DiversityNursing Blog

Source: University of California - Los Angeles

Latinos are the largest ethnic minority group in the United States, and it's expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers. Latinos' low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA: The consequences of not covering undocumented residents. The growth of the Latino population in states that are not participating in the ACA's Medicaid expansion program. The heavier demand on public and private health care systems serving newly insured Latinos. The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

"As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels," Ortega said. "Resolving these four key issues would be an important first step."

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA's expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA's exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

"That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients," Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

"Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems," Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

"It's estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law -- the undocumented and those who have been in the U.S. less than five years," Ortega said. "Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate."

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

"These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time," he said. "So it remains unclear how these clinics will continue to provide care for them."

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers -- Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

"That, of course, is the goal -- to see improvements in the overall health for everyone," Ortega said.

A Dutch organization called "Ambulance Wens" (Ambulance Wish) fulfills the last wishes of terminally ill patients free of charge thanks to its 200 medical volunteers.

The company says, "There are still too many patients who die without getting to close everything. One of those reasons is the inability to achieve certain desires because the patient is no longer mobile and other existing facilities are inadequate for this purpose."

Special ambulances and stretchers help transport the patients safely and comfortably. Typical excursions include a visit to the beach, a visit to a neighbor who is also no longer mobile, and various places where the patient has special memories.

This woman's final wish was to visit the Rijksmuseum in Amsterdam.

Another woman enjoys the view from her favorite vacation destination in Tuscany.

This gentleman asked for one last view from the Euromast observation tower.

And this man asked to see the mills in Kinderdijk one last time.

Amsterdam is not the only place doing such wonderful things. A hospice outside Seattle made an old forest ranger's dying wish come true.

"Ed expressed one last hope to the hospice chaplain: He wanted to commune with nature one more time."

As the hospice wrote on its Facebook page, "People sometimes think that working in hospice care is depressing. This story ... demonstrates the depths of the rewards that caring for the dying can bring."

Source: www.sunnyskyz.com

Elisha Fieldstadt

Red toy wagons, used to help caretakers to transport ill children to and from treatments and appointments, are a staple in the hallways of Children's Healthcare of Atlanta. The pediatric patients' IV poles have always had to be pulled awkwardly behind the wagons — until a grandfather and his son decided that needed to change.

Roger Leggett's granddaughter, Felicity, was diagnosed with a brain tumor at the age of 4 in 2011. While visiting the young girl during her treatment at Children's Healthcare of Atlanta (CHOA), Leggett and his son, Chad, saw a mother pulling her child in a wagon, struggling to also drag his IV behind. "Chad looked at me and said: 'There's gotta be a better way to do that,'" Leggett told NBC affiliate WXIA.

Chad tragically died of heat stroke just a few weeks later, but Leggett remembered that moment, which inspired him to create the not-for-profit, Chad's Bracket, which is dedicated to connecting IV poles to patients' red wagons, according to the organization's Facebook page. With help from students at Chattahoochee Technical College, Leggett has affixed IV poles to more than 100 wagons at CHOA, and is hoping to fill requests from hospitals around the country, according to WXIA. His workshop is currently based in the bed of his late son's pickup truck.

Felicity received news recently that she is in remission, and Leggett is humbled by the support his efforts have garnered. "I don't feel I deserve the praise. I'm just trying to make the time a child and parents spend at CHOA easier and safer," Leggett said.

Source: www.nbcnews.com

James McIntosh

It is vital that treatment for stroke is given as quickly as possible in order to minimize the amount of long-term damage that occurs. Unfortunately, a new study has suggested that one third of Americans would be unable to access a primary stroke center within 1 hour should they need to.

The study, published online in Neurology, was a population-level virtual trial simulating how long it would take for patients to access stroke care following changes to systems of treatment.

"Research has shown that specialized stroke care has the potential to reduce death and disability," says study author Dr. Michael T. Mullen. "Stroke is a time-critical disease. Each second after a stroke begins, brain cells die, so it is critically important that specialized stroke care be rapidly accessible to the population."

According to the authors, stroke is one of the leading causes of death and disability in the US, occurring when the flow of blood to a portion of the brain is blocked or an artery in the brain ruptures or leaks.

In 2012, the beginnings of a three-tiered regionalized system of care were implemented. This involved the designation of certain hospitals as primary stroke centers (PSCs) and comprehensive stroke centers (CSCs), with CSCs providing the highest level of care.

Dr. Mullen and his colleagues decided to create virtual models in order to estimate what percentage of the population would have access to a comprehensive stroke center after selectively converting a number of primary stroke centers to facilities providing a higher level of care.

"In this report, we demonstrate how mathematical optimization modeling can inform the strategic development of the US network of stroke centers by simulating the conversion of PSCs into CSCs," the authors write. "This allows for virtual trials of competing system configurations in order to design a system that maximizes population access to care."

Reduced access to specialized stroke care could worsen pre-existing disparities in health

Data from 2010 was utilized, at which point there were 811 PSCs and no CSCs in the US. The researchers converted up to 20 PSCs in each state into CSCs and calculated how long it would take local populations to access these treatment facilities by ambulance or plane in optimum conditions.

After converting the PSCs to CSCs, the researchers found that only 63% would live within a 1-hour drive of a CSC, with an additional 23% within a 1-hour flight of one. 

"Even under optimal conditions, many people may not have rapid access to comprehensive stroke centers, and without oversight and population level planning, actual systems of care are likely to be substantially worse than these optimized models," says Dr. Mullen.

Levels of access to care also varied in different geographical areas. Worryingly, access to care was lowest in an area often referred to as the "Stroke Belt" - 11 states where stroke death rates are more than 10% higher than the national average, predominantly situated in the southeast of the US.

"Reduced access to specialized stroke care in these areas has the potential to worsen these disparities," says Dr. Mullen. "This emphasizes the need for oversight of developing systems of care."

The authors suggest the actual number of CSCs that will be established is likely to be much smaller than 20 per state, and that increasing the number of CSCs is not an ideal way to improve access for patients due to the high costs involved.

A number of limitations are acknowledged, such as using trauma data to calculate the amount of time taken to reach a hospital, and calculating population access to hospitals using where people live, rather than where strokes occur. However, the authors argue that the majority of strokes (over 70%) occur at home.

In a linked editorial, Dr. Adam G. Kelly and Dr. John Attia suggest that CSC status is likely to be determined more by financial motives, however, rather than a population health basis.

They write that timely accessibility of PSC services, either on-site or via telemedicine, should be the first priority in the organization of regional stroke care. Following this, "CSCs should be added in a coordinated, stepwise manner with regional needs - not hospital bottom lines - as the major determinant for new CSCs."

Source: www.medicalnewstoday.com

By MICHAEL TOMSIC

In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."

Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.

"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack agree they'd give Medical Park a perfect 10 on the satisfaction scale.

My poll of the family is informal, but Medicare's been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.

Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.

Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.

First, says Scott Berger, a staff surgeon, this isn't your typical hospital.

"It kind of feels, almost like a mom-and-pop shop," he says.

Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.

Another key is that no one at Medical Park was rushed to the hospital in an ambulance, or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.

The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."

These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.

"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.

This is the third year hospitals can get bonuses or pay cuts from Medicare (partly determined by those scores) that can add up to hundreds of thousands of dollars.

More typical hospitals that handle many more patients – often massive, noisy, hectic places – are more likely to get penalized, Roades says.

"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they have many more caregivers interacting with each patient.

Still, Roades says, although patient surveys aren't perfect, they are fair.

"In any other part of the economy," he points out, "if you and I were getting bad service somewhere – if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut – we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.

Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication – long before the patient shows up for treatment.

On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery – which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears, and prepare them for what can be a painful process.

"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."

Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.

Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."

But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.

Source: www.npr.org

That’s right—there are men in nursing, too! It’s time to rid ourselves of outdated stereotypes. We don’t live in a society where boys only like blue and girls only like pink. Where boys can only play with legos and girls can only play with dolls. There’s too much variety in this world to limit ourselves to what we think is expected of us. There are women in engineering and mathematics, and there are men in nursing and healthcare.

Population Growing for Men in Nursing

Nursing is a fantastic career. In fact, the number of men in nursing is growing, with the percentage of male nurses increasing almost every year. In addition, there are more men in nursing schools, making up 13% of nursing school students. Find out more facts about male nurses by reading the men in nursing infographic below.

Source: www.collegeamerica.edu

By Karen Weintraub

The parents of children with autism often have to cut back on or quit work, and once they reach adulthood, people on the autism spectrum have limited earning potential.

Those income losses, plus the price of services make autism one of the costliest disabilities – adding $2.4 million across the lifespan if the person has intellectual disabilities and $1.4 million if they don't, according to a new study published in the journal JAMA Pediatrics.

"We've known for a long time autism is expensive, but we've really never had data like this to show us the full magnitude of the issue," said Michael Rosanoff, associate director of public health research for the advocacy group Autism Speaks, which funded the research. "These are on top of the costs to care for a typically developing individual."

Jackie Marks knows the problem firsthand. The Staten Island, N.Y., mom has 13-year-old triplets, all on the spectrum and all with intellectual deficits.

Everything about their care costs more money, she says, from the diapers and wipes she still has to buy to the specially trained babysitters she has to hire every time she wants to go out. For karate classes, she has to pay for one-on-one lessons; the therapist helping with social skills costs $150 an hour per child.

"I enjoy my children immensely," Marks said. "I have a wonderful husband. That, at the end of the day makes it all worth it. But is it like a typical experience? No."

Marks quit her job with the state as a bank auditor to care for Tyler, Dylan, and Jacob. Her husband's job not only has to cover day-to-day needs, but he has to put away enough money to pay for both her and the boys after he retires. She hopes the boys will be able to work someday, but they'll never have the kind of earnings that will sustain them, she said, and will probably receive modest Social Security benefits once they turn 18.

Four things need to change to bring down the cost of autism for families and society, according to David Mandell, director of research for the Center for Mental Health Policy and Services at the University of Pennsylvania.

Adults on the spectrum need more job opportunities. There are many small success stories of individuals or small groups of people with autism who are employed, but "we need to be more creative about thinking about employment on a large scale," Mandell said.

Adult care must be improved so only people who really need expensive residential care get it, and everyone else can find support in their own community, he said. "I think in too many cases, these residential settings represent a failure of our society to provide community-based, cheaper options," he said. "More flexible, cheaper options would be a way to bring these costs down."

Families with autism need more opportunities to stay in the workplace. "Issues that face autism ultimately face all families," Mandell said. "If we had more family-friendly workplace policies, we might see substantial change in the way families were able to manage the work-life balance when they had children with (all kinds of) disabilities."

Society needs to take the long view, he said. Spending money diagnosing and helping young children on the spectrum will probably save money when they are older, by reducing disability and improving employability. "We often talk about the cost of care, and we don't spend much time talking about the cost of not caring," he said.

NUMBERS:

•Cost of supporting someone with an autism spectrum disorder plus intellectual disability: $2.4 million in the USA and 1.5 million pounds in the United Kingdom ($2.2 million in U.S. dollars)

•Cost of supporting someone with an autism spectrum disorder but no intellectual disability: $1.4 million in the USA and .92 million pounds in the United Kingdom ($1.4 million)

Source: usatoday.com

By Kirsten Chua

Everybody knows that the nursing profession has two different sides—it is both science and art. That said, nursing as a science is more apparent.

For example, if you are a nurse, you must know the patient-based nursing care plan (NCP). You must also know the disease mechanisms of all diseases, medications, and management from all sides. Nurses also need to be up to date on new policies, practices, and procedures. Moreover, they need to know how to manipulate new diagnostic equipment and machines.

The science of nursing is easily noticeable and it is very critical for each one to know.

What Is the Art?

Meanwhile, the art of nursing is more than a great deal of science. It is more than just knowing; it is doing. It bridges information from nurses to patients in a skillful way. It is the application of all the science known to nursing to give the utmost care the patient needs.

During your first year in the nursing profession, you are in the heat of the moment. You now belong to that bunch of young professionals who are enthusiastic and motivated in practicing their craft. Maybe many could attest that when you first become a nurse you see the art more than the science of it.

But it is sad to note that as time passes by the semblance of the nursing being an art bleeds out. At the drop of a hat, you get suffocated from the career you once loved.

The Human Touch

In the past 7 years that I have been a clinical instructor, I have seen so many changes in the healthcare arena and how nursing should be. But one thing remains: human nature.

Our patients’ needs have remained constant and relentless. As Maslow’s hierarchy of needs suggests, these include food, sense of belonging, warmth, compassion, self-actualization. These basic needs have been addressed in the same way since the dawn of science. However, the ways to meet them may have changed from time to time.

The art of nursing may have been in each person even before entering the profession. That innate capacity to respond to the needs of individual is already the art of nursing. In nursing school, this vivacity is awakened through constant interaction with the patients in various settings.

Nurses are called to perform relational work. Therefore, the motivation to keep that art in us should be continuously burning. We have the power to heal the sick. An effective nurse is one who gives nursing care independently and collaboratively with other healthcare teams.

The art of nursing comes in as a nurse independently does his or her job. The options s/he considers in taking a certain action and ultimately the action s/he does to respond to patient needs are the art of nursing.

It is in the nurses’ hands to promote positive changes in patients. Everyday we are faced with patients who are in different conditions. In this case, individualized nursing care is noteworthy. Knowledge is not enough. Compassionate care is paramount.

Where Is the Art?

In my experience, I have witnessed things in which nursing as an art is not manifested. I squirmed while hearing a nurse teaching pre-operative patients without compassion. Instead of comfort, fear is built within the patients.  I have observed nurses, who are not well informed about a disease process, explain things to patients without using therapeutic communication. I have noted procedures done outside the context of the protocols and sterile technique.

Sadly, many of these incidents are from those who have been in the profession for so long. Science is applied, but where is the art in this perspective?

Clearly, nurses must be equipped with the science of nursing. But until the art of nursing is recognized as a necessary principle for patient care, nurses will likely to continue to demonstrate behaviors that make them good technicians. However, they will not necessarily be good nurses.

As a field grounded in compassion and direct patient care, the art of the nursing profession is more important than the science. And this is where the so-called calling comes into play. 

Source: nursetogether.com

By Michael McFall

At first, they want to die.

And then forensic nurses such as Monique Turner get to them. She talks to them, asks them about the sexual assault in a safe environment and tends to them — all while collecting the evidence police and attorneys will need to put the perpetrator away. By the time Turner is done, the victims feel like they can face the next day.

"People are ultimately grateful, it’s the greatest thing that we can give them," Turner said.

Forensic nurses have the added expertise to document wounds, collect DNA and look for evidence of neglect or abuse, as well as the ability to comfort a sexual assault victim and ultimately testify in court. And nowhere else are they needed more: Utah ranks 19th in the nation for reported forcible rapes, according to the Utah Department of Health. One in three women in the state will experience some kind of sexual assault in her lifetime, and one in eight will be raped, according to the department.

But as vital as their role is to the criminal justice system, it is one the public is relatively unaware of. November featured National Forensic Nurses Week; you may not have known. You may not have even heard of a forensic nurse before. But their early interactions with victims help define how they deal with their trauma for years to come, and their forensic skills help decide whether the attacker sees the inside of a prison cell.

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"The worst day of their life, forever" » As an emergency room nurse at University Hospital, Turner had never heard of a forensic nurse until a few years ago when she met one. There are several regional teams of forensic nurses around the state, including one that serves the Salt Lake Valley — Salt Lake Sexual Assault Nurse Examiners (SANE). Turner was looking for a little extra money, and with her affinity for "CSI" and familiarity with pelvic exams, she figured it could be a good fit.

Then she got started. Her first case was a woman who had been kidnapped, taken across state lines and been abused the whole way.

"It is really, really hard to see the evil that people do to each other; to listen to how horrible this person was to them," Turner said.

Nationwide, there is a lot of burnout: almost one out of every two forensic nurses will quit within a year. While a whole team of experts, including law enforcement, victims advocates and a Rape Recovery Center representative step in to help, forensic nurses tend to be the first or second people to interact with victims.

But in the three to four hours the exam takes, the nurses see the transformation.

"Our major job is excellent health care and compassionate initial response. It’s that first response a patient gets that has the potential to decide whether they can heal from this traumatic event and whether they stay engaged in the criminal justice system," said Susan Chasson, a forensic nurse on the Salt Lake City team who trains prospective members. "… There’s so much self-blame [after an assault], if we say ‘Oh yeah, it’s your fault,’ we compound that. When someone has a negative response, that keeps them from telling somebody else for a long time."

Victims are not forced to have the exam in the first place, and at any point, they can decline a specific part of the exam. The nurses do that to give back to them that sense of control that a sexual assault robbed from them.

The victims are clearly traumatized, but spending time with them, supporting them and returning "some of that power to them, they walk out … with their head up," said Diane Fuller, who founded the Salt Lake City team. The care does not get rid of their trauma, but it gives them a stronger sense of self, she added.

"I’m sure we can all think back to the many patients who cried and said thank you, and gave us a big hug and said ‘I can’t imagine what I would do if you guys weren’t here,’ " said Beth Weekley, who joined the team about six and a half years ago. That is what keeps Turner and Weekley on the team.

"We help them realize that they can go on, they don’t have to die," Turner said. Few other nursing jobs have such a huge impact on someone, said Turner, who joined the team shortly before Weekley. "… This is usually the worst day of their life, forever. … It’s really, really hard, but the emotional payoff is worth all of the evil nastiness."

And they make sure officers and attorneys have the evidence they need to put that nastiness behind bars.

Salt Lake City police Detective Cody Lougy credits forensic nurses for helping end a high-profile serial date rape investigation he worked several years ago. Azlen Marchet was convicted of sexually assaulting four women in Salt Lake County from 2002 to 2007. He is currently serving 45 years to life in prison.

Forensic nurses also help new officers working their first rape cases — Lougy remembers how nervous he was during his — with their years of expertise, guiding the officer in what to look for based on the evidence they collect.

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Brave new era » As vital as they have become, the nurses are a relatively new addition to the crime scene. The speciality only came about 21 years ago, created by nurses at the University of Minnesota School of Nursing. The Salt Lake City-based forensic nurse team formed about 12 years ago.

"The community needs simply weren’t being met," Fuller said. When she founded the team in 2001, she started off with eight people pulled from all over the place. Now she has 18, and her team is unique to most of the country: they respond to hospitals across the valley instead of being housed in hospitals, which would require the victims to drive to them.

When the nurses start out, they face a lot of intimidation in knowing how to care for a patient in emotional trauma, when before their jobs were focused on the physical.

"It’s a very different ball game," said Weekley, who joined the team shortly after Turner. "Thank goodness we work closely with [the Rape Recovery Center]. They’re with us on every single case we do. I cannot even imagine doing this without them."

Advocates from the Rape Recovery Center work with the nurse during the exam, talking to the victims as well, helping them with paperwork and understanding what comes next and the resources available to them, said Holly Mullen, executive director of the center. She admires the nurses’ ability, with the help of evolving technology, to collect evidence even days after the event, and even if the perpetrator left behind no bodily fluids. Most victims strongly want to see resolution in their case, built in part by that evidence.

But when it comes to testimony, the advocate is a "confidential communicator" — they cannot testify in a case. Not so with the nurses. They play a big part in not only objectively relating what they observed in the exam, but also in educating the jury about what that means, Fuller explained.

Like the first time approaching a traumatized victim, entering the courtroom can be intimidating for a nurse — at first. But since in their day jobs they spend much of their time educating patients, whether about wound care or healthy living, almost every nurse that Fuller has watched on the stand transitions naturally into that mode within the first couple minutes. They are still educating, but this time it’s the jury, not a patient.

Forensic nurses can potentially play a "very significant role" in trial when their findings corroborate one side or the other, said Blake Nakamura, Salt Lake deputy district attorney. "They can be pretty valuable and influential in making the case."

The quality of the evidence they bring is phenomenal, added Salt Lake District Attorney Sim Gill. "What they do is essential for law enforcement, prosecution, and what the victim is going through."

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Healing the healers » As much comfort as they bring to the victims, even the forensic nurses need someone to do the same for them. The team has a counselor on hand when a case hits a nurse particularly hard. For Turner, it was when she was examining a girl about her daughter’s age. "She had so much in common that it really hit home. The counselor helped me box that up."

Weekley knows just what that is like. Many of the stories they hear are haunting. "It might sound callous," she said, "but you need to have some boundaries to not let it completely affect you and your life."

The team is also in touch with people involved in the case if they need to vent or talk it out — since when Turner goes home to her husband, patient-privacy laws prevent her from discussing what she went through that day.

A lot of nurses burn out before long, either from the emotional burden or the hours; for most, being a forensic nurse is a second job. They sign up for six-hour shifts, which cover every hour of every day, during which they could be called out to anywhere in the valley. Turner goes on three to four calls a month, while others might go on five or six.

The nurses who stick around take hiatuses for a few months at a time — Turner is on one now — to recharge or focus on other areas of their lives.

"We want to make the world a better place and provide care in a field that not everybody can do," Weekley said. "We take pride in that. … It takes a special person to be able to do this job."

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Spreading the word » The team is always looking for new members. They hold biannual, three-day training sessions for prospective nurses, though only two or three people in any given 20-person turnout actually want to join the Salt Lake City team, Turner said. Most are either from other areas in the state, are just there to learn or back out once they realize what the job is like.

Ultimately, Turner would like the team to hire enough nurses to have two on call during each six-hour shift, as opposed to the one per shift they have now.

The next training is scheduled for March, then again next fall in Blanding. There is a big need in that corner of the state, since the nurses there often cannot take the time off to travel to Salt Lake City, Chasson said. Bringing the training to them also gives nurses in tribal communities and in neighboring southwestern Colorado, who are likewise isolated, the same opportunity.

Anyone interested in becoming a team member can find more information at slsane.org or by emailingslsane@comcast.net. The website also connects victims with hospitals and law enforcement in the Salt Lake Valley, with a comprehensive list of phone numbers they can call.

Regardless of whether a victim’s region has a trained forensic nurse at the hospital or on call, Mullen encourages victims to call the police or go to the nearest emergency room and report the rape.

Mullen and Fuller worry about the culture surrounding rape that blames the victim instead of the perpetrator that can keep victims silent. More than 88 percent of rapes are not reported to law enforcement, according to a 2007 health department survey.

Regardless of whether a victim’s region has a trained forensic nurse at the hospital or on call, Mullen encourages victims to call the police or go to the nearest emergency room and report the rape.

Mullen and Fuller worry about the culture surrounding rape that blames the victim instead of the perpetrator that can keep victims silent. More than 88 percent of rapes are not reported to law enforcement, according to a 2007 health department survey.

Still, they are thankful to see a slow and steady shift to placing blame where the blame is deserved — with the rapist. For Fuller, her nurses are seeing that proof firsthand.

Years ago, a typical victim would come in two to three days after the assault, Fuller said. Now they are seeing victims within the first 24 hours. "That’s public opinion changing. There is great care available, people really are believing you."

Source: The Salt Lake Tribune

By Debra Anscombe Wood, RN

Psychiatric emergencies can be as serious as a medical condition, but in traditional EDs, mental health patients may wait for treatment. Specialized psychiatric EDs serve that population quickly and efficiently. “They come in with everything from the need for prescription refills to being actively suicidal,” said Brian Miluszusky, RN, BSN, director of nursing in the emergency medicine department at NewYork-Presbyterian Hospital/Weill Cornell Medical Center in New York. “A suicidal person is as much at risk of dying as someone having an MI (myocardial infarction).” 

As demand for emergency care has increased, so has the number of mental health patients seeking services. A study from the Carolina Center for Health Informatics at the University of North Carolina at Chapel Hill reported in 2013 that nearly 10% of ED visits in North Carolina from 2008-2010 were for mental health diagnoses, and the rate of mental health related visits increased seven times more than overall ED visits. Mental health related ED visits increased by 17.7%, from 347,806 to 409,276 from 2008-2010. Stress, anxiety and depressive disorders were most common. 

A January 2012 American Hospital Association Trendwatch report said, “In 2009, more than 2 million discharges from community hospitals were for a primary diagnosis of mental illness or substance abuse disorder. ... Among children, mental health conditions were the fourth most common reason for admission to the hospital in 2009.”

The report said there were more than 5 million visits to EDs in 2009 by patients who had a primary diagnosis of mental illness or a substance abuse disorder. “Access to [psychiatric] care is not easily found [in the community], but if you are having a mental health crisis, you can walk into our emergency department 24/7 and be seen by a psychiatrist within a couple of hours,” said Jennifer Ziccardi-Colson, RN, MSN, BSW, MHA, vice president for nursing services at Carolinas Medical Center-Randolph, a behavioral health center with a psych ED and 66 inpatient beds in Charlotte, N.C. 

Psych EDs serve patients with acute episodes of behavioral health diagnoses, including feeling suicidal, anxious or depressed or abusing substances. “When patients come to us, they are assessed and seen promptly,” Ziccardi-Colson said. “People can feel comfortable coming to our environment to receive care.” 

Not all patients with mental illnesses receive care in a psych ED. Even at those hospitals with a dedicated psych emergency unit or a stand-alone psychiatric emergency services facility, patients with acute medical conditions, such as an MI or a broken hip, are treated in the regular ED. The ED provider must determine if a medical problem is contributing to mental status changes or if the problem is solely psychiatric in origin. 

Some psych EDs, such as San Francisco General Hospital and Carolinas Medical Center care for children as well as adults. Children and teens receive emergency psych services at Carolinas Medical Center-Randolph. Younger children, ages 3 to 6, come in with situational stress related to family dynamics, such as divorce or custody battles; depression or anxiety, often related to bullying at school or at home; suicidal ideation; conduct disorders; and behavioral issues related to autism or developmental delays. “In the emergency room, it’s crisis stabilization,” said Tez Bertiaux, RN, MSN, nurse manager for the ED at Carolinas Medical. “A lot of these children are followed in the community by a mental healthcare provider.”

The hospital’s social worker will arrange outpatient care for children who do not have a current therapist. Many are admitted to inpatient care. The psych emergency services program treats about 700 children and adolescents monthly, and the hospital admits about an equal number to its inpatient units, said Bertiaux.

Pediatric ED visits tend to increase during the school year, with school staff workers referring students for care. Some of the children are in foster care or are homeless or living in shelters. Some parents and guardians will stay during the stabilization and others do not. “It’s a very complex dynamic, because you are not just treating the patient — the family is involved,” Bertiaux said. 

Bertiaux said many of the mental health issues that bring children into the ED are related to their environment. “And that can be challenging,” she said.

Patients seeking care at a psych ED may be treated and discharged, but others require admission to a psychiatric bed for stabilization. Physicians at NewYork-Presbyterian and San Francisco General admit about 30% of their psych ED patients to the hospital. But treatment begins in the psych ED. “It’s amazing how much we can help people,” said Andrea Crowley, RN-BC, interim nurse manager in psychiatric emergency services at San Francisco General. “Some just need someone to talk to and bring them down from the crisis they are in. It makes you feel you are making a difference, and it’s a visible, tangible thing.” 

Psych care a growing need

Carolinas Medical has seen a steady increase in psych ED volume during the past several years. It treats about 18,500 patients annually with a variety of psych disorders and continuously operates at 100% occupancy. Construction is under way to double the psychiatric hospital’s inpatient beds to 132. 
Johns Hopkins Hospital in Baltimore’s psych ED census has experienced a 30% jump this year. “People are sicker, and there are fewer resources in the community,” said Kate Pontone, RN, MSN, nurse clinician 3 and nursing service line leader for Psychiatric Emergency Services at Johns Hopkins. “Outpatient programs that had space available are no longer options. People are running out of medications or cannot afford transportation. Many of the same reasons emergency departments are crowded.” 

A March 2012 Congressional briefing by the National Association of State Mental Health Program Directors reported, “the economic downturn has forced state budgets to cut approximately $4.35 billion in public mental health spending over the 2009-2012 period,” a trend it expects will continue. While at the same time, there was a 10% increase in consumers receiving state-supported mental health services. 

In July 2012, the Treatment Advocacy Center released the paper “No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals,” which found nationwide, closures of such hospitals “reduced the number of beds available in the combined 50 states to 28% of the number considered necessary for minimally adequate inpatient psychiatric services.” And “in the absence of needed treatment and care, individuals in acute or chronic disabling psychiatric crisis increasingly gravitate to hospital emergency departments, jails and prisons.”

Volume at San Francisco General’s psych ED has jumped from 500 per month to 600 per month. “It could be due to closures in programs,” Crowley said. “We are starting to see a fallout from lack of services in the community.” 

Volume also has increased at NewYork-Presbyterian where, typically, a dozen or more psych patients are waiting in the regular ED for a bed in the psych ED, Miluszusky said. Difficulty transferring patients to an inpatient bed clogs up the EDs. A lack of insurance complicates transfers, and patients may end up boarding in a regular or psych ED. 

Patients may walk in, arrive by ambulance or with a petition for involuntary commitment, because they are deemed dangerous to themselves or others. First responders may take a mental health patient to a psych ED rather than to a community hospital without such specialized services. “This is a growing population, and emergency rooms will have to evolve,” Miluszusky said. “The population is getting so big; we are going to have to think of new ways to handle it.” 

Benefits of a separate psych ED

Psychiatric emergency services programs typically are staffed with behavioral health professionals, allowing mental health interventions to begin quickly, and often the onsite team can stabilize the patient, avoiding a hospitalization, according to the article “Treatment of Psychiatric Patients in Emergency Settings” in the journal Primary Psychiatry. “You don’t have agitated psych patients in the emergency room with all of the sick people,” Crowley said. “It’s a specialized environment where you can begin treatment better.”

Nurses and other members of the psych ED team have a solid understanding about different mental health conditions and their treatment. They can begin therapeutically talking with patients immediately. “Our patients appreciate being cared for by someone who is familiar with their medications and their symptoms and can intervene when they begin to decompensate,” Pontone said. “You get specialized care and the rooms are safe,” said Miluszusky, who adds that improves outcomes. 

Psych EDs often are locked units and feature specially outfitted rooms, with no sharp corners, no cords, nonexposed plumbing and a calm atmosphere. The safety features prevent patients from harming themselves or creating tools to harm others. “Our main priority is patient safety,” Ziccardi-Colson said. “There’s no potential for suicide or other negative outcomes.”

Ziccardi-Colson reported Carolinas Medical’s psych ED operates cost effectively, in part because of its ability to begin treatment and stabilize. “We’re able to process people more quickly than a medical ED,” Ziccardi-Colson said. 

Miluszusky said having a psych ED can be cost effective, because it reduces overtime pay necessitated by providing one-on-one oversight of a psych patient in the medical ED. 

Nurse staffing varies by institution, often with psychiatric nurses providing care, such as at San Francisco General’s psych ED. “It’s an exciting job, where you see a wide variety of people,” Crowley said. “You have a profound effect on people’s lives.”

Emergency nurses, who have received specialized training in the care of mental health patients and de-escalating situations, staff the psych ED at NewYork-Presbyterian. Nurses from a Johns Hopkins inpatient psych unit covers the emergency room, and Pontone describes significant interest from the inpatient staff. The hospital also cross-trains the ED nurses, so they can step in during an emergency. Pontone says nurses who love psychiatric nursing are interested in the management of the acutely ill patient, who needs as much care and support as they can get in a safe environment. “We like to be there when patients are in crisis and need help,” she said. “And we are good in a crisis.”

Ziccardi-Colson said every day presents challenges, but the reward of helping patients to wellness is inspiring and keeps nurses motivated. “Those who like it, love it,” Crowley said. “And for those who are not into it, we are happy to do it for them.” 

Source: Nurse.com