DiversityNursing Blog

As a resource for Nurses across the country, DiversityNursing.com wants to be sure our community is aware of the following site: The Future of Nursing: Campaign for Action.

The Future of Nursing: Campaign for Action, an initiative to ensure that all Americans have access to high-quality, patient-centered health care, with nurses contributing to the full extent of their capabilities. Action Coalitions work with the campaign to implement the recommendations of the landmark Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health. The coalitions are comprised of nursing, other health care, business, consumer and other leaders across the country. 48 states have Action Coalitions involved in this initiative.
 
The Campaign for Action is a collaborative effort to implement solutions to the challenges facing the nursing profession, and to build upon nurse-based approaches to improving quality and transforming the way Americans receive health care.
 
Action Coalitions are the driving force of the campaign at the local and state levels. These groups capture best practices, determine research needs, track lessons learned and identify replicable models. Examples of accomplishments to date include:

Texas is collaborating with nursing education leaders to adopt a common menu of core required classes across 106 schools in the state.

New Jersey is advancing practice by disseminating best practice models that demonstrate the benefits of staff nurses working to the full extent of their education and training.

Indiana is working within Indiana University to include inter-professional education into the newly designed curriculum to be used by a number of its health profession programs, including the schools of medicine and nursing.

Virginia is advancing nursing leadership by recognizing and mentoring 40 Virginia registered nurses younger than 40 who positively represent and lead their profession.

To get involved and find out more http://www.thefutureofnursing.org/

By Diane Sparacino via rn.com

Imagine a world where hospitals have become so noisy that the annoyance has topped hospital complaints, -- even more than for the tasteless, Jell-O-laden hospital food (Deardorff, 2011). If you’re a nurse, you know that we’re already there -- with noise levels reaching nearly that of a chainsaw (Garcia, 2012). In fact, for more than five decades, hospital noise has seen a steady rise (ScienceDaily, 2005).

But it wasn’t always that way. At one time, hospitals were virtually noise-free like libraries -- respected spaces, preserved as quiet zones. The culture was such that a loud visitor might be silenced by a nurse’s purposeful glare or sharply delivered “Shhh!” As early as 1859, the importance of maintaining a quiet environment for patients was a topic for discussion. In Florence Nightingale’s book, “Notes on Nursing,” she described needless noise as "the most cruel absence of care" (Deardorff, 2011).
 
Fast forward to 1995, when the World Health Organization (WHO) outlined its hospital noise guidelines, suggesting that  patient room sound levels not exceed 35 decibels (dB). Yet since 1960, the average daytime hospital noise levels around the world have steadily risen to more than double the acceptable level (from 57 to 72 dB), with nighttime levels increasing from 42 to 60 dB. WHO found that the issue was not only pervasive, but high noise levels remained fairly consistent across the board, despite the type of hospital (ScienceDaily, 2005).

Researchers at Johns Hopkins University began to look into the noise problem in 2003. They maintained that excessive noise not only hindered the ability for patients to rest, but raised the risk for medical errors. Other studies blamed hospital noise for a possible increase in healing time and a contributing factor in stress-related burnout among healthcare workers (ScienceDaily, 2005).

Technology is, of course, partly to blame. State-of-the-art machines, banks of useful alarms, respirators, generators, powerful ventilation systems and intercoms all add up to a lot of unwanted racket. When human voices are added to the mix, (i.e.  staff members being forced to speak loudly over the steady din of medical equipment), it’s anything but a restful environment. For the recovering patient in need of sleep, that can be a real issue (Deardorff, 2011).

Contributing to the problem, experts say, are the materials used in hospitals. Because they must be easily sanitized, surfaces cannot be porous where they could harbor disease-causing organisms. Rather than using noise-muffling materials like carpet, acoustic tiles and other soft surfaces, hospitals have traditionally been outfitted using smooth, hard surfaces – especially in patient rooms. Good for cleanliness – not so great for dampening sounds, which tend to bounce around the typical hospital (Deardorff, 2011).

Which brings us to the most recent research, published January 2012 in the Archives of Internal Medicine. In the report, Jordan Yoder, BSE, from the Pritzker School of Medicine, University of Chicago, and his colleagues associated elevated noise levels with “clinically significant sleep loss among hospitalized patients,” perhaps causing a delay in their recovery time (Garcia, 2012). During the 155-day study period, researchers examined hospital sound levels. The numbers far exceeded (WHO) recommendations  for average hospital-room noise levels, with the peak noise at an average 80.3 dB – nearly as loud as a chainsaw or electric sander (85 dB), and well over the recommended maximum of 40 dB. And while nights tended to be quieter, they were still noisier than recommended allowances, with “a mean maximum sound level of 69.7 dB” (Garcia, 2012).

Perhaps most interestingly, the researchers broke down the sources of noise into categories: “Staff conversation (65%), roommates (54%), alarms (42%), intercoms (39%), and pagers (38%) were the most common sources of noise disruption reported by patients” (Garcia, 2012). "Despite the importance of sleep for recovery, hospital noise may put patients at risk for sleep loss and its associated negative effects," they wrote. In addition, researchers found that the intensive care and surgical wards had some work to do in dampening noise levels, with ICU peaking at 67 dB and 42 dB for surgical areas. Both far exceeded WHO’s 30 dB patient room recommendation (Garcia, 2012).

Besides patient sleep deprivation, which itself can lead to a multitude of health problems including high blood sugar, high blood pressure and fatigue, studies have reported that elevated noise levels can increase heart and respiratory rates, blood pressure and cortisol levels. Recovery room noise causes patients to request more pain medication, and preterm infants “are at increased risk for hearing loss, abnormal brain and sensory development, and speech and language problems when exposed to prolonged and excessive noise” (Deardorff, 2011).

There is still more research to be done, of course, but Yoder and his colleagues had good news, as well; much of the hospital noise they identified is modifiable, suggesting that hospitals can take steps to successfully create a quieter environment for both patients and healthcare providers (Garcia, 2012).

Around the country, “quiet campaigns” have been launched by hospitals in an attempt to dampen nighttime noise. Besides dimming lights and asking staff to keep their voices down at night, they are working to eliminate overhead paging systems, replace wall and/or floor coverings – even the clang of metal trashcans. Northwestern's Prentice Women's Hospital in Chicago was built with noise reduction in mind, replacing the idea of centralized nursing stations with the advent of smaller, multiple stations (Deardorff, 2011)

Billed as “one of the nation’s largest hospital construction projects,” Palomar Medical Center in North San Diego County is a state-of-the-art facility that has been designed “to encourage quietness,” according to Tina Pope, Palomar Health  Service Excellence Manager. Slated to open its doors this August, the hospital will feature a new nursing call system to route calls directly to staff and help eliminate the need for overhead paging, de-centralized nursing stations and clear sight lines, allowing staff to check on patients without having to leave unit doors open. With measures already in place including “Quiet Hospital” badges on staff and posters at the entrance of every unit, a “Quiet at Night” campaign (9 p.m. – 6 a.m.), and a “Quiet Champions” program that encourages staff to report noise problems, Palomar is one of a growing number of hospitals working toward a new era of quiet.

By Rose O. Sherman via American Nurse Today

Editor’s note: At American Nurse Today, we believe every nurse can be a leader. This article is the first in what will be occasional guest blogs by Rose O. Sherman, founder of the Emerging RN Leader blog (www.emergingrnleader.com). In addition to her guest blogs, Rose will contribute articles on a regular basis to help nurses achieve their leadership potential.

 You may know that you want to be a nurse leader but are unsure about your next career step. It is important to recognize that you don't have to be a chief nursing officer or a nurse manager to "lead." You can begin leading from wherever you are in the organization. If you manage your career around this concept, you will focus less on your linear progression up the career ladder and more on your own personal mastery and impact.

An important question to ask yourself as you begin your leadership journey is whether you have the qualities that nurses look for in their leaders. Successful leaders are unable to achieve goals without inspired and motivated followers. We have all probably observed nurses who have been placed into leadership positions and had the formal title of leader but are not successful in capturing the heart and soul of those they lead. John Maxwell, in his book The 21 Irrefutable Laws of Leadership, makes the important point that leadership is above all the ability to influence others. We know from research some key qualities that nurses look for in their leaders include:

• ·       A commitment to excellence
• ·       Passion about their work
• ·       A clear vision and strategic focus
• ·       Trustworthiness
• ·       Respectfulness
• ·       Accessibility
• ·       Empathy and caring
• ·       A commitment to developing others

Honest feedback about whether or not you demonstrate these qualities is important at the beginning of a leadership career. A good mentor can help you grow as an emerging nurse leader and open doors to new learning. Unlike the preceptor relationship, which you may be familiar with in the clinical setting, a mentor provides career guidance and helps you become more aware of your strengths and areas where you need development. An ideal mentor for an emerging nurse leader is someone who is knowledgeable, has leadership experience, and is interested in helping you to grow.

For some nurses, just getting noticed in their organization can be a challenge, especially if it is very large or if you work a night tour. When opportunities become available for advancement, you want to be someone that the nurse leaders in your organization think about as a great candidate, so consider these tips:

 1. Look professional

First impressions do count if you want to get noticed. Professional dress and being well groomed matter in creating a good image. When nurse leaders see nurses with wrinkled scrubs and dirty shoes, the impression is generally not favorable. You want to be remembered as someone who will be a good candidate to represent the organization.

2. Stay updated

It is important to stay updated by reading professional journals and attending educational programs. Be a "go-to person" for new information in your specialty area. In addition to staying updated clinically, pay attention to the news and what is happening with health policy. Think about how proposed changes in health reform could impact your organization and share your knowledge with other staff. Recognize that health care is also a business and become knowledgeable about the business of caring.

3. Take leadership roles

Take leadership roles at the unit level. They can be small but it is a great way to get started. Volunteer to take a leadership role on a unit shared-governance committee. Take charge when you have the opportunity. This is an excellent way to connect with other staff and leaders in your organization.

4. Volunteer for task forces and committees

Volunteer for organizational committees and task forces, even if it does mean coming in on your day off to participate. Leaders do notice when staff members are committed enough to an organization that they are willing to give back some of their personal time to be involved in activities.

5. Participate in organization-sponsored community activities

Join the heart walk team, the breast cancer walk, the March of Dimes, or other teams your organization may put together to support the community. Get others on your unit to join you. You will find that organizational leaders participate in these activities, and it can be a great way to introduce yourself in an informal setting and meet many new people.

6. Be professionally involved

Join a professional nursing association and attend the local meeting. You will probably meet staff and leaders from your organization that you might not interact with in other forums. Local professional associations are always looking for members who are willing to assume some leadership responsibilities. Holding office in a local association can be a good way to gain recognition.

7. Serve as a preceptor and cheerleader to other staff

Be ready to share your skills and knowledge with others. Sharing and volunteering to be a preceptor can be a great way to get noticed. Your manager will appreciate your willingness to be a strong team player. Be the first to congratulate others for their achievements and be the person who helps create a healthy work environment on your unit.

8. Keep your commitments

I once asked a great nursing leader what he attributed his success to. He told me that he did what he said he was going to do when he said he was going to do it. This will get you noticed, he assured me, because so few people actually keep their commitments. This is really great advice. If you volunteer, be sure to follow through.

There has never been a better time to choose nursing leadership as a career goal. The retirement of a large number of baby boomer nurse leaders will result in great career opportunities by the end of the decade. Oprah Winfrey often says that “luck is preparation meeting opportunity.” The time to start preparing for these opportunities is now. 

Via MedicalNewsToday

University of Stirling researchers have secured funding to investigate the effectiveness of training student nurses in mindfulness to reduce stress levels.

The study, which begins next month, will involve student nurses undergoing a stress test and then carrying out four weeks of mindfulness training. The participants will then undergo another stress test to find out if the mindfulness has helped reduce stress levels and increase their ability to cope with stress.

The student nurses will have guided meditation sessions and keep a journal about their own practice sessions at home as part of the research.

Mindfulness, or meditation, is a technique which can be learned and helps individuals to relax and cope better with stressful situations.

PhD research student Jenny Jones and Research Fellow Mariyana Schoultz, based at the Highland Campus in Inverness, are carrying out the study with Professor Stephen Leslie, a cardiologist consultant at Raigmore Hospital and Professor Angus Watson.

Researcher Jenny Jones said: "Hospitals can be a very stressful environment to work in. In my nursing training there was no mention of how to cope with stress but this is something that nurses face on a daily basis. Student nurses are not prepared for the very emotional and sometimes traumatic events they may witness at work, or equipped with the tools to cope and carry on with their job effectively. This study hopes to change that.

"We want to find out if mindfulness will impact on how nursing students cope with stress. If the results are positive, we want it to be introduced as part of nursing training. The ultimate hope is that this will make the nurses of the future more resilient to work related stress."

Nurses experience high levels of work related stress and are at risk of stress related illness. At any one time up to four per cent of trained nurses and up to six per cent of health care assistants are off work with stress or stress-related illness.

From USA Today

WASHINGTON – A narrowly divided Supreme Court upheld President Obama's health care law Thursday in a complex opinion that gives the president a major election-year victory.

The historic 5-4 decision will affect the way Americans receive and pay for their personal medical care in the future. It upholds the individual mandate that most Americans get health insurance or pay a penalty — and it was the penalty, or tax, that ultimately saved the law.

Chief Justice John Roberts announced the decision that allows the law to go forward with its aim of covering more than 30 million uninsured Americans. He argued that the mandate is constitutional only because the penalty "functions like a tax" and is therefore allowed under Congress' taxing power.

"Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Roberts wrote.

The court's four liberal justices, Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor, joined Roberts in the majority vote. They argued for a more sweeping approval based on the commerce clause, but the end result was the same.

Conservative Justices Samuel Alito, Anthony Kennedy,Antonin Scalia and Clarence Thomas dissented. Kennedy, who was thought to be the most likely swing vote, delivered a scathing denunciation from the bench.

"The majority rewrites the statute Congress wrote. … What Congress called a penalty, the court calls a tax," Kennedy said. "The Affordable Care Act now must operate as the court has revised it, not as Congress designed it."

President Obama, speaking from the White House after the decision, said, "Whatever the politics, today was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court's decision to uphold it.

"It should be pretty clear by now that I didn't do this because it's good politics," Obama said. "I did it because I believed it was good for the country."

Roberts — a conservative appointed by President George W. Bush— provided the key vote to preserve the landmark health care law, which figures to be a major issue in Obama's re-election bid against Republican opponent Mitt Romney.

From Advance for Nurses By Beth Puliti

The Institute of Medicine recently appealed for a change in nurses' roles, responsibilities and education, proposing to implement nurse residency programs to assist in the clinical practice transition (Advancing Health, October 2010).

The Hospital of the University of Pennsylvania, Philadelphia, identified the need for support much earlier.

Its Gateway to Critical Care Program started 10 years ago and offers new nurses and registered nurses with less than 1 year of critical care experience the opportunity to work alongside experienced ICU nurse preceptors to become safe and competent critical care nurses.

"The competency-based orientation program helps foster the knowledge and skills necessary to care for patients within the different critical care units in our hospital," said Lisa Fidyk, MSN, MS, RN, coordinator of the Gateway to Critical Care Program.

Catering to the Adult Learner

Participants enrolled in the program adhere to an educational plan that defines competency expectation, patient assignment and preceptor/learner responsibilities.

"We base our program on Patricia Benner's From Novice to Expert model. We work to assist the graduate nurse's progress from advanced beginner to competent nurse utilizing her framework," explained Fidyk, who is also a professional development specialist in the Department of Nursing Education, Innovation and Professional Development.

As Fidyk mentioned, Benner's framework of skill acquisition and development of the essence of critical thinking is utilized in the Gateway to Critical Care Program. Goals are reached through segmented learning, faculty guidance, a supportive environment and preceptor/orientee relationships.

The 16- to 20-week program consists of 4-5 weeks of classroom/clinical and 11-16 weeks of full-time clinical. It enrolls new-to-practice surgical, cardiac, neuroscience, cardiothoracic and medical ICU nurses, as well as nurses from the emergency department. Fidyk noted the nurses learn from various teaching strategies, including classroom instruction, clinician-supervised skill labs and clinical experiences.

"The program caters to the adult learner and provides different ways for these nurses to learn about the critical care arena. We incorporate case studies, lectures, discussions and simulation to help them develop the skills they would need to care for critically ill patients," she said.

Throughout the program, nurses learn the following core competencies: airway and ventilator management; cardiac monitoring; critical care pharmacology; hemodynamic monitoring; arterial blood gases analysis; acid-based balance; pain, sedation, neuromuscular blockade; and end-of-life care.

Working Alongside Experienced Nurses

Clinical support comes in the way of clinical preceptors, Gateway to Critical Care faculty and critical care advanced practice nurses/clinical nurse specialists/clinical nurse IV staff nurses.

While enrolled in the program, nurses work beside experienced ICU nurse preceptors.

"A preceptor is a mentor," Fidyk said. "They work with that person when they are on the unit taking care of patients. Preceptors are experienced nurses who know what it's like to go through the Gateway Program, how to collaborate and how to make it a great experience."

When the nurses return to their floor, they practice and hone their skills with a preceptor for the duration of the program.

"My nurse preceptor was a nurse on the unit for 5 years," recalled Lauren Mang, BSN, RN, clinical nurse I in the neuro ICU at the Hospital of the University of Pennsylvania. "She was fabulous. She really gave me the confidence and courage I needed to become a better nurse."

Mang noted preceptors help new nurses become more at ease because, as an experienced nurse who knows the ins and outs, they are able to impart their knowledge at a comfortable level.

"She was there side by side with me until toward the end when she started to hide from me so I would learn how to answer questions on my own. She gave me the confidence to be able to do that," she said.

New Graduate Nurse Retention

After the Gateway to Critical Care program, nurses are enrolled in the Nurse Residency Program, a yearlong series of learning and work experiences designed to support nurses as they transition into professional nursing practice.

The Hospital of the University of Pennsylvania participates in the United HealthSystem Consortium (UHC)/American Association of Colleges of Nursing (AACN) National Nurse Residency Program and was actually the first Philadelphia hospital to participate in the National Nurse Residency Program.

The UHC/AACN Nurse Residency Program consists of an evidence-based curriculum developed by academic and nursing experts across the country. It boasts a reduction in voluntary turnover rate for first-year nurses to well below the median of 27.1 percent. Programs that have implemented this residency program model have attained retention rates of more than 94 percent.

Fidyk commented that both the Gateway to Critical Care Program and the Residency Program at the Hospital of the University of Pennsylvania act as a great support system, and with that support she's seen a "huge" increase in retention. A 98 percent retention rate to be exact.

A higher nurse retention rate delivers better patient outcomes by increasing the nursing staff's experience and competency. Retention also helps preserve new graduate nurses' knowledge, experience and competence gained during the first year of professional practice.

"I know a lot of hospitals don't have these programs, and when I was in a leadership class in nursing school, we actually talked about Penn's Gateway program. That really opened my eyes to research this program more," Mang said. "I needed just a little bit of extra help one-on-one and it really helps you with that. Right now, I'm only 11 months into this and I feel very confident and have learned a lot from this program."

Fidyk noted that, for most of the nurses who come into the program, it's their first job - and it's an intense arena.

"You're saving people's lives, you're dealing with emotional aspects of your job, you're coming in contact with many different healthcare providers - it's all very overwhelming. The Gateway to Critical Care Program is a great way to help new nurses figure everything out and have someone to talk to who will listen," she concluded.

From Nurse.com News

Contrary to what many trauma teams believe, the presence of family members does not impede the care of injured children in the ED, according to a study.

Professional medical societies, including the American Academy of Pediatrics and the American College of Emergency Physicians, support family presence during resuscitations and invasive procedures. The degree of family member involvement ranges from observation to participation, depending on the comfort level of families and healthcare providers.

"Despite the many documented family and patient benefits and previous studies that highlight the safe practice of family presence, trauma providers remain hesitant to adopt this practice," lead author Karen O’Connell, MD, FAAP, a pediatric emergency medicine attending physician at Children’s National Medical Center in Washington, D.C., said in a news release.

"A common concern among medical providers is that this practice may hinder patient care, either because parents will actually interfere with treatment or their presence will increase staff stress and thus decrease procedure performance."

The aim of the study was to evaluate the effect of family presence on the trauma teams’ ability to identify and treat injured children during the initial phase of care using the Advanced Trauma Life Support protocol. ATLS is a standard protocol for trauma resuscitation shown to limit human error and improve survival.

Over a four-month period, researchers reviewed recordings of 145 trauma evaluations of patients younger than 16. Of the patients, 86 had family members present.

Investigators compared how long it took the trauma team to perform important components of the medical evaluation (such as assessing the child’s airway, breath sounds, pulse and neurologic disability, and looking for less obvious injuries) when families were present and when they were not. Investigators also compared how frequently elements of a thorough head-to-toe examination were completed.

Results showed no differences in the time it took to complete the initial assessment with and without family members present. For example, the median time to assessing the airway was 0.9 minutes in both groups. In addition, the researchers found no difference in how often components of the head-to-toe exam were completed. The abdomen was examined in 97% of all patients when families were present, for example, and 98% of patients when families were not present.

"Parents are increasingly asking and expecting to be present during their child’s medical treatment, even if it involves invasive procedures," said O’Connell, who also is an assistant professor of pediatrics and emergency medicine at George Washington University School of Medicine and Health Sciences.

"We found that medical teams were able to successfully perform needed evaluation and treatments of injured children both with and without family members present. Our study supports the practice of allowing parents to be present during the treatment of their children, even during potentially painful or invasive procedures."

From Advance for Nurses

Findings from the NLN's Annual Survey of Schools of Nursing Academic Year 2010-2011 attest to the continued need for more nurse faculty to meet the needs of the U.S. healthcare system.

Conducted October-November of last year, the NLN survey reveals demand for pre-licensure program entry continues high despite a shifting student demographic, while competition for entry into post-licensure is increasing.

Unfortunately, notes NLN CEO Beverly Malone, PhD, RN, FAAN, the percentage of post-licensure programs that turned away qualified applicants also rose between 2009 and 2011.

Most strikingly, the percentage of MSN programs turning away qualified applicants jumped by 15 percent over the past 2 years, from just one in three programs to almost half in 2011.

The survey also shows the percentage of racial-ethnic minority students enrolled in pre-licensure RN programs fell from a high of 29 percent in 2009 to 24 percent in 2011.

The majority of that decline stems from a steep reduction in African American students enrolled in associate degree nursing programs, which dropped by almost 5 percent to 8.6 percent in just 2 years.

Hispanics remain dramatically underrepresented among nursing students as well, according to NLN, representing only 6 percent of baccalaureate and associate degree nursing students.

But while educational capacity is still insufficient to keep up with demand, some promising trends were uncovered by the survey, says NLN president Judith Halstead, PhD, RN, FAAN,

"For example, the percentage of male pre-licensure graduates in 2011 was up to 15 percent after inching up only a percentage point a year since 2009," she notes. "In addition, the percentage of pre-licensure RN students over age 30 has declined in recent years."

From RNCentral.com

I love my computer. I drag it and my iPhone almost everywhere, including to the NANDA-I Conference I attended last week. I take notes while listening to speakers, I use my phone or my digital camera to record the slides the experts use in their presentations, I post conference updates on Twitter and Facebook, and I bring it all together for this blog. I live an e-life it seems.

This is important because it has a direct bearing on healthcare, nursing, and as it would seem, nursing language (what NANDA-I uses to define “the knowledge of nursing”). My vocabulary enlarged last week as I learned a new word, some new phrases, and some new perils to look out for when I am working at the hospital.

E-Iatrogenic

We should all know that “iatrogenic” means “of or relating to illness caused by medical examination or treatment.” One of the terms we see a lot these days is “HAI” or “hospital acquired infection.” This, along with other illnesses and injuries, which happen as a result of other medical care, are no longer being paid for by the Center for Medicare and Medicaid Services (CMS) or by most insurance companies. And, there is new area of concern of which we must be aware: E-iatrogenic issues.

In the simplest way I can explain it, all the computers we’ve come to rely on in healthcare have their own perils and we are really starting to see evidence of that.

Elizabeth Borycki, RN, PhD, is an assistant professor of health information science the University of Victoria, in British Columbia, Canada. While attending NANDA-I she presented a paper on identifying and reducing “technology-induced errors” (one of those new phrases) or e-iatrogenic.

Technology-induced errors are errors that arise from the design and development of technology and the implementation and customization of that technology. In 1995 the U.S. Institute of Medicine endorsed the use of electronic health records (EHRs) as an intervention that could reduce errors. Healthcare organizations around the world ran with it and some follow-up studies reported the systems could replace the number of errors happening each year.

However, 10 years later, journal articles started publishing findings that described how EHRs and component software systems could, in themselves, lead to errors. Some of the types of errors Borycki highlighted included automatic defaults, incorrect medication dosages, and incorrect patient data. She cited some of the factors involved in these technology-induced mistakes:

• Human factors including usability and workflow.
• Organizational behavior such as socio-technical issues and system/organizational fit.
• Software engineering including testing approaches.

While chatting with Borycki, after her presentation, we noted several ways these errors happen to all of us. For example, you put in some data but forget to hit return and “oops,” the patient’s last set of vital signs don’t actually get recorded. Or the drop down box you have to pick from auto-populates an answer if you don’t pick one, or something unusual happens and there is no free-text box to record the event—all of these are situations I’ve actually dealt with as hospital’s I’ve worked in become more automated. These are all potential patient safety issues.

And this brings us to why Borycki presented at NANDA-I. Borycki and her fellow researchers believe that we need to extend the NANDA-I taxonomy to include the emergence of these new patient safety issues. That is, technology-induced errors arising from the widespread implementation of health information systems. We need some new nursing diagnoses.

According to Borycki, examples of potential interventions include:

• Reporting if computer system is not working or is malfunctioning.
• Reporting if computer system causes hazards due to inefficiencies or negatively affects workflow.
• Awareness of limitations of computer systems in nursing.
• Questioning computer generated results that may not appear to match the right patient.
• Recognizing problems in dangerous “work-arounds” due to technology.
• Training on how to proceed in situations where a computer system goes down or is not available.

Nurses I have worked with come from many camps. Some like charting electronically, some miss paper charting (although there are error problems there too) and some want EMRs to work but don’t trust the systems. The reality is EMRs and electronic charting are here to stay. It is our job as nurses to get involved, to point out where entries could be more efficient or easier to use, to learn more about the systems we are given and use every day and to be proactive in finding the best possible means for using them. For that, we need a language because it all comes back to standardized communication techniques are the best ways to keep our patients safe—our primary concern as RNs. NANDA-I has a new challenge, defining the e-knowledge of nursing.

From The Associated Press via SouthCoastToday.com

A visit to the emergency department or a physician's office can be confusing and even frightening when you're trying to digest complicated medical information, perhaps while you're feeling pain or discomfort. For the 25 million people in the United States with limited English proficiency, the potential for medical mishaps is multiplied.

A trained medical interpreter can make all the difference. Too often, however, interpreter services at hospitals and other medical settings are inadequate. Family members, including children, often step in, or the task falls to medical staff who speak the required language with varying degrees of fluency.

According to a study published in March, such ad hoc interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters.

The study, published online in the Annals of Emergency Medicine, examined 57 interactions at two large pediatric emergency departments in Massachusetts. These encounters involved patients who spoke Spanish at home and had limited proficiency in English.

Researchers analyzed audiotapes of the visits, looking for five types of errors, including word omissions, additions and substitutions as well as editorial comments and instances of false fluency (making up a term, such as calling an ear an "ear-o" instead of an "oreja").

They recorded 1,884 errors, of which 18 percent had potential clinical consequences.

For professionally trained interpreters with at least 100 hours of training, the proportion of errors with potential clinical significance was 2 percent. For professional interpreters with less training, the figure was 12 percent. Ad hoc interpreter errors were potentially clinically significant in nearly twice as many instances — 22 percent. The figure was actually slightly lower — 20 percent — for people with no interpreter at all.

It makes sense that trained interpreters, especially those with more experience, would make fewer errors, says Glenn Flores, a professor and director of the division of general pediatrics at UT Southwestern Medical Center and Children's Medical Center of Dallas, who was the study's lead author. Experienced interpreters "know the medical terminology, ethics, and have experience in key situations where you need a knowledge base to draw on," he says.

Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color or national origin. Courts have interpreted that to mean that all health-care providers that accept federal funds — because they serve Medicare and Medicaid recipients, for example — must take steps to ensure that their services are accessible to people who don't speak English well, according to the National Health Law Program, a nonprofit that advocates for low-income and underserved people. (Doctors whose only federal payments are through Medicare Part B are exempt from this requirement, however.) The Census Bureau estimates that nearly 9 percent of the population age 5 or older has limited English proficiency, which the bureau defines as people who describe themselves as speaking English less than "very well."

Hospitals and other medical providers are in a tough spot, say experts. The law prohibits them from asking patients to pay for translation services, and they may not receive adequate or in some cases any other reimbursement. "It's a civil rights law, not a funding law," says Mara Youdelman, managing attorney in the Washington office of the National Health Law Program.

A dozen states and the District of Columbia reimburse hospitals, doctors and other providers for giving language services to enrollees in Medicaid, the joint federal-state program for low income people, and in CHIP, a federal-state health program for children, according to Youdelman. Virginia and Maryland do not.

A 2008 survey by America's Health Insurance Plans, an industry trade group, found that 98 percent of health insurers provide access to interpreter services, but providers and policy experts question that figure. According to a survey by the Health Research and Educational Trust, in partnership with the American Hospital Association, 3 percent of hospitals received direct reimbursement for interpreter services, most of that from the Medicaid program.

"Most hospitals that make this a priority make it a budget item," Youdelman says.

Hospitals and other providers realize that offering competent interpreter services can help ensure that they don't miss or misdiagnose a condition that results in serious injury or death, experts say. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures.

Youdelman cites the example of a Russian-speaking patient in Upstate New York who arrived at an emergency department saying a word that sounded like "angina." The emergency staff ran thousands of dollars' worth of tests, thinking he might be having a heart attack. The real reason for his visit: a bad sore throat.

Like many hospitals, Children's Medical Center of Dallas provides interpreter services around the clock via varying modes of communication — face-to-face, telephone and video — delivered by a mix of trained staff interpreters and outside contractors.

When Nadia Compean, 23, was six months pregnant, her doctor in Odessa, Texas, told her that her baby had spina bifida, a condition in which the spinal cord doesn't close properly, leading to permanent nerve and other damage.

The local hospital wasn't equipped to handle the birth and subsequent surgery that her daughter would require, so Nadia and the child's father traveled to Dallas, about 350 miles away.

Neither speaks much English, but at Children's Medical Center of Dallas, interpreters helped them understand what to expect, Nadia said (through an interpreter).

Nadia says she learned that her daughter, Eva, would be born with a lump on her back and would require immediate surgery. She also learned about problems that Eva may experience walking and using the toilet, she says.

Eva was born March 6. Because of her medical needs and the lack of adequate interpreter services in Odessa, the couple is considering relocating to Dallas, where the father hopes he can find construction work.

This column is produced through a collaboration between The Washington Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.