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ICU, trauma, gerontology, wounds
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Teresag_CNS has 34 years experience and specializes in ICU, trauma, gerontology, wounds.

RN since 1982, mostly in critical care. I completed my PhD in 2004. Now I lecture around the U.S. on trauma, critical care, and gerontology. My practice is in hospice, mainly skin and wound care. I have a passion for improving care of older adults in the the ICU. Also passionate about undergraduate nursing education.

Teresag_CNS's Latest Activity

  1. Teresag_CNS

    Introducing #SilentNoMore

    While we may never eradicate violence in the health care workplace, that is not a reason to give up. Nurses deserve good security in our workplaces. We deserve the right to prosecute patients and visitors (and coworkers) for assault. We deserve administrators who listen to our concerns. Violence should not be "just part of the job," yet most nurses I speak to have experienced it. What it "looks like" to me is: support from managers to engage in self-care after an assault (no matter how severe the physical injury), a policy to ensure no nurse is ever left alone with a potentially dangerous person, and rapid responses from security personnel when a nurse calls for help.
  2. Teresag_CNS

    "That's a myth about nursing"

    "There is a shortage of nurses willing to work under current bedside nursing conditions." AMEN!
  3. Teresag_CNS

    You Know You're A Nurse If...

    What a sweet story! Is he still with you?
  4. I was interviewed two days ago by NBC news reporter Elizabeth Chuck regarding sexual harassment of nurses. She wants to hear from others. My interview lasted about 15 minutes. We need to tell these stories. Thank you for speaking up, nurses!
  5. Teresag_CNS

    Order that says "Don't call MD for pain meds"?

    Acetaminophen has been shown to be little better than placebo for musculoskeletal pain. Since nurses spend the bulk of the time at the bedside, we deserve a rationale for such an order. Fractures hurt. Several people here have speculated, but you need to know the reason. A past history of addiction does not justify inflicting unnecessary pain.
  6. Teresag_CNS

    Nursing is Just a Job- common myths in nursing

    I think it's important that we nurses not allow employers to define us. Although they may treat us as a necessary evil (and I believe that is true), we don't have to embrace that misrepresentation of our profession. Nursing is a profession. Employers (and policymakers, and often the public and physicians) might choose to treat us as less than a profession, but that does not change my identity.
  7. Teresag_CNS

    Nursing is Just a Job- common myths in nursing

    I may have misunderstood what you meant by "Nightingalish," but it sounds like you're not familiar with her life and career. Florence Nightingale defied her parents as a young woman to study the nursing profession because she felt strongly about devoting herself to something useful in life rather than marrying and settling down to what she considered a life of idleness typical of upper-class women. She revolutionized hospital care and nursing education. She was the first woman inducted into the Royal Statistical Society for her work in the then-new field of epidemiology. She was not doing "a job." She was committed to improving health through nursing.
  8. Teresag_CNS

    HELP! Threats to call BON!

    Speak directly with your board of nursing. Tell them what's happening. He is probably making empty threats, but if you contact the BON first, you're much less likely to appear guilty. Tell them the facts and ask for advice. Also, your state nursing association (if you're a member) may have a service that gives you a short free lawyer consultation. Mine does. Ask them. And best wishes to you. This shouln't happen to anyone.
  9. Teresag_CNS

    What We Don't Measure

    Nineteen-eighty-two was the year I began nursing, associate's degree proudly in hand, in a community hospital's coronary care unit. My excitement about practicing in critical care was tempered by the fear of inadequacy familiar to many new nurses. Early in my career, a man had a huge myocardial infarction in the coronary care unit, right before my eyes. He was sweating, in pain, panicked, and dyspneic. This was before the thrombolytic era, so the treatment was to use our standing orders for nitroglycerin, valium and morphine. He lived through the night, and the following morning he gratefully told the day shift RN, "The night nurse held my hand." He didn't know I gave him nitroglycerin to dilate his vessels, improving coronary blood flow and reducing preload. He wasn't aware that morphine is both an analgesic and a mild vasodilator. Nor was he aware that the valium tablet was to reduce myocardial oxygen demand, not just to temper his well-justified anxiety. "The night nurse held my hand." This statement reflected the priorities of a man in a changing, unknown and threatening situation, when safety and comfort predominate. No standardized tool measures hand-holding or other intangibles such as projecting an aura of confidence. Giving backrubs, reducing noise, and changing sweaty linens figure only obliquely into patient satisfaction measurements. Yet, when you are the man having the MI, they stand out. Patient satisfaction scores are not synonymous with quality scores for this reason: patients' priorities are not clinical, they are personal. Naturally patients want the best care, but they are not equipped to judge whether the nurse gave medications correctly or made the correct judgment about an abnormal lab test. Nurses spend at least 30% of our time documenting. Electronic health records (EHR) may have increased this. They are designed for documentation from a regulatory, reimbursement, and quality management perspective, not a nursing practice perspective. These administrative purposes matter, of course, but they are not why the patient thinks we're there. The patient believes we are there for them. What we value, we measure. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey tool asks a handful of questions regarding nurses and physicians: if they treated the patient with courtesy and respect, if they listened, and if explanations were clear. Pain management is included, too. HCAHPS is important administratively because patient satisfaction scores influence group purchasing power, reducing costs for high-scoring hospitals. The problem is that courtesy, respect, listening and pain relief are nursing fundamentals, not indicators of excellence. What if we also measured nurses' skill in modifying the environment to enhance rest? What if we measured the many aspects of comfort, such as pillow-fluffing, linen changes, backrubs, and the nurse's ability to convey information with confidence and reassurance? Why not ask if we included the patient's family in our care? What if we simply asked patients if they honestly felt cared for? Excluding this information from our data-gathering efforts sends the message that these things are not valued, which may well hurt our efforts to improve patient satisfaction, and ultimately the financial well-being of our healthcare institutions. Would scores for respect and pain management rise if we captured skills like maintenance of a therapeutic healing environment and holistic family care? Possibly. Patients may not know that the backrub is a pain and anxiety management strategy, or that it promotes restorative sleep, but they do know whether they felt cared for and comforted. Measuring comfort interventions may bolster comfort and satisfaction by emphasizing their importance to clinicians, who might otherwise give them low priority in their busy schedules. However, to measure, we must document, and no nurse has more time for documentation. If we add non-pharmacological nursing measures to our EHRs, then something would have to go. Fortunately, nurse scientists have given us ample candidates for removal from nursing routines. Examples include 2-hour turning for pressure ulcer prevention (Bergstrom, Horn, Rapp, Stern, Barrett & Watkiss, 2013) and auscultation of bowel sounds prior to feeding post-operatively (Noblett, 2010). Enumerating the many candidates for elimination is beyond this article, but every registered nurse should know and have the right to practice up-to-date nursing that will improve outcomes and eliminate pointless practices. As a profession, we must reduce nursing time spent in practices that do little to improve patient outcomes. As we do this, we should reconsider the effective fundamental nursing practices that seem to have lost their place among our routines. Valuing (and measuring) them will benefit our patients, our employers, and our profession. References Bergstrom, N., Horn SD, Rapp MP, Stern A, Barrett R,& Watkiss. (2013). Turning for Ulcer ReductioN: a multisite randomized clinical trial in nursing homes. Journal of the American Geriatric Society, 61, 705-13. Noblett, H. (2010). Bowel Management After Surgery. ADVANCE for Nurse Practitioners, (18), 2, 45.
  10. Teresag_CNS

    I think I will give negative feedback

    Definitely. This is inappropriate. They were speaking above you, as if you weren't there.
  11. Teresag_CNS

    New RN having the worst time

    First, those who say a nursing home gives you no experience are flat-out wrong. Your practice is complex, as your dilemmas illustrate. What is the best way to prevent and treat skin tears and UTIs? How is delirium best managed? How to make decisions about end of life? And so on....These are questions that demand expert knowledge of gerontological nursing. My first suggestion is to join the National Gerontological Nurses' Association - Home - the journal is excellent, and you will have a cohort of other nurses skilled in caring for aging adults to back you up. My second suggestion is to read, read, read about gerontological nursing. It is a growing specialty, and those who have these skills will be in HUGE demand in coming years. We need great gerontological nurses like you. Stick with it! And best of luck.
  12. Teresag_CNS

    Regret becoming a nurse....

    I think you're expressing the same frustrations that many nurses experience. I agree with those who suggest a change of practice area; maybe outside of the hospital? Hospitals pay best, but they also have the least sense of why we became nurses, in my experience. Hospital administrators seem to think that physicians provide all the care and nurses are but a necessary evil. Get away and into a more nurse-friendly environment, such as home care, hospice, or an outpatient clinic setting. I wish you well. You sound dedicated to the profession and we need people like you.
  13. Teresag_CNS

    The View From Under the Bus

    A year ago I got a certificate in the mail celebrating my 30th year of certification as an intensive care nurse (CCRN). I smiled to remember how proud I was when I attained certification, 30 years younger and just 2 years into my nursing career. But the anniversary was bittersweet, because I no longer practiced in ICU. It was time to leave. I had begun to dread each workday - too much rising early, too many weekends, too many hours pushing buttons, scanning wristbands and ticking the boxes in electronic forms. Too many burned-out coworkers just getting through the day. When stress overtakes me, I write. My writing began as private journaling and eventually extended into the blogosphere as venues for blogging multiplied. For years, I wrote popular blog posts that my coworkers read, laughed at, liked” and talked about. I communicated the realities of nursing – the stress, the decisions to be made, the humor, the unreasonable demands, and the joy. It was fun, and I felt I was doing a service to nursing by telling readers what we REALLY do, until one of my posts hit a nerve. I wrote about two errors that had been made and how they were handled. In one case, a tourniquet had been left on a patient's arm too long, and in the other, a dangerously low potassium level was overlooked. These happened on the same day, done by the same RN who was new to our unit. In the chaos and complexity of a busy trauma intensive care unit at a top trauma center, a new RN can easily overlook a few things. Fresh off orientation, she (and the resident who also should have noticed the potassium) made mistakes. I've made mistakes, and any nurse who says she has not is likely to be lying. So it wasn't the fact of the errors that was uncommon. Errors in health care are a scourge about which much has been written. What distinguished these errors was the fact that a nurse wrote about them. In describing the errors, I said I apologized and gently informed the family of the potential skin damage done by the tourniquet. I wrote that I quickly got an order and gave a couple of horse-sized potassium tablets to the man with the low potassium. I disclosed one error, and not the other, because of who the patients were, what else they were going through (deciding to have a risky surgery or not), and timing. It would have been inappropriate to interrupt the surgeon explaining the risky surgery to disclose an error that had done no harm. And that was the point of the post. That sometimes it makes sense to disclose an error promptly, and sometimes not. The powers-that-be in the hospital didn't take well to my sharing this information publicly. No names or places were revealed. No protected health information was shared. Identities were always masked in my blog by changing essential details and omitting identifiers. No part of the Nurse Practice Act or HIPAA was violated. I was informed one morning at 7 a.m. by a coworker, as we waited for report, that I was to phone the nurse manager. The the charge nurse came in and repeated the message. She told me to phone the manager immediately. The manager told me to go home because there was a complaint pending against me. She would not describe the complaint, in violation of the union contract. I waited seven tense days for a meeting with Human Resources, Information Security, the director of intensive care, and the nurse manager. Fortunately, union representation meant I did not have to face this phalanx of institutional soldiers alone. In preparing for the meeting, the information security officer searched every logon I had ever made onto the electronic health record to build his case. He presented a list of names of the people whose records I had accessed. His first question was, Have you ever taken the HIPAA course?” followed by, Do you know what protected health information is?” He was taken aback when I defined the 18 elements of PHI. He continued, implying that I was mining” medical records for material for my blog. At one point, I stated, This feels like an interrogation, and one in which I am presumed guilty of some violation.” A week after the initial meeting, my computer access was suddenly cut off. I had no access to my research files, emails, nor to my calendar. Human Resources informed me this was routine.” Most of the incidents of unnecessary” medical records access were accounted for by a study I was conducting. The information security guy wanted to know if it was approved by the Institutional Review Board, implying I was too naive to understand that requirement. Although he'd research all my computer accesses, he obviously hadn't research my education. I assured him it was, and I securely shared with the administrators the names of my study subjects so they could see I had legitimately accessed their records. There were a few medical records left over that I did not recall accessing, and which I had no reason to access. The only way to account for these was that I left my work station without logging out of the computer, and someone else used my login to view a patient's record. And that is why they asked me to resign. It was the only infraction they could find. While employed there, I worked with staff nurses on a study that improved glycemic management in the cardiac surgery intensive care unit. The study generated several presentations and a publication. It was included in our application for Magnet status as an exemplar of how research is used to improve our care. I was the only faculty member at the School of Nursing with a clinical practice in the hospital. I lent my expertise as a clinical nurse specialist and certified skin and wound care specialist to the Trauma ICU, and to the hospital nursing quality committee. I sat on the hospital nursing research committee and mentored staff nurses who wanted to do research. None of these were requirements of my position. And none of these contributions mattered when the hospital felt threatened. The hospital filed a formal complaint against me with the Board of Nursing, which was later dismissed. The hospital would not disclose what was in the complaint, and the Board informed me that they were not permitted to share it. I still don't know what I was accused of. The hospital gave me the opportunity to resign, which I took, and now that I've survived being thrown under the bus, life is good. I've taken a new and much-needed direction in my career. I learned some things. An acquaintance harshly warned me, Those information security guys are Nazis,” which seems like it may be accurate now. There seemed to be a deep desire to catch and punish me. The presumption of innocence that one might expect was absent, and information that was due me was withheld. Like other nurses before me, I witnessed a willingness to toss me aside, disregarding my contributions, in order to support the aims of the institution. I'm not the first RN to tell this type of story, nor am I the first to bemoan the practice of hospitals treating nurses like a consumable commodity. This attitude does hospitals a disservice, yet it persists. Throwing away nurses for not being good little compliant employees is extremely costly. Recruiting and orienting a nurse can cost $100,000, not accounting for the harm potentially done when novices make mistakes. So why does this attitude persist? Partly, because our profession is almost entirely female, and females are less valued than males in our culture. Partly, because nurses are still viewed by administrators as interchangeable widgets that can be removed and replaced readily, in the face of obvious contradictory truths. Partly, because the anachronistic image of nurse-as-any-woman is still endorsed by many healthcare leaders, whose willful ignorance of nursing continues to drive decisions in health care. Partly by lateral violence; nurses report other nurses if they have any suspicion that one among them is no longer drinking the Kool-Aid. The psychological origins of lateral violence are beyond the scope of this article, but have been explored elsewhere, by authors more knowledgeable than me. When the causes of any phenomenon are complex and arise from multiple foci, the solutions are not easy. You can't tweak one single step in the inflammatory cascade and expect to cure septic shock. My one hope is that the gradual progress we've seen in our profession will continue, and some day fewer nurses will find themselves staring up at the oily undercarriage of the bus.
  14. Teresag_CNS

    Comparative Effectiveness Research in Nursing Care

    Thank you, Beth. I sat on a systematic review panel on pressure ulcer prevention recently; it may be the one you cited. It was done at Oregon Health & Science University. I was part of the initial team, then had to move on to other projects, so I wasn't an author. I think the conclusion is that we really don't yet know how often hospital patients should be turned. Another topic of interest: What is the evidence base for nursing physical assessment in hospitalized people? Nurses spend a great deal of time checking pupils, listening to lungs, and feeling for peripheral pulses, yet there is very little evidence to support these practices. Nurses carry out frequent assessments because they are the facility's standard of care, and often physicians order frequent assessments without thinking of the workload they impose on the nurse, allowing those orders to stay in effect well after they are needed. I wonder if we could develop evidence-based physical assessment standards instead of the one-size-fits-all approach, saving time and resources. Patients may get better sleep with fewer interruptions, and their privacy will be enhanced if we aren't lifting the gown as often.
  15. I am interested, but I'd like more explanation of what you mean by "medicalization." Thanks.
  16. Teresag_CNS

    Why do nurses clean off their shoes at work?

    Doesn't do any harm to clean your shoes more often. And it may reduce the bacterial burden on your shoes, keeping you from tracking it everywhere.