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Exercise your right to be fit!

 

Nearly all clinicians know exercise is good for our physical and mental health. But incorporating it into our busy lives can be a challenge. The only types of exercise some clinicians have time for are working long shifts, juggling life’s demands, balancing the books, jumping on the bandwagon, climbing the ladder of success, and skipping meals.

Clinicians are in a unique position to help patients change their behavior to improve their health. Ironically, the first behavior clinicians need to change is to work toward improving our own exercise habits.

Jumping through hurdles

Clinicians have no problem describing the many benefits of exercise to patients, but most of us don’t have a regular exercise program for ourselves. Even with strong evidence supporting the benefits of exercise, only about 25% of adults follow the recommendation to get at least 30 minutes of moderate-intensity physical activity daily; 37% admit they get no exercise at all. Our high-tech society makes it convenient to be sedentary; figuring out how to get Americans out of their seats and away from their TVs and computers poses a real challenge.

Moving in new definitions

One barrier that can be overcome may be as simple as semantics. For many, the word exercise carries the stigma of sweat, pain and, when neglected, guilt. So simply replacing exercise with movement may be liberating. Movement is any bodily action produced by skeletal muscle contraction that increases energy use above the baseline level and requires tissue oxygenation. Movements with the most health-promoting and disease-preventing benefits include those that build cardiorespiratory endurance and muscle strength, toning, and flexibility.

Get moving

According to the Department of Health and Human Services, the more physically active you are, the more health benefits you gain for life. Physical activity guidelines established in 2008 can help physical educators, policymakers, healthcare providers, and the public understand the amounts, types, and intensity of physical activity needed to achieve health benefits across the lifespan. Combined with the Dietary Guidelines for Americans, these evidence-based documents support the physical activity objectives established for Healthy People 2020.

Exercise guidelines and prescriptions

Exercise guidelines and prescriptions are based on the FITT formula, which stands for:

• Frequency (how often you exercise)

• Intensity (how hard you exercise)

• Time (how long you exercise)

• Type (which exercises you do).

Frequency recommendations are based on multiple research studies that show cardiovascular benefits occur with 2½ hours of exercise weekly.

The intensity level must be customized to each individual’s health, age, and limitations. The American Heart Association recommends reaching target heart rate (THR), calculated with this formula: 220 minus your age. Reach ing THR helps you achieve maximum cardiovascular exercise, but you must sustain it for 20 to 30 minutes. Safety is a priority, though, and not everyone should attempt to reach 100% of THR. People taking beta blockers, for instance, may not be able to reach even 70%.

Time recommendations are 20 to 60 minutes of continuous aerobic exercise of moderate to vigorous intensity 3 to 5 days per week.

The type of exercise depends on individual preference and ability. Generally, aerobic exercise is best because it supplies oxygen for muscle movements. Anerobic exercise, done while holding your breath, may create lactic acidosis and side aches. Even while doing static exercise or weight training, pay attention to breathing.

Exercise caution

How much to exercise depends on your health status, initial fitness level, available time, activity preferences, personal goals, and available equipment and facilities. The minimum caloric expenditure for health is 150 kcal/day or 1,000 kcal/week. For the maximum health benefit, you’ll need to perform 5 to 6 hours of physical activity per week and expend 2,000 kcal/week above your basal metabolic rate.

For an even higher fitness level or weight loss, you’ll need to exercise in the upper end of the range by expending 300 to 400 kcal/day. But be aware that age, gender, and health status can influence the totals. Thirty minutes of moderate activity daily is equivalent to 600 to 1,200 cal/week of energy expenditure. Modify this expenditure if you have neuropathy, retinopathy, cardiac disease, or medication contraindications. People with asthma should carry emergency inhalers and bronchodilators. Sedatives and antihistamines may cause drow si ness, slow reaction time, and impair balance and coordination, creating a safety risk during exercise. Stimulants may increase the heart rate and cause unwanted side effects. Exercise is contraindicated in people with known aortic aneu rysms, aortic stenosis, decompensated heart failure, pulmonary or systemic embolism, thrombo phle bitis, uncontrolled metabolic disorders, and ventricular tachycardia or other dangerous arrhythmias.

Training technologies

Although technology might be at the root of our sedentary lifestyles, we can use it to improve our movement and activity level. Numerous smartphone apps can track walking, eating, sleeping, and exercise levels to promote self-awareness and progress toward goals. Finding these tools is as easy as exercising your fingers to an online search engine. (See Exercise and fitness apps.)

Movement mantras

You can help drive a shift toward a more active lifestyle by spreading the word that public health officials have been preaching—but tone it down to the kinder and gentler philosophy of getting into shape simply by moving more. And by all means, set an example yourself. By becoming better examples of healthy living, clinicians can help eliminate the mantra “No pain, no gain” and replace it with this sage advice: If you don’t have time for your health today, you won’t have health for your time tomorrow.

Tracey Long is on the nursing faculty at the College of Southern Nevada in Las Vegas.

Selected references

Ahmad T, Chasman DI, Mora S, et al. The fat-mass and obesity-associated (FTO) gene, physical activity, and risk of incident cardiovascular events in white women. Am Heart J. 2010;160(6):1163-9.

American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Lippincott Williams & Wilkins; 2013.

American Heart Association Recommendations for Physical Activity in Adults. American Heart Association. Updated May 16, 2014.

Britton KA, Lee IM, Wang L, et al. Physical activity and the risk of becoming overweight or obese in middle-aged and older women. Obesity (Silver Spring). 2012;20(5):1096-103.

Exercise benefit equals drugs for some health problems. Harv Mens Health Watch. 2014;18(6):8.

Five easy ways to start exercising. Get moving by changing your thinking and working exercise into daily activity. Harv Health Lett. 2014;39(4):6.

Global recommendations on physical activity for health. World Health Organization. 2014. Accessed May 29, 2014.

Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423-34.

Healthy People 2020. Physical activity. U.S. Department of Health and Human Services. May 29, 2014.

How much physical activity do adults need? Centers for Disease Control and Prevention. Last reviewed December 1, 2011. Accessed May 29, 2014.

Panel on Macronutrients, Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients). Washington, DC: National Academies Press; 2005.

2008 Physical Activity Guidelines for Americans. U.S. Department of Health and Human Services. October 2008.

Buzz Report: Latest trends, part 2

Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild on Wounds (WOW) conference held each September in Las Vegas. Every year, I present the opening session, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.

In the January issue, I discussed some of the updates from my 2015 Buzz Report. Now I’d like to share a few more, along with some of my favorite resources.

Product buzz

Wound dressings with silicone are designed to reduce pain and trauma during dressing changes and to protect the wound. Coloplast’s new Biatain® Silicone Lite does just that, combining an absorbent polyurethane foam dressing with a semipermeable, water- and bacteriaproof top film and a soft silicone woundcontact layer. The thin foam provides a closer fit at skin level, resulting in increased mobility and product comfort.

Anasept® Antimicrobial Wound Irrigation Solution provides a new dimension in antimicrobial wound care and negative-pressure wound therapy (NPWT). This FDA-cleared solution is a clear isotonic liquid that delivers 0.057% broad-spectrum antimicrobial sodium hypochlorite via a NPWT device. Kill studies for Anasept® are fascinating: a 30-second kill time for infections with Clostridium difficile, methicillin-resistant Staphylococcus aureus, vanc o mycinresistant enterococci, Pseudo monas, and many more. Anasept comes with an easyto- use spikable container with an integrated hanger that can be quickly attached to an I.V. pole or NPWT device. It can be used with most NPWT systems that have instillation or infusion capability.

Cutimed® Sorbact® Hydroactive B from BSN Medical provides infection control and fluid management for up to 4 days in a single wound dressing. It helps fight and prevent infection without chemical agents or antibiotics. The bacteria-binding, absorbent gel dressing with an adhesive border absorbs and locks wound exudate and bacteria in a hydropolymer gel core; with each dressing change, bound bacteria are removed. The hydrogel matrix helps maintain a moist wound environment.

No scissors? No problem! Hy-Tape International, maker of the Original Pink Tape®, has come to the rescue with Hy- Tape® Pre-cut Strips and Patches. These latex free, waterproof, zinc–oxide-based adhesive tape products are perfect for extended wear, soothing to delicate skin, and adherent to wet, oily, or hairy skin. The single-use strips measure 1.25″ x 6″ and come in packs of four. They can quickly be used to secure devices or to “picture-frame” wounds or ostomy barriers. The patches are designed to cover a large area. Available in 4″ and 5″ squares, they’re perfect for making hydrocolloid dressings completely occlusive.

The American Diabetes Association’s report “Comprehensive Foot Examination and Risk Assessment” states that all individuals with diabetes should get an annual foot exam to assess peripheral neuropathy and protective sensation, including a test for vibration perception. Typically, the clinician uses a tuning fork to test for vibration sensation, but this can be difficult for those unfamiliar with the feel; also, the results are totally subjective. The new portable, handheld noninvasive Dynamic Neuroscreening Device (DND) from Prosenex provides objective and consistent quantitative testing for vibration sensation. It offers five grades of vibration and temperature discrimination to screen for large- and small-fiber neuropathy. FDA approved and made in the United States, DND was named the 2014 New Hampshire High Tech Product of the Year.

Zinc oxide ointment is a “go-to” product for incontinence-associated dermatitis. But its consistency makes it difficult and messy to spread evenly over the skin. Mission Pharmacal Co. has created a new solution for this—Dr. Smith’s Adult Barrier Spray. This 10% zinc oxide solution comes as an easy, touch-free, spray application, offering accurate, uniform coverage with no rubbing necessary.

Incidence data reveal that the heel is the most common site of facility-acquired pressure ulcers. Once a heel pressure ulcer develops, complete elimination of heel

pressure using a pressure-relief device is critical. The new TruVue™ Heel Protector from EHOB positions a pillow under the Achilles tendon to elevate the heel. Constructed

with an anti-shear pad that serves as a barrier to shearing forces, the device has a deep, V-cut heel well that fully off – loads the heel without product interaction and relieves product-to-heel engagement with foot flexion.

Resource buzz

Accessing the Internet for information using smartphones and tablets has quickly become a huge part of health care. Two major wound care companies have released mobile applications to help healthcare professionals and consumers use and order their products. Several new woundcare books were published in 2015 as well. (See What’s the buzz on books?)

The iOn Healing™ mobile app from Acelity offers a suite of tools to improve customer support. In addition to product guides, features include the ability to connect and consult directly with an Acelity representative, track outcomes to support  documentation of medical necessity, and order V.A.C.® Therapy and instantly transmit the signed prescription to Acelity. The HIPAA-compliant app offers high-security data protection. Designed for use by licensed clinicians in the United States, it’s free to download and available for iOS and Android.

The Johnson & Johnson Wound Care Resource app helps identify new wounds, provides recommendations on wound care treatment, and keeps track of the daily checklists that come with continued treatment. It’s available free for iOS at iTunes and for Android at GooglePlay.

A dream come true for wound care clinicians—an app that measures wounds! With the Mobile Wound Care app from Tissue Analytics, you can take a wound photo with a smartphone camera and stream it directly to your desktop, where you can measure, track, and manage your patients’ wounds on a secure web portal. It’s available for iOS at iTunes and for Android at Google Play.

The Agency for Healthcare Research & Quality (AHRQ) produces evidence that can be used to make health care safer, better, more accessible, more equitable, and more affordable. AHRQ websites offer a wealth of useful information for clinicians A few of my favorites are the Patient Safety Channel on YouTube, Innovations Exchange, Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention, and Service Delivery Innovation Profile, such as this one, which details various healthcare projects around the country.

Donna Sardina is editor-in-chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution,its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

 

Seeing healthcare from a new perspective

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By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

As healthcare clinicians, our world is full of tasks to be completed. Some are new, but many are tasks we repeat every day and thus have become routine—things we could almost do in our sleep.

But what’s routine for us may not be routine for our patients. For some patients, these routine tasks of ours may be their first encounter with a healthcare situation.

When a member of my family needed health care recently, I observed as a family member, not a clinician, and learned what it’s like to be on the other side of the clinician’s routine. What follows are some shareworthy observations.

  • Read health record notes in the computer before talking with the patient. Asking patients about the care they’ve already received or what medications they’ve been given doesn’t build their confidence in your care.
  • Keep the patient updated. If you’re waiting for an order, lab result, or call-back from X-ray, tell the patient this—if possible, more often than once a shift. Think how powerless and vulnerable you would feel lying in a strange bed away from home with no control.
  • Don’t be too cheery and giggly. Remember—the patient is sick and may not be feeling well. Also, you may have great coworkers and a great job, but when you’re conducting the patient assessment, the patient and family don’t want to hear a 20-minute description of the fun you have in your department. This could make them think you’re so busy chatting that you’re not paying attention to detail. Focus on the patient and your assessment instead of trying to become the patient’s buddy.
  • Check bandages at least every shift, even if you’re not going to change them. If you’re checking them with a casual glance or combining this with another task, make sure the patient knows you’re checking.
  • Inspect surgical drains or collection devices at least once every shift, and empty them as indicated. Surgical drains can be extremely scary to patients, who may feel as if their guts or blood are draining from their body.
  • If the patient’s skin is hairy, shave or trim the hair before applying tape or a transparent film dressing. If you don’t feel comfortable removing the hair, ask another clinician for help. Always explain to the patient the reason for hair removal. (Most patients prefer hair removal to the alternative of hair-pulling pain.) A self-adherent elastic wrap is a great alternative to tape for securing bandages on hairy skin, although you still need to use caution when removing it.
  • Before changing a surgical or wound dressing, find out if the patient has seen the incision or wound; if not, ask if he or she wants to see it. When appropriate, it’s best for patients to understand what’s under the bandage. They may be relieved to find out that what they’d been envisioning as a fist-sized wound is much smaller—or, if it’s a large wound, they may be surprised by its size.
  • Don’t complain about the computer or tell patients you have poor computer skills as you’re typing information into their health record.
  • If the patient is required to use a computer stylus to sign something in the health record, make sure to clean it before handing it to him or her. Do this even if the stylus has already been disinfected, because the patient doesn’t know that.
  • Ask visitors to leave the room before you provide care or discuss the patient’s health condition. This way, you spare the patient the burden of having to ask friends or family to leave.
  • Don’t rush discharge. Make sure you’ve reviewed everything, including post-care follow-up and whom to contact for help. Verify that transfer arrangements are in place. Most important,ensure that the patient and family members have received and understand patient and caregiver education. (The teach-back method is a great way to determine their understanding. For more information, visit http://www.teachbacktraining.org.)

As clinicians, we should strive to make every patient encounter special, not routine. Remember—it’s always about the patient.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Editor-in-Chief

Wound Care Advisor

Cofounder, Wound Care Education Institute

Plainfield, Illinois

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

“Best of the Best” three-peat

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By: Donna Sardina, RN, MHA, WCC, CWCMS

What do the Los Angeles Lakers, Green Bay Packers, Montreal Canadiens, and New York Yankees have in common? All three have “three-peated”, meaning they have won three consecutive championships. This year, we at Wound Care Advisor, the official journal of the National Alliance of Wound Care and Ostomy (NAWCO), mark our own three-peat—our third annual “Best of the Best” issue.

This may be the first time you have held Wound Care Advisor in your hands because normally we come to you via the Internet. Using a digital format for this peer-reviewed journal allows us to bring you practical information that you can access anytime, anywhere and gives you the ability to access videos and other links to valuable resources for you and your patients. However, it’s still nice sometimes to hold a print version of a journal, so once a year, we bring you a compendium of our most popular articles to create a resource you can turn to again and again.

If you’re new to Wound Care Advisor, this print edition is an opportunity for you to experience what you’ve been missing. If you’re a regular reader, this edition gives you the opportunity to revisit some of our best articles.

Within these pages you’ll find feature articles, best practices, step-by-step how-to’s, clinical resources, and news. Along with wound-related topics such as palliative wound care, you’ll find a variety of other topics, ranging from helping patients overcome ostomy challenges to caring for patients with lower-extremity cellulitis. You’ll also hone your skills by reading articles on how to assess wound exudate and use of medical gauze. We haven’t forgotten your nonclinical related needs—check out the article on creating effective education programs on a shoestring budget.

Also included as part of this special edition, is an exclusive directory of the 2015 Wild on Wounds Exhibitors Guide. Wild on Wounds (WOW) is an annual, multi­disciplinary national wound conference presented by the Wound Care Education Institute. The exhibitor guide features names, products, and contact information for many different manufacturers and companies that can offer solutions to assist in caring for your patients.

In keeping with our digital format, this compendium will also be available electronically at our website, www.woundcareadvisor.com, where you’ll be able to download resources and access links to videos, clinical resources, and much more.

Thanks to our readers, Wound Care Advisor is a champion. We appreciate your support and look forward to bringing you many more articles designed to help you achieve excellence in your clinical practice. Look for our four-peat in 2016!

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

Editor-in-Chief

Wound Care Advisor

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Motivational interviewing: A collaborative path to change

PDF-iconBy Sharon Morrison, MAT, RN

Michael had diabetes and a history of elevated blood glucose levels. A long-time drinker, he seemed to have no interest in giving up the habit. I met him while working as a diabetes nurse educator for the Boston Health Care for the Homeless Program, traveling from shelter to shelter to help persons with diabetes set goals to improve their health.

If our meeting had taken place a decade earlier, I might have given Michael information about diabetes and talked with him about his alcohol use. I would have encouraged him to stop drinking by explaining the problems alcohol can cause for people with diabetes.

Instead, I asked him to talk about his alcohol use, including what he liked about drinking. I assured him I wouldn’t tell him to stop drinking. He explained he was shy and alcohol served as a social lubricant. Also, it kept him warm on cold nights when he slept outdoors. Then I asked if there was anything he didn’t like about drinking. He said his drinking hurt his mother, and his sister wouldn’t allow him to sleep in her home if he’d been drinking. Had I not asked these open-ended questions, I may not have been able to ferret out this important information about Michael’s strong connection to his family. I knew the relationship I was establishing with him could serve as an important motivation for change—once he was ready.

When I asked Michael how much he drank each week, he said he had no idea. I told him this was important information for us to have as we worked together to gain control of his blood sugar. He was still incredulous that I wasn’t going to simply tell him to stop. I asked him if he could record how much he drank in a notebook for 1 week, and then return for another meeting with me. He agreed. But he didn’t come back the next week.

However, he did return a few months later. He told me that once he started keeping a record of his drinking, he was shocked by the amounts and got himself into a detoxification program. He’d been sober for 3 months.

Understanding this approach

I attribute the outcome of my interaction with Michael to motivational interviewing, a counseling approach

developed largely by clinical psychologists William R. Miller, PhD, and Stephen Rollnick, PhD. Its origins lie in the treatment of alcoholics, although today it’s used with patients struggling to quit smoking, lose weight, or manage such chronic diseases as high blood pressure and diabetes.

Miller and Rollnick describe motivational interviewing as “a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” The technique often is referred to as a way of “helping people talk themselves into change.”

As a nurse working with homeless people, I’ve found motivational interviewing to be a powerful way to interact with them, helping them make important changes leading to healthier lives. It also has allowed me to get to know clients on a much deeper level.

Using the OARS mnemonic

Motivational interviewing has four central tenets, known by the mnemonic OARS:

Open-ended questions. Open-ended questions invite people to tell their stories in their own way. What unfolds is often far more—and far richer—information than one could imagine. Examples of open-ended questions include, “How would you like things to be different?” and “What will you lose if you give up this behavior?”

This can be quite empowering for homeless persons, who may have had precious few experiences where their input was solicited or valued. Listening carefully can help clinicians tailor the solution to a client’s values and lifestyle, increasing the likelihood of behavioral change.

Here’s an example of how to use open-ended questions: A patient struggling with weight loss for better diabetes control doesn’t need to hear from me that certain foods are forbidden; such a direct instruction is a set-up for failure. Instead, I might ask the patient to tell me what she eats in a typical day. I would focus my questioning to bring out the significance of food as a means of comfort and try to find out what kinds of food are available in the shelter. Then I’d work to come up with a plan to change portions or gradually move the patient toward foods that could improve her blood glucose control.

Affirmation. Affirmations are statements that affirm people’s experiences and help them see their own strengths. They must be genuine and proportional to the person’s accomplishment. Examples include: “You showed a lot of resilience when you resisted the urge to _______” and “I wonder how you found the strength to _______.” An affirmation differs from praise; the latter implies judgment.

Reflective listening. When clinicians listen reflectively and then paraphrase for the patient what they think they’ve heard, they get a chance to prevent misunderstandings. In some cases, this might require them to interpret the implicit emotions behind the patient’s statements. The expectation is that the client will correct significant misinterpretations.

Summarizing. At the end of a session, the clinician summarizes what has taken place. Besides letting the patient know the clinician has been listening, summarizing can be an opportunity to include information from other sources, such as clinical knowledge or research. It may be a good time to restate what the patient hopes to do before the next session, if one will occur. (I always strive to schedule another sesssion. Motivational interviewing is about building a relationship, and its effect often is cumulative.)

A spirit that informs every interaction

Breaking down a complex communication model into four basic tenets such as OARS runs the risk of reducing it to a formulaic tool. And motivational interviewing is anything but formulaic. Being trained in the technique is important, but beyond the technique and the OARS mnemonic is a spirit that needs to inform every interaction.

With motivational interviewing, patients are the experts. They know themselves and their lives better than anyone else, so they must play a large role in figuring out how to effect change. The clinician’s role is to help steer the conversation in certain directions, remembering that the patient is ultimately the driver.

I’ve found motivational interviewing effective and powerful with the homeless because it gives these largely voiceless, powerless, invisible people a voice, power, and visibility. It invites them to tell their own stories and feel listened to and empowered. It’s conversational and collaborative, not prescriptive and hierarchical. If you’re genuine with patients and their struggles, you build a relationship that guides you through difficult times—even when the patient is resistant or seems to have lost hope. (See Is the technique effective? By clicking on PDF icon above.)

Widening the focus

One of the beauties of motivational interviewing is that it encourages clinicians to engage their patients in a more holistic examination of their lives and health. If I’d addressed Michael’s elevated blood glucose levels only from the perspective of what he needed to do to lower them, he may not have done the introspection that ultimately led him to quit alcohol. Over and over, I’ve found motivational interviewing leads to changes for my patients that surprise and delight even an old veteran like me.

Sharon Morrison works for Boston Health Care

for the Homeless Program (BHCHP) in Boston,

Massachusetts, where she has provided care in

settings ranging from shelter clinics to the

streets. She currently works at BHCHP’s clinic

at the New England Center for Homeless Veterans

in Boston.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Creating high-performance interprofessional teams

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By Terry Eggenberger, PhD, RN, CNE, CNL; Rose O. Sherman, EdD, RN, NEA-BC, FAAN; and Kathryn Keller, PhD, RN

Kate Summer, a wound care clinician in a urban hospital, is leading an initiative to reduce pressure ulcers. She knows from experience that more effective communication and collaborative planning by the interdisciplinary team managing these patients is crucial for reducing pressure ulcers. But doing this has been challenging for Kate.

Recently, a local university asked her to present a talk on strategies to reduce pressure ulcers to students in interprofessional education classes. She is intrigued that students from multiple disciplines now attend classes together—something that never happened during her nursing education.

The language of healthcare is evolving rapidly. Consider the term interdisciplinary. Many clinicians associate this word with the interdisciplinary team meetings required for regulatory compliance or discharge planning, as in the scenario above. Just getting everyone to attend these meetings can be daunting logistically. Typically, the meetings occur weekly and have a designated start and end time, or are convened for a particular project or outcome.

But the concept of healthcare professionals from different disciplines coming together and working in teams is changing. Reflecting this change, the term interdisciplinary has given way to interprofessional in many settings. Interprofessional teamwork refers to the cooperation, coordination, and collaboration expected among members of different professions in delivering patient-centered care collectively.

Creating an interprofessional team

Getting team members on the same page—or even getting them together in the same place, as Kate hopes to do—can be difficult. Helping team members get past their day-to-day duties, conflicts, and communication problems to attain the goal of working together effectively is a significant leadership challenge. Nowhere are the stakes higher than in health care, where good patient outcomes hinge on team synergy and interdependence.

Most medical errors involve communication breakdowns among team members. Ineffective interprofessional teamwork jeopardizes patient safety, and some experts believe it correlates strongly with higher mortality. An interprofessional-team approach could benefit many situations. Opportunities for team effectiveness exist in many key areas, including medication reconciliation, discharge planning, length of stay, care transitions, end-of-life issues, error disclosure, and reducing 30-day readmissions.

In any setting, high-performance work teams rarely occur naturally. They must be created and managed. To instill effective teamwork into health care, leaders need to recognize and emphasize its importance. They play a key role in helping a team develop the ability to collaborate effectively, build relationships and trust, innovate, and achieve results at a consistently high level.

Promoting more effective teamwork

If you’ve worked on a highly effective and smooth-running team, you know it’s an experience you won’t soon forget. Effective teams share the following characteristics:

  • clear goals that everyone on the team works towards
  • clarity about each team member’s role and contributions
  • clear and open communication
  • effective decision making
  • engagement of all members in the work of the team
  • appreciation of diversity in terms of generation, culture, and thinking
  • effective conflict management
  • trust among members
  • cooperative relationships
  • participative leadership.

Achieving this level of teamwork can be challenging. Communication breakdowns and conflict are inevitable, especially if team members keep changing.

When managed effectively, teams provide an opportunity for growth. But this doesn’t always happen. The most common obstacles to effective teamwork are blaming others, turf protection, mistrust, and inability to confront issues directly. Without complete trust, members are more likely to withhold their ideas, observations, and questions.

People also are more likely to leave a team that has trust issues. Trust begins with communication. As a leader, emphasize to team members that relationships live within the context of the conversations they have—or don’t have—with one another. Without open and frank communication, things can and do go wrong on teams.

Also, never assume healthcare professionals completely understand the unique knowledge, skills, and abilities that members of other disciplines bring to the team. Seeing through the lens of another professional as a way of building trust can be enlightening and enhance one’s understanding of roles and responsibilities. Each discipline has a unique culture, language, and model through which it approaches patient situations. Spending time with or shadowing members of other disciplines helps professionals understand what it’s like to experience patient care from another perspective.

As a leader, you can assess whether your team is working effectively. (See Assessing a team’s effectiveness.)

The future of interprofessional practice

With healthcare reform, interprofessional practice has become even more crucial. Most new care-delivery initiatives being tested today involve team-based care. Using the skills of each discipline is important in reducing healthcare costs and improving patient outcomes through shared responsibility.

On a multidisciplinary team, each professional functions independently of the others, and one person usually makes treatment decisions. In contrast, interprofessional teams reach decisions collectively. In many healthcare settings, collective decision-making will require a major shift in thinking. In response to Crossing the Quality Chasm: A New Health System for the 21st Century, a 2001 report from the Institute of Medicine, healthcare education programs increased the emphasis on students from different healthcare professions coming together to learn about collaborative teamwork from and with each other.

In 2011, the Interprofessional Education Collaborative published Core Competencies for Interprofessional Collaborative Practice. This report states that healthcare professionals need certain core competencies to provide high-quality, integrated care. Together, these competencies offer a structure for best practices. The competencies fall into four domains:

  • values and ethics for interprofessional practice
  • roles and responsibilities
  • interprofessional communication
  • teams and teamwork.

In today’s academic programs, students of medicine, pharmacy, social work, and other related disciplines come together side by side to learn how to communicate, work in teams, and discuss pertinent issues, such as ethics and policy. This may be an unusual case where academic settings are ahead of their practice partners (especially in acute-care settings) in implementing new professional competencies. Healthcare students frequently comment that they don’t see such behaviors in practice. When educating students about evidence-based tools for communication and conflict resolution, teachers must support and model these skills in clinical practice so students can increase their proficiency and effectiveness. Academic and clinical practice partners must be aware of evolving priorities and trends.

Building and maintaining effective teams and interprofessional practice is a journey that never ends. As new members join the team, leaders should encourage them to participate in building a collaborative team culture and should urge team members to nurture these novices.

Selected references

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%

20report%20brief.pdf. Accessed September 16, 2014.

Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice. Washington, DC: Interprofessional Education Collaborative; 2011. www.aacn.nche.edu/education-resources/ipecreport.pdf. Accessed September 16, 2014.

Keller KB, Eggenberger TL, Belkowitz J, et al. Implementing successful interprofessional communication opportunities in academia: A qualitative analysis. Int J Med Ed. 2013;4:253-9. www.ijme.net/archive/4/interprofessional-communication-in-health-care.pdf. Accessed September 16, 2014.

Lencioni P. The Five Dysfunctions of a Team: A Leadership Fable. San Francisco: Jossey-Bass; 2002.

Sherman RO, McClean G. Developing a high-performance OR team. OR Nurse. 2009;3(1):10-12.

The authors work at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton, Florida. Terry Eggenberger is an assistant professor, Rose O. Sherman is a professor and director of the Nursing Leadership Institute, and Kathryn Keller is a professor. (Names in scenarios are fictitious.)
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Healthcare reform and changes provide opportunities for wound care clinicians

 

 

By Kathleen D. Schaum, MS

Qualified healthcare professionals (QHPs), such as physicians, podiatrists, physician assistants, nurse practitioners, and clinical nurse specialists, are taught to diagnose the reasons that chronic wounds aren’t healing and to create plans of care for aggressively managing the wound until it heals. Wound care professionals—nurses and therapists—are taught to implement those plans of care. All of these highly skilled wound care professionals know how to manage chronic wounds from identification through healing.

Unfortunately, many wound care professionals don’t currently have the opportunity to follow patients with chronic wounds from beginning to end because the patients move from one site of care to another before their wounds heal. Suppose, for example, a patient with a chronic wound is in an acute-care hospital, then moves to a skilled nursing facility, then returns to his or her home under the care of a home health agency, and is later referred to the care of a hospital-based outpatient wound care department. The same wound care professionals rarely follow the patient through all these site changes. In addition, the plans of care and the wound care products may change because each site of service has different staff and a different Medicare payment system. This lack of consistency leads to:

  • nonspecific or inconsistent diagnoses
  • duplicate tests
  • inconsistent clinical practice guidelines or plans of care
  • incomplete documentation or documentation not transferred to the next site of care
  • wasted dressings
  • inconsistent use of devices or advanced technology
  • selection of services, procedures, or products based on reimbursement to the provider
  • lack of wound care–related quality measures.

Nearly all, if not all, of this inconsistency can be traced to the lack of a consistent wound care QHP leader and a consistent wound care case management team that directs the wound care as the patient moves to various sites of care. However, the current unique site-of-service Medicare payment systems don’t provide the incentives for wound care case management across the continuum of care.

A new way

The Centers for Medicare & Medicaid Services (CMS) and private payers also recognize the need to develop new payment systems that will provide excellent outcomes, at the lowest total cost of care and with excellent patient satisfaction. Therefore, the payers (both CMS and private payers) have released a variety of demonstration projects and risk-sharing contracts that will incentivize providers to think outside the box to manage care throughout the continuum rather than within their silos of care. This should be great news for wound care QHPs and wound care professionals. As a wound care professional, you will finally be able to use your skills to manage wounds from the beginning through to healing.

The first step you need to take to reap the benefits of payment system changes is to recognize when networks are being developed to participate in these demonstration projects and risk-sharing contracts. Some of the first clues that networks are forming in your community include:

  • multiple QHP practices joining together
  • multiple hospitals joining together
  • multiple sites of care joining together into one large health system.

As soon as you notice these activities, seek out the leader of the initiative and request a meeting. During the meeting, first learn the reason for the consolidation. After listening carefully to the leader, share some ideas of how QHP case management teams can provide high-quality wound care that will result in excellent outcomes, at the lowest total cost of care, and with a high level of patient satisfaction.

Once you capture the attention of the leader, he or she will start opening doors for you to participate in the network. At that point, you will have to start thinking innovatively to develop wound care case management teams that can service this new network. Remember, the new network will usually be paid some type of bonus if it can reduce overall spending of the payer on the population group that it services, if it achieves excellent outcomes, and if it achieves a high level of patient satisfaction.

Medicare patients will have two parallel payment systems: their current Medicare volume-based payment system and the new value-based system that wound care QHPs and wound care professionals will help to design. You will now be incentivized to:

  • provide evidence-based patient-centered care
  • coordinate care with all stakeholders
  • improve efficiency
  • eliminate unnecessary tests
  • reduce duplication of effort
  • reduce medical mistakes and postsurgical complications
  • reduce hospital and emergency department readmissions
  • reduce waste
  • emphasize prevention
  • use data to show quality of care provided.

Therefore, this is your opportunity to gain further recognition as a wound care specialist—but only if you open your eyes to what’s going on in your medical community and develop case management teams that can service the new network design by providing the right patient-centered care, for the right reason, at the right time, and for the right total cost of care. Yes, this will require you to step out of your comfort zone, but you will be stepping into your new, exciting future where you can manage wounds from start to finish. This can be your mission, if you choose to accept it.

ICD-10-CM opportunities

Wound care QHPs and wound care professionals are often frustrated because payers don’t understand the complexities involved in treating patients with chronic wounds and often deny coverage for needed treatments or advanced technology. When making coverage decisions, payers rely heavily on the diagnosis codes and the documentation in the health record. Wound care QHPs must realize their responsibility to show what they know about each patient encounter and to paint that picture for the payer through the use of diagnosis codes and documentation. Unfortunately, these activities are typically wound care QHPs’ weaknesses.

Granted, the current ICD-9-CM diagnosis codes don’t offer wound care QHPs the opportunity to explain the total complexity of treating their wound care patients. Luckily, this 40-year-old system is going to be replaced with the new ICD-10-CM coding system on October 1, 2015. (You can view the ICD-10-CM codes and specific descriptions at http://www.cdc.gov/nchs/icd/icd10cm.htm.)

When these new codes take effect, wound care QHPs will finally be able to describe the complexity of each patient encounter through diagnosis codes, owing to the work of QHPs who designed the new ICD-10-CM. To maximize the use of these new diagnosis codes, wound care QHPs and wound care professionals must learn the specificity that’s built into the descriptions of the new diagnosis codes. You will probably not memorize the ICD-10-CM code numbers (because there are too many of them), but you can easily memorize the level of specificity about each patient encounter that must be documented in the health record.

When the ICD-10-CM is introduced, documentation will be more important than ever before. Wound care QHPs and wound care professionals should take advantage of the period before the implementation of ICD-10-CM by identifying the top 20 current ICD-9-CM diagnoses that define their patients’ conditions and then identifying the level of specificity that will be required in the new ICD-10-CM codes that define those same conditions. Wound care QHPs and wound care professionals should then work on improving their documentation for one major condition every 3 weeks. Once the documentation for that condition becomes a new habit, they can move on to improving their documentation for the next condition on their list.

Prepare for the future

The beauty of improving your documen­tation is that it will help you communicate your patients’ conditions to payers today while preparing you for the documentation that will be required to prove medical necessity for your work when ICD-10-CM takes effect on October 1, 2015. Wound care QHPs and wound care professionals should take this opportunity to prepare for their future wound care case management roles by improving their clinical documentation, which will help them justify aggressive wound management and demonstrate their patient outcomes and the quality of their work. You have 10 months to improve your clinical documentation so that you can easily slide into ICD-10-CM. Prepare now; don’t procrastinate!

Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, Florida. Contact her with questions or consultation requests at 561-964-2470 or kathleendschaum@bellsouth.net.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Helping Sandwich Generation nurses find a work-life balance

By Kari Olson Finnegan, BSN, and Liz Ferron, MSW, LICSW

If you have at least one parent age 65 or older and are raising children or financially supporting a child age 18 or older, you’re part of the Sandwich Generation. Coined in 1981 by social worker Dorothy Miller, the term originally referred to women, generally in their 30s and 40s, who were “sandwiched” between young kids, spouses, employers, and aging parents. While the underlying concept remains the same, over time the definition has expanded to include men and to encompass a larger age range, reflecting the trends of delayed childbearing, grown children moving back home, and elderly parents living longer. The societal phenomenon of the Sandwich Generation increasingly is linked to higher levels of stress and financial uncertainty, as well as such downstream effects as depression and greater health impacts in caregivers.

If you’re a clinician and make your living as a caregiver, the Sandwich Generation may feel like a club you don’t really want to belong to. Perhaps you’ve fantasized about quitting your job, leaving your family behind, and decamping to an exotic South Seas island. Of course, you know you’re unlikely to do that. But you also need to avoid the opposite extreme: trying to avoid thinking about your multiple caregiving roles and just soldiering on, typical of many clincians. The impact of caregiving is real and tangible. It must be taken seriously and approached in a way that protects the caregiver’s physical, mental, and financial well-being.

Physical and mental health effects

In a 2007 “Stress in America” report, the American Psychological Association found that Sandwich Generation mothers ages 35 to 54 felt more stress than any other group as they tried to balance giving care to both growing children and aging parents. Nearly 40% reported extreme levels of stress (compared to 29% of 18- to 34-year-olds and 25% of those older than 55). Women reported higher levels of extreme stress than men and felt they were managing their stress less effectively. This affected their personal relationships; 83% reported that relationships with their spouse, children, and other family members were the leading source of stress. Stress also took a toll on their own well-being as they struggled to take better care of themselves.

Another study focusing exclusively on health-related issues found employed family caregivers had significantly higher rates of diabetes, high cholesterol, hypertension, chronic obstructive pulmonary disease, and cardiovascular disease across all ages and both genders. Depression was one-third more prevalent in family caregivers than non-caregivers, and stress in general and at home was higher across all age and gender cohorts. (See A perfect storm for the Sandwich Generation.)

Reaching out for help

No doubt, some of you reading this article are living the Sandwich Generation experience. As a clinician, you may find it hard to reach out for help and support. But that’s the most important first step—acknowledging that not only is it okay to ask for help, but it’s critically important. Asking for help may reduce the stress associated with fulfilling your responsibilities at home and at work. Clinicians talk a lot about the importance of a work-life balance; such a balance is essential to coping effectively with the many demands faced by clinicians, especially those of the Sandwich Generation.

What does it really mean to balance work and life? In our practice, we see clinicians come to us for help when they feel overwhelmed; many have multiple presenting issues. As we work with them, we learn these issues sometimes are linked. For instance, financial stress can lead to family or relationship strains. Stress, anxiety, and depression can result from juggling too many home and work demands. Being responsible for dependent children or supporting an out-of-work spouse or partner can be daunting. The additional support that grown children and aging parents require can push even the most resilient clinicians past their tipping point.

For some of you, employers may have resources and programs that can help. Providing more flexible scheduling can help employees better handle family responsibilities. Speak to your supervisor to see if together you can devise a plan that allows you to take time off for such things as school events or doctor’s appointments while still meeting your organization’s staffing needs. Some employers offer eldercare benefits, which can help with planning and identifying resources.

It’s also helpful to learn from others. Speak to your human resources department about forming and promoting a lunchtime or after-work support group for “sandwiched” employees to share experiences and resources—and providing the space where the group can meet. Most larger healthcare organizations offer an employee assistance program (EAP), which can provide valuable counseling and support for:

• coping skills and resilience-building
• prioritizing and time management
• setting and maintaining appropriate boundaries
• finding resources to assist with caregiving
• eldercare-related education and resources on financial and life planning for parents
• financial and budget planning to manage your money wisely while planning for your retirement, your children’s college expenses, and other needs.

Some EAPS provide RN peer coaches and master’s-prepared counselors to help employees deal with stressors both inside and outside of work.

Self-care

The following guidelines can help Sandwich Generation clinicians (or anyone, really) take care of themselves.

Watch for depression. Studies show family caregivers are at higher risk for depression, which may creep up on you. If you or your spouse or partner has access to an EAP, ask those counselors for help with this. Otherwise, if you’re experiencing signs or symptoms of depression, speak to your primary care physician for a more complete screening and assistance or a referral to a therapist or psychologist.
Put yourself in the “balance” equation. Be intentional about setting aside time for yourself. If you wait until you have free time, you may well be waiting until retirement, leaving you susceptible to burnout. Set aside regular time for self-care, such as by taking a yoga or exercise class or scheduling time to jog with a friend.
Set boundaries. This ensures you have time to take care of yourself as well as other important things. Be honest about what’s absolutely necessary—and where there’s room for compromise or saying no. Being at your child’s school play? Not negotiable. Baking cookies for the party afterward? No one is likely to remember 15 minutes after the party ends.
Ask for help. People ask you for help all the time; ask them to return the favor. They can always say no, but most won’t—and may be delighted to lend
a hand.
Hold family meetings. This is important—to set expectations and boundaries, get help, and enlist others to share some of the responsibilities. Even young children and frail elders can be part of the solution, but you have to let them understand the needs and give them a chance to meet them.
Find and use a financial planner. You can relieve a lot of stress not only by helping yourself and your parents protect your future and manage the present but also by setting reasonable boundaries and conditions around financial support for grown children
and elders.

For tips on caring for yourself and to learn how to switch on and off to transition from home to work, download and use the Helper Pocket Card.

Eldercare can be especially challenging—but many sources of help are available. A good place to start is with the Elder­care Locator, a federally funded service that connects caregivers with local resources (available online at www.eldercare.gov/Eldercare.NET/Public/Index.aspx or by phone: 1-800-677-1116). Every county or multicounty area in the United States has an Area Agency on Aging that receives federal funding to provide information and referral to family caregivers on aging and caregiving services, such as adult day care, respite care, home repair and modification, personal care, and more.

Selected references

Coughlin J. Estimating the impact of caregiving and employment on well-being. Outcomes Insights Health Manag. 2010;2(1):40185. www.pascenter
.org/publications/item.php?id=1092
. Accessed May 18, 2014.

MetLife Mature Market Institute. The MetLife study of working caregivers and employer health care costs: new insights and innovations for reducing health care costs for employers. June 2011. www.caregiving.org/wp-content/uploads/2011/
06/mmi-caregiving-costs-working-caregivers.pdf
. Accessed May 25, 2014.

MetLife Mature Market Institute, National Alliance for Caregiving, and University of Pittsburgh Institute on Aging. The MetLife study of working caregivers and employer health care costs: double jeopardy for baby boomers caring for their parents. February 2010. www.metlife.com/assets/cao/mmi/publications/
studies/2011/mmi-caregiving-costs-working-caregivers.pdf.
Accessed May 25, 2014.

Parker K, Patten E. The sandwich generation: rising financial burdens for middle-aged Americans. Pew Research Center. January 30, 2013. www.pewsocial
trends.org/files/2013/01/Sandwich_Generation_
Report_FINAL_1-29.pdf
. Accessed May 24, 2014.

Sandwich generation moms feeling the squeeze. APA Psychology Help Center. May 2008. www.apa.org/helpcenter/sandwich-generation.aspx. Accessed May 18, 2014.

Kari Olson Finnegan is the director of Employee Occupational Health & Safety at Park Nicollet in Minneapolis, Minnesota. Liz Ferron is vice president of Clinical Services at Midwest EAP Solutions, Minneapolis, Minnesota.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.