vari-able prandial doses by writing astanding order to cover futuremeals so you dont have to callhim or her.

If you administer insulin to pa-tients receiving basal-prandial in-sulin, consider the type of diettheyre on. Here are some examples: Patients receiving nothing by

mouth (NPO) shouldnt receiveprandial boluses.

Those on clear liquid diets dontconsume enough carbohydrateto warrant prandial insulin ad-ministration. Typically, theyreon these diets to rest the guttherapeuticallyfor instance, be-cause of a poor appetite or nu-tritional absorption problems.If your patient is NPO or on a

clear liquid diet and has an orderfor prandial insulin boluses, clarifythe order with the attending physi-cian. Take, for instance, Mr. Jonesthe 87-year-old on a clear liquid di-et whose blood glucose level is 223mg/dL. He needs insulin to reducehis blood glucose to a normal levelto avoid further hyperglycemia, but not so much insulin that hypo-glycemia occurs. So you need towithhold prandial insulin. Call the

attending physician to clarify thecorrectional insulin dose.

Mealtime blood glucose levelsand insulin administrationAlthough youll need to assess nu-tritional intake at each meal formealtime boluses, you should givecorrectional insulin as indicated re-gardless of diet type, appetite, andoverall intake. Correctional insulinaims to correct the blood glucoselevel based on the premeal glucoselevel. Ideally, measure blood glu-cose as close to mealtime and in-sulin administration as possible.This helps ensure that the insulindose you give is appropriate forthe patients current blood glucoselevel to prevent over- or underdos-ing, which could lead to hyper- orhypo glycemia.

You may be concerned (legiti-mately so) about giving insulinwhen a patient is NPO. Many hos-pitals have adopted NPO correctionscales. Typically, these scales pro-vide reduced insulin coverage andbegin covering blood glucose at amuch higher level. This level de-pends on target blood glucosegoals set by the hospital. If yourhospital doesnt have an NPO slid-ing scale, review the patientsblood glucose levels with the at-tending physician to determine ifhe or she should receive insulinwhile NPO.

Although you may feel comfort-able giving insulin when the pa-tients blood glucose level is elevat-ed, you may have concerns aboutgiving scheduled insulin doseswhen the glucose level is normal.Rememberthe purpose of prandi-al insulin is to cover the carbohy-drate consumed in a meal, so youshould give prandial insulin bolus-es even if the blood glucose levelis 70 to 140 mg/dL, as with Mrs.Smith. Because she has type 1 dia-betes and doesnt produce insulin,she must receive exogenous insulineven when her blood glucose levelis normal to avoid diabetic ketoaci-

This table shows a typical correctional insulin scale for patients with moderate in-

sulin resistance.

Blood glucose level (mg/dL) Correctional insulin

< 70 Intervene according to hypoglycemia

protocol and notify physician.

71 to 199 0 units

200 to 249 4 units

250 to 299 6 units

300 to 349 8 units

> 350 10 units; call physician.

Generic correctional insulin scale


dosis. But if a patient has a bloodglucose level below 70 mg/dL,treat the blood glucose accordingto your hospitals hypoglycemiaprotocol and notify the attendingphysician. As part of the hypo-glycemia notification process, re-view all premeal blood glucoselevels and scheduled prandial in-sulin doses.

Coordinating meals and insulinCoordinating insulin administrationwith meals can be a daunting task.Mealtimes are often the busiesttimes of a nurses day. You mayhave other medications to give andother tasks to do. But timing in-sulin administration with the firstbite of food can reduce the risk ofperiprandial hypoglycemia andsubsequent blood glucose variabili-ty. To avoid variability, administermealtime boluses within 15 min-utes before or after the first bite.

Prandial insulin doses are givenas rapid-acting insulin. To under-stand the rationale for the adminis-tration times, you must be familiarwith the pharmacokinetics of rapid-acting insulin. Its an analog in-sulin, meaning its chemically engi-neered to be absorbed morerapidly in the subcutaneous tissueand behave more like endogenousinsulin than regular insulin. Whenwe eat, our bodies begin produc-ing insulin within 5 to 15 minutesof the first bite. Within 1 to 2hours, endogenous insulin andpostprandial glucose reach peakconcentrations; within 3 to 4 hours,they return to baseline. Similarly,rapid-acting insulin has an onset of5 to 15 minutes, a peak time of 1to 2 hours, and a duration of 3 to 4hours. You must give it within 5 to15 minutes of the first bite tomatch the peak postprandial bloodglucose level.

An advantage of rapid-acting in-sulin over regular insulin as amealtime insulin is that it can begiven before or after the first bite.This offers some scheduling flexi-

bility and the ability to assess howmuch the patient eats before givinginsulin. In Mr. Browns case, he haseaten part of his meal before youarrive with his insulin dose. Somenurses may be tempted to withholdhis insulin for fear of inducing hy-poglycemia, but withholding thisdose would put Mr. Brown in dan-ger of hyperglycemia. Rapid-actinginsulin analogs can be given safelyup to 15 minutes after the first bite,avoiding hypoglycemia.

You may not always know howa patient will respond to a giveninsulin dose, as with patients whohave poor renal function or com-plex diabetes states (brittle dia-betes). This can be challenging atmealtimes, when many factors de-termine patient response, includingthe insulin type, purpose of insulin,current blood glucose level, diseasestate, renal function, and nutritionalstatus.

Answers to the questions youmay have about giving insulin atmealtimes may not always bestraightforward. Mrs. Smith, for in-stance, has a long history of type 1diabetes and a serum creatininelevel of 1.6 mg/dL. Because of her

poor nutritional status, impaired re-nal function, and diabetes state,her blood glucose response to in-sulin is less predictable. She needsclose evaluation for each mealtimeinsulin dose. If you think a dosemay need to be omitted orchanged, consider all relevant fac-tors to determine the proper courseof action, and make recommenda-tions to the attending physician.

Dont take insulin therapy forgrantedSome nurses may take insulin ad-ministration for granted becausethey perform it every day. Butoversimplifying this task can putpatients at risk for adverse out-comes, such as hyper- or hypo-glycemia. Insulin administration in-volves a complex decision-makingprocess, and clinicians need to col-lect and evaluate a great deal ofdata to reduce the risk of adverseoutcomes. By considering all rele-vant patient data, you can reducethe likelihood of an insulin-relatedadverse outcome. O

Selected referencesAmerican Diabetes Association. Standards of

medical care in diabetes2013. Diabetes

Care. 2013;36 Suppl 1:S11-66.

Cobry E, McFann K, Messer L, et al. Timing

of meal insulin boluses to achieve optimal

postprandial glycemic control in patients

with type 1 diabetes. Diabetes Technol Ther.

2010;12(3):173-7.

Freeland B, Penprase BB, Anthony M.

Nursing practice patterns: timing of insulin

administration and glucose monitoring in

the hospital. Diabetes Educ. 2011;37(3):357-

62.

Freeman JS. Insulin analog therapy: improv-

ing the match with physiologic insulin secre-

tion. J Am Osteopath Assoc. 2009:109(1):26-36.

Umpierrez GE, Smiley D, Zisman A, et al.

Randomized study of basal-bolus insulin

therapy in the inpatient management of pa-

tients with type 2 diabetes (RABBIT 2 Trial).

Diabetes Care. 2007;30(9):2181-6.

Julie S. Lampe is a diabetes clinical nurse specialist

at the Orlando Regional Medical Center, Orlando

Health, in Orlando, Florida. (Names in scenarios are

fictitious.)

Timing insulinadministration with

the first bite of food can

reduce the risk of

periprandial hypoglycemia

and subsequent blood

glucose variability.


RAP ID RESPONSE

A swift, decisive response to GI bleeding

Coffee-ground emesis tips off caregivers to acute upper GI bleeding.

By Ira Gene Reynolds, MSN, RN

Strictly Clinical

DAVID SANDERSON, age 63, is admitted to the or-thopedic unit after surgical repair of a compoundfracture of the right radius. His medical history in-cludes cholecystectomy and depression. Currentmedications are paroxetine and occasional aceta-minophen for headache. Before surgery, he re-ceived I.V. hydromorphone and ketorolac to reduceinflammation and help control pain. He also re-ceived 1 G cefazolin I.V.

After surgery, he continues on I.V. antibiotics andis started on I.V. morphine or oral acetaminophen/oxycodone (Percocet), plus I.V. ketorolac for paincontrol. He continues to receive paroxetine.

History and assessment hints On the third day after surgery, as he is about to be dis-charged, Mr. Sanderson suddenly becomes lightheaded,dizzy, and nauseated while getting dressed. He vomits amoderate amount of coffee-ground emesis. You find himlying on the bed, pale, lightheaded, and somewhat dis-oriented. His vital signs are blood pressure 68/32 mmHg, heart rate 136 beats/minute (bpm), respiratory rate24 breaths/minute, and oxygen (O2) saturation 93%.

While you call the rapid response team (RRT) and thephysician, the charge nurse administers 2 L oxygen vianasal cannula and starts an 18G I.V. line. Then you hanga bag of normal saline solution. Mr. Sanderson vomits alarge amount of emesis; this time, it includes frank blood.

On the sceneThe RRT arrives, starts another I.V. line, hangs anotherbag of normal saline solution, and orders a completeblood count and chemistry panel. Now Mr. Sandersonsvital signs are blood pressure 82/44 mm Hg, heart rate124 bpm, respiratory rate 20 breaths/minute, and O2saturation 96%. He seems more alert. You continue tomonitor for signs and symptoms of worsening GI bleed-ing, such as another drop in blood pressure, an in-creased heart rate, and loss of consciousness.

The physician orders a liver panel and coagulationstudies, a 1-L bolus of normal saline solution followed bya continuous infusion at 150 mL/hour, one dose each ofondansetron and pantoprozole I.V., and a nasogastric tube

to avoid aspiration from recurrent nausea and vomiting.

OutcomeYou prepare Mr. Sanderson for an emergency endo -scopy to assess the extent of his GI bleeding. Endo -scopy reveals a small bleeding ulcer near the duode-num. The physician obtains a biopsy and cauterizesthe bleeding; the patient recovers in the endoscopylab before returning to the nursing unit. He is moni-tored for additional bleeding for several days and isbeing considered for discharge.

Education and follow-upAcute upper GI bleeding requires quick intervention. The most common signs and symptoms are hematemesis(vomiting of blood or coffee-ground-like material), andmelena (black, tarry stools). In contrast, lower GI tractbleeding is more closely associated with hematochezia(red or maroon blood in the stool). Depending onbleeding extent and severity, the patient may have eithera significant blood pressure reduction and increasedheart rate, or just minor alterations in these vital signs.

Causes of GI bleeding vary and generally are classifiedby anatomic and pathophysiologic factors. More com-mon classifications include bleeds from ulcerations orerosion, portal hypertension, vascular malformations,trauma or surgery, and tumors.

A wide range of drugs can cause ulcers and erosionof the stomach lining, leading to GI bleeding. Usingcertain concurrent medications increases the risk of GIbleeding, too. The combination of ketorolac and parox-etine increased Mr. Sanderson's risk.

Patients who have a GI bleed stand a higher chance ofrecurrence. Before discharge, you teach Mr. Sandersonhow to recognize signs and symptoms of GI bleeding andwhat to do if these occur. You advise him to be aware thathis antidepressant medication combined with certain otherdrugs can raise his risk. You stress the importance of shar-ing his drug information with all healthcare professionals.O

Visit www.AmericanNurseToday.com/Archives.aspx for a list of select-ed references.

Ira Gene Reynolds is a staff nurse on the medical/oncology unit at Utah ValleyRegional Medical Center in Provo.


AN ESSENTIAL ELEMENT of professional practice,nurse advocacy for patient safety is embedded in the

American Nurses Associations Code of Ethics. Yet evi-

dence suggests nurses and other healthcare profession-

als dont always speak up with their patient-safety

concerns. In 2005, the Silent Treatment Study involving

1,700 nurses, physicians, and other healthcare profes-

sionals found that 84% observed fellow clinicians take

dangerous shortcuts but fewer than 10% confronted

these individuals about their actions.

Why are so few of us willing to speak up on our pa-

tients behalf? Amy C. Edmonson, a social psy-

chologist and professor of leadership and

management at Harvard, studied the

fears of people working in groups.

From her observations in health

care and other industries, she

found employees believe oth-

ers in the workplace are

constantly evaluating them.

For workers in all settings,

protecting ones image is

important. The added

stress of maintaining

ones image while un-

der a perceived micro-

scope of scrutiny at

work is the main rea-

son clinicians dont

speak up; they feel its

not safe to do so.

Edmonson uses the

term psychological safe-

ty to describe an indi-

viduals perception that

the practice environ-

ment is conducive to tak-

ing a potentially image-

threatening risk. In

psychologically safe environ-

ments, healthcare professionals be-

lieve they wont suffer adverse conse-

quences if they report a mistake or ask

for help, education, or feedback. In environ-

ments that lack psychological safety, on the other hand,

workers tend to keep their concerns to themselves.

Fears that promote silenceEdmonson identified four distinct fears that promote

silencefear of being perceived as ignorant, incompe-

tent, negative, or disruptive. Lets examine how each

of these fears can affect patient safety.

Fear of being perceived as ignorant

Fear of being perceived as ignorant makes a per-

son less inclined to ask questions. For in-

stance, a nurse who floats to a different

unit may lack recent experience accessing

central venous catheters. Shes afraid to

ask for assistance because she thinks

nurses on the unit will

look down on her for

not understanding

this seemingly ba-

sic skill. So she ac-

cesses a patients

catheter on her

own and unknowingly

violates sterile technique.

As a result, the patient devel-

ops a bloodstream infection.

Fear of being viewed as

incompetent

Fear of being viewed as incompetent

makes a person less likely to report

a mistake or near-miss. Suppose a

nurse narrowly avoids giving a medica-

tion to the wrong patient because she is

distracted by a phone call from the lab.

She fails to report this near-miss because

she fears her manager and peers will think

shes incompetent.

Failing to report events and near-misses is par-

ticularly harmful because it prevents organizational

learning. Learning from this event could have led

to systematic changes to limit nurse distractions during

Managing our fears toimprove patient safety By Susan Tocco, MSN, CNS, CNRN, CCNS, and James DeFontes, MD

Practice Matters

Leaders must develop a structured

process for team learning and

communication.

THE HUMAN S I DE OF PAT I ENT SAFETY


medication administration, which

might prevent future medication er-

rors from harming patients.

Fear of being seen as negative

Fear of being seen as negative can

stop someone from giving accurate

individual and team performance ap-

praisals. Say, for example, a nurse

manager conducts a meeting with her

staff. She reports that two patient

falls occurred in the past week, and

she seeks feedback from the team on

how these falls could have been pre-

vented. One of the units newer nurs-

es witnessed significant delays in an-

swering patient call bells but was

afraid to speak up because she

feared the team would think shes

negative. If she had spoken up,

strategies to improve call-bell respon-

siveness could have been addressed,

helping to prevent future falls.

Fear of being seen as disruptive

During a time-out in the operating

room, a nurse isnt sure if the pa-

tients correct hip was marked for

surgery. She considers speaking up,

but the orthopedic surgeon is run-

ning behind and has encouraged

everyone to be as efficient as possi-

ble so he can finish all of his cases

before his sons soccer game starts.

The nurse keeps her concern to her-

self, fearing shell be seen as disrup-

tive if she speaks up. If she had spoken up, the pa-

tient could have avoided wrong-site surgery.

Communication failure: A leading cause of patientharmOverwhelming evidence points to communication fail-

ure as a leading cause of patient harm. To address the

communication problem, a foundation of psychologi-

cal safety must be achieved. Laying this foundation re-

quires a deliberate process on the part of team mem-

bers at all levels of the organization.

Transforming power-based relationshipsPresence of someone with higher status in the organi-

zation intensifies the perceived risks of speaking up.

Team leaders are responsible for transforming these

power-based relationships and flattening the hierarchy.

To influence psychological safety in a positive way,

leaders must make sure theyre directly accessible to

the team. Traditional access barriers, including the

need to go through assistants or residents, should be

removed. This increases the likelihood of team mem-

bers approaching the leader with questions or con-

cerns and speaking up immediately as patient-care

issues arise.

When confronted with questions or disclosure of

mistakes or errors, the leader must make a conscious

effort to treat team members with respect to reinforce

their willingness to share information. She must clearly

convey shes receptive to hearing bad news. Also, she

can acknowledge her own humanness by telling her

team she needs them to speak up because she knows

she may overlook certain things. She can seek feed-

back directly from team members at all levels to show

she wants their input.

When encouraging participation, the leader must es-

pecially encourage junior or lower-status team mem-

bers to speak up, as by asking junior team members

Structured processes used in healthcare settingsBriefings, debriefings, and time-outs promote communication and feedback in

healthcare settings.

Surgical settings

Before a briefing in the operating room, the first names and roles of each team

member should be written on a whiteboard. During the briefing, the surgeon dis-

cusses critical steps and problems that may be encountered, asks team members

how theyd respond to a specific problem should it occur, and encourages them

to voice concerns they may have during the case. The anesthesiologist discusses

relevant patient comorbidities, availability of and potential need for blood prod-

ucts, and interventions to prevent complications. Nursing staff discuss relevant is-

sues, such as sterility, availability of instruments, need for special equipment, and

a plan for breaks. During the time-out, critical information about patient identifi-

cation, surgical site, procedure, antibiotic selection and timing, and display of

necessary imaging is reviewed.

After the procedure, debriefing includes verifying equipment counts, speci-

men labeling, and equipment issues that need to be addressed. The team re-

views key concerns for the patients continued care and discusses what went

well, any challenges that arose, and what should be done differently the next

time as a result of learning from this case. The World Health Organizations Surgical

Safety Checklist includes essential elements of surgical briefings, time-outs, and

debriefings. (Visit www.who.int/patientsafety/safesurgery/tools_resources/

SSSL_Checklist_finalJun08.pdf?ua=1.)

Nursing units

On the nursing unit, a briefing should occur at the start of the shift. Any new or

float team members are introduced and welcomed. Patients at risk for instabili-

ty are discussed. Patients at high risk for falls and pressure ulcers are reviewed,

and the team discusses the plan for toileting and ensuring skin integrity. The

charge nurse or nurse manager encourages the team to ask questions and report

problems or near-misses immediately.

At the end of the shift, the debriefing includes discussion of the high points of

the day as well as challenges that arose (such as falls, medication errors, patient

transfers to higher levels of care, and near-miss events). Finally, the team discuss-

es changes that need to be made based on learning from the shift.


for their input and calling on them

before calling on senior team mem-

bers. In addition, she must manage

overpowering behaviors of higher-sta-

tus team members. Leaders must not

tolerate inappropriate, demeaning,

bullying, or disruptive behaviors by

any team member.

Structured processes for learningand communicationTo succeed in creating a psychologi-

cally safe practice environment,

healthcare leaders must develop

structured processes for team learn-

ing and communication. The healthcare industry has

taken particular notice of airline safety improvements

over the last few decades. The Commercial Aviation

Safety Team was founded in the late 1990s in re-

sponse to multiple serious events; 10 years later, the

rate of commercial air travel fatalities had dropped

83%. Like the healthcare industry,

airlines have highly skilled employ-

ees who must function effectively as

team members to ensure safe per-

formance. Structured, open commu-

nication is a key driver of this safety

improvement.

In health care, the main purpose

of promoting open communication

and feedback is to generate learning

to improve the safety and quality of

patient care. The leader must create

a structure to support this process.

One such structure involves briefings

and debriefings. Briefings have been

used successfully in many high-risk

industries, including aviation, to

unite the team in a shared frame-

work or mental model for perform-

ance. The groups task defines the nature of the brief-

ings and debriefings. (See Structured processes used

in healthcare settings.)

Providing a common structure for

communication

For teams to communicate safely and effectively within

structured processes, a common communication style

and common assertion techniques must be established.

Nurses and physicians are taught to communicate in

markedly different ways, which can cause or contribute

to reluctance to speak up about safety concerns.

Physicians are taught to be concise and get to the point

quickly. Nurses, on the other hand, are reminded dur-

ing their educational process that they cant make diag-

noses; this message can make them insecure about pre-

senting their assessment results, causing them to paint

a broad picture of the patients condition when com-

municating with physicians. The physician on the re-

ceiving end of this lengthy message becomes impatient,

waiting for the nurse to just ask for what she wants.

The SBAR (Situation, Background,

Assessment, Recommendation) tool

can provide a common structure for

communication. When SBAR is used

as intended, the nurse is asked to sug-

gest a diagnosis and ask for a specific

treatment or action from the physi-

cian. But many nurses are uncomfort-

able doing this and havent been

taught to think and communicate

within this structure. Role-playing and

practice with case studies can make

them more comfortable. Faculty at

some nursing schools already are

working to embed this communication

style in the new generation of nurses.

Because of the entrenched health-

care hierarchy, nurses tend to com-

municate deferentially and indirectly

when they speak up about patient-safety concerns.

How can leaders pave the way for team members to

assert their concerns effectively? One organization has

empowered nurses to bypass SBAR in critical obstetric

situations simply by stating, I need you to come now

and evaluate this patient. Physicians understand

theyre accountable for responding promptly every

time. Another example of mutually agreed-upon criti-

cal language derives from United Airlines safety pro-

gram, called CUSan acronym for Im Concerned, Im

Uncomfortable, This is unSafe.

For critical language to be effective, leaders must

ensure all team members understand it, grasp its in-

tent, and adopt a culture that enables immediate ac-

tions to address patient-safety concerns when this

How staff nurses can promote psychological safetyLeaders arent the only team members responsible for creating a psychologi-

cally safe environment. Every nurse is accountable for promoting a safe envi-

ronment, regardless of his or her role.

Psychological threats can occur in both the horizontal and vertical hier -

archies of teams. Reflect on your personal experience with other nurses:

How comfortable were you speaking up as a student nurse? A graduate

nurse? A float nurse?

Have you witnessed colleagues belittle fellow nurses, clinical technicians,

or residents? Did you intervene when you witnessed such behavior?

Do patients and their families feel its safe to ask questions of you and your

nurse colleagues? How do you respond to their assertive questions?

Nurses and physicians are taught to

communicate inmarkedly different ways,

which can cause or

contribute to reluctance

to speak up aboutsafety concerns.


language is used. (See How staff nurses can promotepsychological safety.)

Implementing new communication modelsImplementing these new communication models can bechallenging. Formalized education addressing effectivecommunication has been lacking. Many clinicians lackthe skills they need to engage in crucial conversationsin their personal livesyet we expect them to draw onsuch skills when patient safety is at stake.

Other factorsgender, age, race, religion, culture,tenure, education, and cliquesalso can threaten teamcommunication. Leaders must have robust administra-tive support to ensure the success of this new commu-nication framework. Organizational development teamscan be crucial in creating classes and promoting role-play and other creative interactive learning strategiesto help launch new communication models.

Emerging from the cloak of silenceIn a broad sense, all healthcare professionals report tothe patient. If we were all players on a basketballteam and our communication and teamwork werepoor, wed lose games and our coach would be fired.When we exhibit similar shortcomings in our health-care teams, the patient suffers harm. Embracing this

shared mental model of accountability to the patient isthe first step in laying the foundation for psychologicalsafety. This model empowers nurses to emerge fromthe cloak of silence and take an active, professionalrole in keeping patients safe. O

Selected referencesCAST: The Commercial Aviation Safety Team. www.cast-safety.org.

Accessed March 14, 2014.

Edmonson A. Managing the risk of learning: Psychological safety in

work teams. In: West MA, Tjosvold D, Smith KG, eds. International

Handbook of Organizational Teamwork and Cooperative Working.

London: Blackwell; 2003.

Leonard M, Graham S, Bonacum D. The human factor: the critical

importance of effective teamwork and communication in providing

safe care. Qual Saf Health Care. 2004;13(Suppl 1):i85-i90.

Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings

and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43.

Maxfield D, Grenny J, Lavandero R, Groah L. The silent treatment:

Why safety tools and checklists arent enough to save lives; 2011.

www.silenttreatmentstudy.com/. Accessed March 11, 2014.

World Alliance for Patient Safety. WHO surgical safety checklist and

implementation manual. 2008. www.who.int/patientsafety/

safesurgery/ss_checklist/en/index.html. Accessed March 11, 2014.

Susan Tocco is the director of operational effectiveness at Orlando Health in

Florida. James DeFontes is the assistant executive medical director at Kaiser-

Permanente in Pasadena, California.

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MONICA IS LATE for work again. June has bodyodor. Brian doesnt comply with the hospi-

tals cell-phone policy.

As a nurse manager, you know you

need to do something. Are you

avoiding the tough conversations

required to deal with these

issues? Whats holding you

back from communicating

openly with your staff? This ar-

ticle can help you open up your

communication style and stop

avoiding tough conversations.

(See Topics that can make for

tough conversations.)

Preparing for difficultconversationsAs with anything, preparation is im-

portant. Before confronting someone

about a prickly topic, ask yourself:

Whats the problem?

How do I feel about it?

What do I want to be different?

Suppose you need to confront a staff nurse

who has been bullying new nurse graduates. Here

are the key questions to ask yourself beforehand,

along with possible answers:

1. Whats the problem? Answer: A staff nurse is bully-

ing new graduates, who arent getting the support

they need as they transition to the work environment.

2. How do I feel about it? Answer: I am angry and

frustrated. If this keeps up, I will lose staff. Theres

also the issue of patient safety if new nurses cant

seek help.

3. What do I want to be different? Answer: I want the

bullying to stop. I want a positive work

environment with collaboration and co-

operation.

Putting STOP to workThe STOP strategy helps guide you

through difficult conversations. Here are

the key components:

State the situa-

tion or problem.

Tell the person-

what you want.

Offer an opportunity

to respond.

Provide closure (review, sum-

mary, or thanks).

State the situation or problem

Sharing facts increases your confi-

dence: for example, This is the third

time this week. But be sure to sepa-

rate the behavior from the person doing it. Rather than

labeling the person lazy or sexist, describe the behav-

ior. For example, Ive noticed that.

Share your feelings: I feel or When you do A, I

feel B. Avoid saying, You make me feel.

Sometimes its hard to start a difficult conversation.

Here are some tentative beginnings:

Perhaps youre not aware

Im beginning to wonder

I need your help with something.

Tell the person what you want

Dont expect people to know what you want unless you

tell them. Suppose your college-age son is home for a

weekend and running the washing machine and dryer

outside your bedroom at midnight. If you tell him his

laundry chores are interrupting your sleep, he may think

he should stop at, say, 10 P.M. So be specific: Id like

you to be done with your laundry by 8 P.M.

STOP: A strategy for dealingwith difficult conversations By Kathleen Pagana, PhD, RN

Career Sphere

This four-step process guides you through prickly

topics with your staff.

Topics that can make for toughconversations Asking for a promotion Noncompliance with policies

Bullying and incivility Poor hygiene

Discrimination Tardiness

Lack of teamwork Sexual harassment


Offer an opportunity to respond

Make this a two-way conversation. Otherwise, yourejust delivering criticism. Invite the other person to re-spond: Do you agree? or Can we work somethingout? or What do you think about this? The personsresponse provides an opportunity to evaluate how theconversation is going.

Provide closure

To prevent rambling and repetition, review or summa-rize the conversation. For instance, thank the personfor meeting with you: Thanks for getting together todiscuss this important issue. I hope you can improve.Wed hate to lose you. Youre an excellent clinician.

Using STOP for common workplace problemsSometimes the best way to learn something is to seeexamples in common workplace situations. Review thesix examples below.

Problem: Tardiness

S: Monday and Tuesday, you arrived 20 minuteslate for work.

T: I want you to be here at 6:45 A.M. (Dont sayYou have to be punctual.)

O: Can we agree to this?P: Thanks. This will help us work better together.

Problem: Body odor

S: I need to talk to you about a personal issue,and theres no way to make it easy for eitherone of us. Ive noticed you often have bodyodor that you may not be aware of. It couldbe your personal hygiene, diet, or a physicalproblem.

T: I hope youll check this out and do somethingabout it. Im sure you can improve this situation.

O: Am I making sense?P: Thanks for meeting with me.

Problem: Sexual harassment

S: Perhaps youre unaware that when you talk tome, your eyes move up and down my body. Sometimes, you put your hand on my shoulderor around my waist. These behaviors make meuncomfortable.

T: I want them to stop.O: Can we agree to this?P: Thanks. That will help us work together better.

Problem: Incivility

S: The way you told me the staff thinks Im an id-iot has me worried. You smiled when you saidit. I wonder if you take pleasure in giving menegative feedback.

T: Id like to have a better working relationshipwith you. Lets talk about a different way tospeak to one another.

O: So that we can resolve this issue, whats yourtake on the situation?

P: Thanks for meeting with me. I want us towork together better.

Problem: Lack of teamwork

S: Working on this project takes a lot of team-work. Youve been late with your last twodeadlines. Im frustrated being held up andhaving to catch up.

T: I want you to have your work done on time.O: Can we agree to this?P: Thanks. This is a very important project.

Problem: Dress-code violation

S: I see you have a new eyebrow piercing. Its aviolation of our dress code.

T: Please remove it during work hours.O: Do you have any other questions about the

dress code?P: Thanks. See you later at the staff meeting.

Getting startedFear can hold us back from difficult conversations. Fearis based on the importance of the subject and of therelationship. Dealing with a store clerk about a dam-aged product is easier than dealing with a coworkerabout body odor. Build your confidence as you prac-tice the STOP strategy in situations with a lower fearfactor.

Knowing how to handle tough discussions yieldsmany benefits. (See Reaping the benefits.) The STOPstrategy is simple and easy to use. It can improve yourcommunication as you gain confidence and stop avoid-ing difficult conversations. O

Kathleen D. Pagana is a keynote speaker and professor emeritus at Lycoming

College in Williamsport, Pennsylvania. She is the author of The Nurses

Communication Advantage and The Nurses Etiquette Advantage. She is also the

coauthor of Mosbys Diagnostic and Laboratory Test Reference, 11th ed. To contact

her, visit www.KathleenPagana.com.

Reaping the benefitsThe benefits of handling tough conversations include:

better workplace environment

improved staff retention

personal growth

enhanced working relationships

greater patient safety.

WHY IS IT that some things dont bother us, whileother things catapult us from an emotional 0 to 60 mphin a heartbeat? We all know what it feels like whensomeone says or does something that gets our juicesflowing. We feel it in our bodies, emotions, and mood.We have an overwhelming urge to react. We may ex-press it in words at the time or take our frustrations outlater on someone else. It just doesnt feel good. Wewant to explode, set the record straight.

If the button pusher is your boss, you may internal-ize your reaction. Your mind is still buzzing with whatyoud like to say, but youre not likely to express thoseangry words to a superior at work. On the other hand,if the button pusher is a significant other, colleague,child, or friend, you may choose not to hide your feel-ings. Perhaps youll have a minor explosion and letthem know how you feel.

But what are you really reacting to? You might thinkits the situation at hand, but it isnt. Instead, youre re-acting to something about that situation. Maybe it re-minds you of a past emotional wound. Perhaps youreinterpreting it in a certain way. Whatever it is, its usu-ally something deeper. When someone pushes a but-ton, theres always more to the story than just the cur-rent situation.

Having our buttons pushed is uncomfortable, andwed prefer to avoid it. But the truth is, we cant avoidit. It will happen again and again, each time buildingon the last. So instead of trying to avoid it, try to em-brace it.

Pause and dig deeperThe next time someone pushes one of your buttons,dont react instinctively. Instead, pause for a momentand dig deeper to try to find the cause of your reac-tionsomething beneath the surface that needs to beexcavated and studied gently.

Often, when a button gets pushed, we blame thebutton pusher for how it makes us feelfor what thatperson did to us to cause this reaction. We externalizethe issue and dont take responsibility or own whatour bodies are telling us. (See Button pusher asteacher.)

But what if we looked at our buttons in a wholenew light? Instead of hiding them and never knowingwhen and where they will be pushed, what if we un-

earthed them and shone light on them?To look at a situation honestly and gently requires

compassion toward yourself. Getting to whats beneaththe issue at hand or the surface emotion is a growthopportunity. It gives you the chance to look at the situ-ation differently. It means youve opened yourself upto learning and healing.

Mind/Body/Spirit

What to do when someonepushes your buttons By Laura L. Barry, MBA, MMsc, and Maureen Sirois, MSN, RN, CEN, ANP

GET HEALTHY !

Having your buttons pushed

can help you find invisible

cords of connection that need

your attention.



Unearthing unresolved woundsRecently, a most tender button of

mine was pushed; someone made a

comment that was unexpected and

unappreciated. Thats it. But it really

bothered me. I immediately thought,

This person always does this to

menever has anything nice to say.

This feels humiliating.

I restrained myself from respond-

ing (although Im sure my body lan-

guage and facial expression spoke

volumes). Instead, I paused, and once

I was away from that person, I did

some deep breathing to release my

feelings. I thought about what was

said and how I felt. During that

pause, I realized my body was telling me there was

more to this than just the unappreciated comment. I re-

alized the intensity of my feeling was out of proportion

to the comment.

As I let myself sit with this disturbing emotion, I

asked myself, Why does this bother me? I realized it

bothered me because it made me feel I hadnt been

heard. So what does that mean and where else in my

life do I feel I havent been heard? As I continued to

dig, I remembered many of the other times Id felt this

way. I realized that not being heard is an old wound

coming from my childhood in a big family. To me, not

being heard means not being loved or cared aboutor

at least thats how I interpreted it.

The current issue had brought up those old, unre-

solved hurts and beliefs from childhood so they could

be healed. As an adult, I can look back at that child-

hood me who was hurt and tend to the wound so it

doesnt have to keep resurfacing at unpredictable

times. And when it does arise, I can lovingly say, Oh,

its you again. I can pause, honor my feelings from

the past, and give myself permission to feel what Im

feeling. I can remind myself that this is an old wound

surfacing now for healing.

This perspective helps me realize the experience is

happening for me, not to me. That shift in my perspec-

tive allows room for investigation, curiosity, and most

importantly, healing. When something happens for me,

it implies its good; when it happens to me, Im a vic-

tim. For me comes with intention and purpose. To

me comes with blame and hurt.

Cords of connectionIn a sense, invisible hollow cords connect us to every

experience and relationship from our past. Even when

an experience or relationship is complete (perhaps

youd describe it as over), those invisible cords of

connection remain. I use the word complete rather than

over because when we complete something, we ac-

knowledge a finality, sometimes with a sense of ac-

complishment, and move to the next door thats open-

ing. We complete grade school and move on to high

school. We complete an exam and become certified in

a field. We complete grocery shopping and go home to

make dinner. Complete removes judgment.

The invisible cords of connection can be a drain if

they are cords of fear, anger, hurt, resentment or if they

carry a should-have implication. Those cords need to

be cutwith kindnessby a willingness to look deep-

er into our reactions. Theyre energy drains. When the

function of the umbilical cord is complete, it must be

cut for the greatest good of mother and child. So, too,

with past experiences or relationships that are com-

plete. For the greatest good of all involved, the cord

that no longer serves a loving, peaceful purpose must

be cut. Only cords of love, compassion, peace, and joy

can sustain.

Pause, digest, reflect, and respondHaving your buttons pushed can be a wonderful way

to find out what invisible cords of connection need

attention. Through a willingness to excavate the un-

derlying cause of our reaction, we begin the healing

process.

So for today, I will notice and be grateful when

someone pushes my buttons. I will pause, digest, re-

flect, and respond. Knowing its being done for me and

not to me, Ill be grateful for the growth and awareness

it can bring, grateful that my body speaks to me.

And you? What buttons will be pushed for you to-

day? When they are pushed, will you pause, digest, re-

flect, and dig deep to find the cause of your reaction?

Will you cut the invisible cord? O

Laura L. Barry is business consultant and leadership coach. Maureen Sirois is a

nurse consultant on health and wellness.

Button pusher as teacherIts hard to like someone who pushes your buttons. But what if you view this per-

son as your teachersomeone whose role is to help you dig deeper to find the

cords that keep you tethered to hurt, disappointment, fear, or anger? When you

pause to view this other person as your teacher, you shift and soften. You step

out of the victim role. In this softness, healing can begin.

Pausing gives you the space and opportunity to see things differently, to op-

erate out of lovenot anger, the past, or fear. Instead, youre operating out of

love for yourself. As you look on the other as your teacher, you may feel gratitude

for that personor perhaps even love.

RACHEL is an experienced critical care nurse whoprides herself on her abilities. During her current

travel assignment, several nurses invite her to take

the CCRN exam with them. She has been thinking

about taking the exam and looks forward to getting

to know the nurses at her assigned hospital better,

so she agrees. Despite taking an online review course

and spending hours

studying with her

coworkers, she fails the

exam. Shes extremely

upset, in part because

she's afraid they will

think less of her as a

nurse, making her re-

maining time in her as-

signment more difficult.

Most of us have had

the experience of failing

to achieve a goal, mak-

ing a poor judgment

call, or being overlooked

for a coveted position.

Sometimes our failures

are public. More often,

theyre private and we

never discuss them with

anyone. On the other

hand, we celebrate our

successes. Similarly, most

journal articles focus on

whats working in organ-

izations; few focus on

initiatives that failed.

Youve probably heard

the famous line from

the movie Apollo 13:

Failure is not an op-

tion. Ive seen it as a

tagline in many e-mail signatures.

Although few professionals openly discuss their

failures, failure is part of the professional experience.

According to author and resilience expert Martin

Seligman, PhD, failure is an inevitable part of work.

Along with dashed romances, work failure is one of

lifes most common traumas. If you never fail, Selig -

ma

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