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A small study by researchers at The Ohio State University Wexner Medical Center found that a workplace mindfulness-based intervention reduced stress levels of employees exposed to a highly stressful occupational environment, according to a news release.

Members of a surgical ICU at the academic medical center were randomized to a stress-reduction intervention or a control group. The eight-week group intervention included mindfulness, gentle stretching, yoga, meditation and music therapy in the workplace. Psychological and biological markers of stress were measured one week before and one week after the intervention to see if these coping strategies would help reduce stress and burnout among participants.

Results of this study, published in the April 2015 issue of Journal of Occupational and Environmental Medicine, showed levels of the chemical salivary alpha amylase, were significantly decreased from the first to second assessments in the intervention group. The control group showed no changes. Chronic stress and stress reactivity have been found associated with increased levels of salivary alpha amylase, according to the release. Psychological components of stress and burnout were measured using well-established self-report questionnaires. “Our study shows that this type of mindfulness-based intervention in the workplace could decrease stress levels and the risk of burnout,” one of the study’s authors, Maryanna Klatt, PhD, associate clinical professor in the department of family medicine at Ohio State’s Wexner Medical Center, said in the release. “What’s stressful about the work environment is never going to change. But what we were interested in changing was the nursing personnel’s reaction to those stresses.”

Klatt said salivary alpha amylase, which is a biomarker of the sympathetic nervous system activation, was reduced by 40% in the intervention group.

Klatt, who is a trained mindfulness and certified yoga instructor, developed and led the mindfulness-based intervention for 32 participants in the workplace setting. At baseline, participants scored the level of stress of their work at 7.15 on a scale of 1 to 10, with 10 being the most stressful. The levels of work stress did not change between the first and second set of assessments, but their reaction to the work stress did change, according to the release. 

When stress is part of the work environment, it is often difficult to control and can negatively affect employees’ health and ability to function, lead author Anne-Marie Duchemin, PhD, research scientist and associate professor adjunct in the department of psychiatry and behavioral health at Ohio State’s Wexner Medical Center, said in the release. “People who are subjected to chronic stress often will exhibit symptoms of irritability, nervousness, feeling overwhelmed; have difficulty concentrating or remembering; or having changes in appetite, sleep, heart rate and blood pressure,” Duchemin said ih the release. “Although work-related stress often cannot be eliminated, effective coping strategies may help decrease its harmful effects.” 

The study was funded in part by the OSU Harding Behavioral Health Stress, Trauma and Resilience Program, part of Ohio State’s Neurological Institute.

  PAULA SPAN

What she wanted, the patient told the geriatricians evaluating her, was to be able to return to her condominium in Boston. She had long lived there on her own, lifting weights to keep fit and doing her own grocery shopping, until a heart condition worsened and she could barely manage the stairs.

So at 94, she consented to valve replacement surgery at a Boston medical center. “She never wanted to go to a nursing home,” said Dr. Perla Macip, one of the patient’s geriatricians. “That was her worst fear.”

Dr. Macip presented the case on Saturday to a meeting of the American Academy of Hospice and Palliative Medicine. The presentation’s dispiriting title: “The 30-Day Mortality Rule in Surgery: Does This Number Prolong Unnecessary Suffering in Vulnerable Elderly Patients?”

Like Dr. Macip, a growing number of physicians and researchers have grown critical of 30-day mortality as a measure of surgical success. That seemingly innocuous metric, they argue, may actually undermine appropriate care, especially for older adults.

The experience of Dr. Macip’s patient — whom she calls Ms. S. — shows why.

Ms. S. sustained cardiopulmonary arrest during the operation and needed resuscitation. A series of complications followed: irregular heartbeat, fluid in her lungs, kidney damage, pneumonia. She had a stroke and moved in and out of the intensive care unit, off and on a ventilator.

After two weeks, “she was depressed and stopped eating,” Dr. Macip said. The geriatricians recommended a “goals of care” discussion to clarify whether Ms. S., who remained mentally clear, wanted to continue such aggressive treatment.

But “the surgeons were optimistic that she would recover” and declined, Dr. Macip said.

So a discussion of palliative care options was deferred until Day 30 after her operation, by which time Ms. S. had developed sepsis and multiple-organ failure. She died on Day 31, after life support was discontinued.

The key number here, surgeons and other medical professionals will recognize, is 30.

Thirty-day mortality serves as a traditional yardstick for surgical quality. Several states, including Massachusetts, require public reporting of 30-day mortality after cardiac procedures. Medicare has also begun to use certain risk-adjusted 30-day mortality measures, like deaths after pneumonia and heart attacks, to penalize hospitals with poor performance and reward those with better outcomes.

However laudable the intent, reliance on 30-day mortality as a surgical report card has also generated growing controversy. Some experts believe pressures for superior 30-day statistics can cause unacknowledged harm, discouraging surgery for patients who could benefit and sentencing others to long stays in I.C.U.s and nursing homes.

“Thirty days is a game-able number,” said Dr. Gretchen Schwarze, a vascular surgeon at the University of Wisconsin-Madison and co-author of an editorial on the metric in JAMA Surgery. Last fall, she led a session about the ethics of 30-day mortality reporting at an American College of Surgeons conference.

“Surgeons in the audience stood up and said, ‘I can’t operate on some people because it’s going to hurt our 30-day mortality statistics,’” she recalled. The debate is particularly urgent for older adults, who are more likely to undergo surgery and to have complications.

Those questioning the 30-day metric point to potential dilemmas at both ends of the surgical spectrum. Surgeons may decline to operate on high-risk patients, even those who understand and accept the trade-offs, because of fears (conscious or not) that deaths could hurt their 30-day results.

At a hospital in Pennsylvania, for instance, a cardiothoracic surgeon declined to operate on a man who urgently needed a mitral valve replacement. He wasn’t elderly, at 53, but he was an alcoholic whose liver damage increased his risk of dying.

Dr. Douglas White, the director of ethics and decision-making in critical illness at the University of Pittsburgh School of Medicine, was asked to consult. According to Dr. White, the surgeon explained that “we have been told that our publicly reported numbers are bad, and we have to take fewer high-risk patients.”

Other surgeons at the hospital, under similar pressure, also refused. A helicopter flew the patient to another hospital for surgery.

An outlier case? A study in JAMA in 2012 compared three states that require public reporting of coronary stenting results to seven nearby states that didn’t report. Older-adult patients having acute heart attacks had substantially lower rates of the stenting in the reporting states. Doctors’ concerns about disclosure of poor outcomes might have led them to perform fewer procedures, the authors speculated; they might also have weeded out poorer candidates for surgery.

Perhaps as important for older people, when things go wrong, surgical teams concerned about their 30-day metrics may delay important conversations about palliative care or hospice, or even override advance directives.

“There are no good published studies on this, but it’s something we see,” Dr. White said. “Surgeons are reluctant to withdraw life support before 30 days, and less reluctant after 30 days.”

That may have been what happened to Ms. S. Or perhaps her aggressive treatment resulted from a surgical ethos that has little to do with mortality reports.

“We want to cure patients and help them live, and we consider it a failure if they don’t,” said Dr. Anne Mosenthal, who heads the American College of Surgeons committee on surgical palliative care.

With surgeons already prone to optimism and disinclined to withdraw life support, the effect of reporting failures, if there is one, is subtle. Surgeons tell themselves, “Maybe if we wait a little longer, he’ll improve; there’s always a chance,” Dr. Mosenthal said.

But many older patients, and their families, have different ideas about what makes life worth sustaining and might welcome a frank discussion before a month passes.

“The 30-day mortality statistic creates a conflict of interests,” said Dr. Lisa Lehmann, an associate professor of medical ethics at Harvard Medical School. “It can lead to the violation of a physician’s duty to put patients’ interests first.”

Leaders at the nonprofit National Quality Forum, which just endorsed 30-day mortality as a measure for coronary bypass surgery, find such fears overblown. The forum evaluates quality measures for Medicare and other insurers, and went ahead with its endorsement despite some physicians’ objections.

“There is some concern,” said Dr. Helen Burstin, the chief scientific officer of the forum, but “certainly no evidence” that the metric is unduly influencing patient care.

“Is it better not to measure and compare, just because we can’t get it perfect?” added Dr. Lee Fleisher, a co-chairman of the forum’s surgery standing committee.

But critics think other quality measures might serve better. Perhaps the benchmark should be 60- or 90-day mortality. Perhaps patients having palliative surgery to relieve symptoms should be tracked separately, because comfort is their goal, not survival.

Maybe quality should include days spent in an I.C.U. or on a ventilator, Dr. Schwarze said.

“Medicine isn’t just about keeping people alive,” she said. “Some of it is about relieving suffering. Some of it is about helping people die.”

Source: www.nytimes.com

By Terri Peters

When 2-year-old Ryan Aprea had cochlear implant surgery in November, his mom, Jennifer, says she wasn’t sure what to expect when the device was activated a month later.

Aprea shared the moment last week in a video that has now gone viral. In the clip, the Huntington Beach, California, mom says, “Hi, Buddy,” to her son, and is rewarded with a reaction she calls “amazing” — a fit of giggles from her little boy.

Born as a micro preemie at only 25 weeks gestation, Aprea says Ryan began his life with a seven-month stay in the neonatal intensive care unit, where she and her husband learned that he was deaf shortly before his discharge.

But a cochlear implant offered hope.

“We went into the appointment not knowing if he would respond at all. Throughout this process, they had informed us that while sound would enter his brain, every child has a different response. We weren’t sure if his brain would process the sound, but we wanted to give him a chance to hear us and communicate because he is also visually impaired,” said Aprea.

Aprea, who has posted frequently about the cochlear implant process on the Facebook page of her cloth diaper supply company, tells TODAY Parents that since the activation, Ryan has been doing great — exploring toys that make sounds for the first time and taking in his surroundings with his newfound ability to hear.

“He’s been interacting with us and giving us more intentional eye contact just in the few days since he’s had it turned on. My heart melts every single time he looks at me,” said Aprea.

As for future plans for Ryan’s treatment, Aprea says she and her family are taking things one day at a time. The mother of two says she’s looking forward to taking her son for a drive to look at holiday lights while listening to Christmas music — a tradition her family shares every year, but one that will have new meaning this season.

Aprea says she is shocked that her video has gone viral, adding that she looks forward to seeing more people learn about cochlear implants as videos and articles about stories like Ryan’s become more prevalent.

She’s heard a lot of strong opinions about cochlear implants from online commenters — including some negative ones — and offers some advice to parents dealing with big decisions about their child’s health care.

“You know your child better than anyone — I learned that one in the NICU. You need to do what’s best for him or her and give them every opportunity available to succeed in life. I would say, do a lot of research, talk to people who have been through it with their own kids, and then go with your heart,” she said.

Source: www.today.com

Researchers at Loyola University Medical Center in Maywood, Ill., have published a study of emotional and psychological anguish, known as moral distress, experienced by nurses in an ICU for burn patients.

The study by first author Jeanie M. Leggett, RN, BSN, MA, and colleagues is published in the Journal of Burn Care and Research.

Moral distress occurs when a person believes he or she knows the ethically ideal or right action to take, but is prevented from doing so because of internal or institutional barriers. Moral distress can result in depression, anxiety, emotional withdrawal, frustration, anger and a variety of physical symptoms. It also can lead to job burnout.

“Given the intense and potentially distressing nature of nursing in a burn ICU, it is reasonable to hypothesize that nurses in these settings are likely to experience some level of moral distress,” Leggett, manager of Loyola’s Burn Center, and co-authors Katherine Wasson, PhD, MPH; James M. Sinacore, PhD; and Richard L. Gamelli, MD, FACS, wrote, according to a news release.

The pilot study included 13 nurses in Loyola’s burn ICU who participated in a four-week educational intervention intended to decrease moral distress. The intervention consisted of four one-hour weekly sessions. The first session outlined the study aims, definitions of moral distress and related concepts. Session two focused on signs and symptoms of moral distress. Session three dealt with barriers to addressing moral distress. And in session four, nurses were encouraged to identify strategies they could use or employ to deal with moral distress. 

The nurses completed a questionnaire called the Moral Distress Scale-Revised that measures the intensity and frequency of moral distress. They were divided into two groups: One group completed the survey before the intervention, and the other group took the survey after completing the sessions.

Researchers had expected that the group taking the survey after the intervention might have lower moral distress scores. But they found just the opposite: The group taking the survey after the intervention had a median moral distress score of 92, which was significantly higher than the 40.5 median score of the group that filled out the survey before taking the course. (The moral distress score can range from 0 to 336, with higher scores indicating greater moral distress).

Researchers said in the release that the reason moral distress scores were higher among nurses who took the survey after the educational sessions could be due to a heightened awareness. 

Six weeks after completing the intervention, both groups took the moral distress questionnaire again, and this time, there were not significant differences in their scores. There also was no significant difference between the groups’ scores on a second questionnaire called Self-Efficacy Scale, which is designed to measure a person’s effectiveness in coping with daily stressful events.

After each weekly session, nurses completed a written evaluation. 

“They appreciated the individual sessions and case discussions, felt the session lengths were appropriate and expressed validation of their feelings of moral distress after having participated,” researchers wrote. “They indicated that learning the definition of moral distress was valuable, found it helpful to learn that others in similar work environments were experiencing moral distress and appreciated hearing what others do to cope with moral distress. Participants expressed a desire for this type of intervention to continue in the future and for more time to be spent on coping strategies.”

Researchers concluded that a larger study, involving more nurses from multiple burn centers, is needed. 

“The larger study should be refined to develop strategies for implementing effective interventions that become part of the culture and that ultimately reduce moral distress,” researchers concluded. “In so doing, effective strategies for dealing with the moral distress experienced by this population can be more readily put in place to help cope with it.” 

Source: Nurse.com

By Debra Anscombe Wood, RN

Some patients are trached and vented. Other patients are on dopamine drips or receiving total parenteral nutrition. This sounds like a critical-care unit, but hundreds of children in New York and New Jersey are receiving this type of intensive care at home from nurses and other healthcare professionals. 

“There are many more children (with complex care needs) going home,” said Ana L. Pacheco, RN, MS, director of patient services at Montefiore Medical Center Home Health Agency in New York City. “There’s more high-tech in the home. It’s incredible. Being in their home is so much better for the children and parents.”

Bringing the child home despite needing complex care reduces the risk of nosocomial infection and often is easier on the family than continued hospitalization, said Kathy Pfeiffer, RN, BSN, director of pediatric clinical operations for BAYADA Home Health Care, headquartered in Mount Laurel, N.J.

“These kids are acute,” Pfeiffer said. “The homes are set up like an ICU.” 

St. Mary’s Home & Community Programs in New York City has experienced an increase in home care volume as medical advances have allowed premature and other medically needy children to survive longer with a better quality of life. 

“We’re getting sicker kids home, and their needs are much greater,” said Lois Long, RN, nurse coordinator at St. Mary’s Home Care. “Our job is a little more challenging because of that.”

Children may receive home care because they have been diagnosed with pulmonary and cardiac diseases, congenital defects, traumatic injuries and other conditions. They range in age from newborns to young adults. Some may live in shelters or in foster care. 

Certified agencies provide intermittent care and licensed agencies offer hourly or shifts of care, including accompanying the child to school. Some organizations, such as St. Mary’s, offer both types of home services. 

Teaching and doing

Nurses teach parents how to care for the child while still in the hospital, but once discharged, home care nurses reinforce that education, fine tune techniques, perform treatments such as peritoneal dialysis, tube feedings and nebulizer and monitor the patient’s condition and the family’s progress with providing care. “We do a lot of education,” said Anne Calvo, RN, BSN, MPS, assistant vice president at the Winthrop-University Hospital Home Health Agency in Mineola, N.Y. 

Home health nurses collaborate with physicians, parents and a multidisciplinary home team, including rehabilitation therapists, social workers and home health aides. 

“We do a lot of care coordination,” said Eno Onda, RN, MEd, coordinator of care in the Children & Family program at the Visiting Nurse Service of New York. “It is patient-centered, family-centered care, and we have to keep good lines of communication.”

VNSNY focuses on short-term care with extensive education to strengthen families to manage the complex care needs of their patients, Onda said. Nurses draw on scientific knowledge, research and nursing theory as they identify needs and coordinate care. 

“What the nurse does is very challenging,” Onda said. “You have to know your values and emotions, so you can [hear] the stories people are telling you and put everything together.” 

Staying for hours at home, school

Some children require constant care. When their parents go to work or sleep, home care nurses often fill in, even accompanying the child to school to perform necessary treatments and medications, according to physician orders and company protocols. 

“They are fragile (children with complex care needs), but despite that, they are kids,” said Donna McNamara, RN, MPA, assistant vice president of community programs at St. Mary’s. “You want to support their growth and development and cognitive function.”

St. Mary’s nurses try not to intrude on family life but become part of the daily flow of activities. McNamara said it takes a team approach to keep these children at home. At BAYADA, a transitional care manager meets with the family in the hospital. Then a clinical manager makes the initial home assessment, collaborates with physicians and other members of the team, and ensures supplies are in the home and the nurse caring for the child is competent to provide treatments. BAYADA conducts simulation drills to hone responses to emergency situations, such as a trach tube coming out or a seizure lasting longer than expected, and reassesses competencies annually.

“In a hospital, you have a team and can call out if there’s a crisis,” said Lisette Alicea, RN, RRT, clinical manager at BAYADA’s Hackensack, N.J., office. “We have to make sure we have the orders [for various situations] and train our nurses to know what to do.” 

Challenges and rewards

In addition to providing highly technical care employing the latest equipment and products, home care remains highly personalized. Nurses offer support, while watching for stressors or signs of abuse and neglect. 

“It’s difficult for parents to have a sick child, whether born premature or (born) healthy and something happens,” said Alyson Bolton, RN, CPN, BAYADA transitional care manager. “The family dynamics are challenging.”

Nurses help by showing parents they are capable of taking care of the child and identifying what the child can do, added Shawn Carroll, RN, clinical manager at BAYADA in Hackensack. 

Psychosocial issues present some of the greatest challenges for nurses. 
“We work with child protective services when needed and with social work,” Calvo said. “We are totally involved in the care.”

Home-care nurses collaborate with others on the team and community resources, such as homeless shelters, counseling and housing authority officials, to resolve concerns.“You become part of the families from day one and then watch them grow and become more self-sufficient,” Carroll said. “It’s a special type of nursing.”

Jeanette Carter, RN, team coordinator at St. Mary’s Home Care, agreed it is rewarding to care for patients who came into the program as fragile infants and watch them improve as they become young adults. 

Despite poor prognoses, many children experience positive outcomes, walking or talking when experts doubted it possible. 

“The good outcomes are really rewarding,” Calvo said. “You see the children blossom.” 

Source: Nurse.com