Are You Choosing Wisely in Your Professional Practice?

To enhance the value of care provided to Americans, the American Board of Internal Medicine and Consumer Reports launched the Choosing Wisely® initiative in 2012. Choosing Wisely educates providers and patients about high-frequency, low-value care practices that can be avoided to decrease cost and increase the value of health care. The Oncology Nursing Society collaborated with the American Academy of Nursing to add the first-ever nursing-focused list to those previously submitted by more than 70 specialty societies.
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Risk factors for increased in-hospital mortality: a cohort study among cardiac surgery patients.

BACKGROUND: Mortality is an important healthcare index for assessing the quality and the effectiveness of the provided nursing care. AIM: The aim of this study was to identify the risk factors for increased in-hospital mortality among cardiac surgery patients. METHODS: We followed up prospectively 313 consecutive patients who were admitted to the cardiac surgery intensive care unit (ICU) of a general, tertiary hospital in Athens during a 1 year period. Data collection was performed by using a short questionnaire and two instruments, the Nursing Activities Score (NAS) and the logistic EuroSCORE for assessing the nursing workload (NWL) and the perioperative risk for each patient respectively. RESULTS: Patients with a high 1st day NAS had an almost 3.3 times greater probability of death during their hospitalization (OR 3.3, 95%CI 1.4-8). Moreover, patients with increased perioperative risk (OR 4.2, 95%CI 1.50-12) and ICU length of stay (ICU-LOS) (OR 16.8, 95%CI 4.8-58.6) had statistically significant higher in-hospital mortality. CONCLUSION: Increased level of NWL, patient perioperative risk and ICU-LOS are closely associated with increased in-hospital mortality of cardiac surgery patients. The correlation between NWL and mortality represents the strong link of the nursing profession with the improvement of the effectiveness and quality of care.

Heart failure specialist nurses' use of palliative care services: a comparison of surveys across England in 2005 and 2010.

Heart Failure Nurse Specialists play a key role in facilitating the provision of palliative care for patients with advanced heart failure where supportive and palliative care needs are comparable to those with cancer. This article describes the attitudes of heart failure nurse specialists towards palliative care in the management of patients and their interface with specialist services in the context of changing policy drivers over this time period. Data is drawn from two national surveys, the first in 2005, and repeated in 2010 following national educational initiatives. This comparison provides encouraging results that over five years there has been a growing partnership between heart failure nurses and palliative care services and that heart failure nurses play a pivotal role in ensuring provision of both general and specialist palliative care for their patients. The importance of integrating cardiology and palliative care clinical services, and aspects of local, regional and national service provision in the setting of the Innovative Care for Chronic Conditions framework is highlighted.

2008 ONS research priorities survey.

PURPOSE/OBJECTIVES: To determine the priorities of oncology nursing research, including the effect of evidence-based practice resources as identified by the Oncology Nursing Society (ONS) membership in June 2008. DESIGN: Descriptive, cross-sectional. SETTING: A Web-based survey of ONS members. SAMPLE: Stratified into three groups: a representative random sample of the general membership (n = 4,460, 421 responded), an over-sampled random sample of advanced practice nurses (n = 980, 149 responded), and all ONS members who were doctorally prepared (n = 589, 143 responded); 713 responded overall. METHODS: The 2004 survey was revised and the new 2008 survey was beta tested. The invitation to complete the survey was sent via e-mail with a link to the survey Web site. A follow-up reminder was sent one week after the initial invitation. MAIN RESEARCH VARIABLES: 70 oncology nursing research topic questions, divided into five categories, and two additional categories regarding ONS Putting Evidence Into Practice resources. FINDINGS: Quality of life and pain were the two highest rated topics, consistent with 2000 and 2004 research priority survey findings. Eleven topics were new to the top 20 ranked priority topics in 2008. Differences in rankings were apparent between member groups. CONCLUSIONS: The respondents represented the broad spectrum of ONS membership. Changes in topic rankings indicate that oncology nursing research priorities have shifted since the 2004 survey. The lag in research result dissemination to clinical practice may account for differences in topic rating between groups. IMPLICATIONS FOR NURSING: The survey results will be used to develop the 2009-2013 ONS Research Agenda. The results also will assist the ONS Foundation and other funding agencies in setting priorities.

Low and declining cigarette smoking rates among doctors and nurses: 2006 New Zealand Census data.

AIMS: To examine smoking status among doctors and nurses using data from the 2006 Census and to describe recent trends in smoking prevalence among doctors and nurses. METHODS: Analysis of smoking status in 2006 New Zealand Census among medical practitioners and midwifery and nursing professionals, and comparison of cigarette smoking prevalences with findings of previous analyses of the census and surveys of doctors. RESULTS: There were 6312 male and 4197 female doctors, and 2469 male and 32,682 female nurses included in the 2006 Census. Non-response to the smoking status questions were less than 5%. Only 4% of male doctors and 3% of female doctors were regular cigarette smokers in 2006. Among specialist groups, the highest smoking prevalence was 12% among male obstetricians and gynaecologists, and 10% among female radiologists and radiotherapists. 13% of female and 20% of male nurses were smokers. The highest smoking prevalences were among psychiatric nurses (26% male and 30% female nurses). There has been a steady decline in cigarette smoking among doctors and nurses in New Zealand since the 1960s and 1970s. CONCLUSIONS: The results from the 2006 Census demonstrate that non-smoking among doctors and nurses is increasingly the norm, around 90% of younger doctors have never been regular smokers. The results show that it is possible to achieve very substantial decreases in smoking prevalences and to establish smokefree cultures among substantial occupational groups who are well informed about the degree of risk, are aware of the reality of the health consequences of smoking, and work in a substantially non-smoking environment.

Treating claudication in 5 words (stop smoking and keep walking) is no longer enough: an audit of risk factor management in patients prescribed exercise therapy in New Zealand.

AIM: To assess the documentation and modification of vascular risk factors in patients with intermittent claudication enrolled in an exercise programme in Christchurch, New Zealand. PATIENTS/METHOD: A retrospective review of case notes of patients who presented to the vascular outpatient department with intermittent claudication and were given "Green Prescriptions" for an exercise programme was performed. Referral letters, clinic letters, vascular nurse notes, and handwritten hospital notes were searched for evidence of documentation of risk factors for atherosclerosis. Modification of these risk factors was also noted. Positive attempts at risk factor modification included starting or asking the GP to start a medication or asking the GP to assist with smoking cessation. RESULTS: Sixty patient notes were reviewed which included 81 referral letters (66 from GPs), 118 surgeon letters/clinic notes, and 43 vascular nurse assessments. Of the 60 patients referred, risk factor documentation (positive or negative) was antiplatelet therapy (40), hypertension (48), hyperlipidaemia (39), current tobacco use (40), diabetes mellitus (37), and coronary artery disease (38). Vascular surgeons saw 58 patients and documentation was antiplatelet therapy (42), hypertension (46), hyperlipidaemia (45), current tobacco use (48), diabetes mellitus (44), and coronary artery disease (29). Attempted modification of risk factors by vascular surgeons occurred in 12 patients for antiplatelet therapy, 11 patients for lipid lowering therapy, and 10 for current smokers. Forty-three vascular nurse assessments resulted in documentation of antiplatelet therapy (0), hypertension (42), hyperlipidaemia (42), current tobacco use (43), diabetes mellitus (42), and coronary artery disease (6). CONCLUSION: There is suboptimal communication of vascular risk factors by referrers to specialist vascular services. The recording and modification of risk factors for atherosclerosis in our unit compares favourably with other reported series, but improvement is needed. Furthermore, the role of clinicians with an interest in risk factor management, and patients' understanding of their vascular risk factors, needs clarification.

A clinical audit of a nurse colposcopist. Colposcopy: cytology: histology correlation.

The role of the nurse colposcopist has been established in some countries for a number of years. At National Women's Health the first New Zealand nurse colposcopist training programme was developed in 2000. A clinical audit was undertaken to assess the diagnostic skills of the nurse colposcopist measuring colposcopy: histology: cytology correlation. A retrospective audit of the colposcopy clinical records was performed during the nurse's training programme between July 2000 and March 2002. An 82% (82/100) histology: cytology: colposcopy correlation was achieved by the nurse in the third phase of her training programme. The results are comparable with other reported studies involving medical and nurse colposcopists. Expertise in colposcopy examination can be incorporated into the broader role of a Nurse Practitioner working in the area of women's health.

Careers in child health nursing: the influence of course experiences.

Findings presented in this paper are drawn from a longitudinal study of nurses' careers (Robinson et al 1998, 1999). As part of this study, a large cohort of child branch diplomates were asked about their clinical experience while on the course and its effects on their initial work plans. For 12 of the 23 specialties listed, more than half of the 634 respondents felt that they did not have sufficient experience to comment. Findings indicate that there were five specialties which more than half of those who had experience during the course felt encouraged to work in: general paediatrics (73 per cent), community (63 per cent), oncology (60 per cent), PICU (59 per cent), and cardiac (53 per cent). Overall, course experiences were more likely to encourage than discourage diplomates from wanting to work in a particular specialty; this was the case for 19 of the 23 specialties. Course experiences were significantly more likely to have discouraged than encouraged diplomates from considering working in theatres and psychiatry. Seventy-seven per cent of respondents (417) had obtained a first job in their preferred clinical specialty. Findings from this study indicate that course experiences influence the initial career plans of child branch diplomates. Data obtained from further phases of this longitudinal study will indicate to what extent course experiences influence later career decisions.

A cross-sectional study of the health effects of work schedules on 3212 hospital workers in France: implications for the new French work schedules policy.

This study was designed to investigate the effects of work schedules on the health of hospital workers at the Assistance Publique-Hôpitaux de Paris (AP-HP). Out of 40 hospitals, 17 volunteered to participate in this study. The Standard Shiftwork Index and a questionnaire concerning physicians' work schedules were used. Ten thousand questionnaires were distributed anonymously to hospital workers between March and April 1999. Professional categories comprised head nurses, nurses, nursing auxiliaries, hospital agents, midwives and full time physicians. Departments included internal and geriatric medicine, general paediatrics, orthopaedic and general surgery, operating and emergency rooms, and anaesthesiology and intensive care units. 3250 questionnaires were returned. Demographics for the respondents were: 79.2% female, average age 38.1 +/- 9.1 years old. Eleven work schedules were identified. One fourth of the personnel had fixed morning work schedules. The highest level of job satisfaction was found in personnel working in paediatrics while dissatisfaction was strongest in the gerontology and, emergency room personnel. General Health Questionnaire (GHQ) scores were high for head nurses, operating room nurses and junior doctors as well as for personnel with rotating and flexible shifts. This study will be used to make recommendations concerning the reduction of working time for French hospital workers.

The incidence of smoking amongst nurses: a review of the literature.

Over the years there has been an ongoing debate about the implications of the smoking behaviour of nurses in relation to their own health and in the context of their professional role and responsibilities. However it is difficult to determine with any degree of accuracy the current incidence of smoking amongst nurses and most of the available research is based on small samples which embrace nurses of different levels and status. Very few recent studies in the United Kingdom or elsewhere have focused on this issue. A confused picture therefore emerges. This paper presents a critical overview of the literature and where appropriate provides data about the incidence of smoking in comparable groups of the general population.

Substance use among nurses: differences between specialties.

OBJECTIVES: Valid data on factors that increase a health care worker's likelihood of substance use are integral in ensuring professional standards and quality health care for consumers. This study explored the association between nursing specialty and past-year substance use. METHODS: In an anonymous mailed survey, a balanced stratified sample of registered nurses (n = 4438) reported their use of marijuana, cocaine, and prescription-type drugs, as well as cigarette smoking and binge drinking. RESULTS: Prevalence of use of all substances was 32%. Rates varied by specialty, even when sociodemographics were controlled. Compared with nurses in women's health, pediatrics, and general practice, emergency nurses were 3.5 times as likely to use marijuana or cocaine (odds ratio [OR] = 3.5; 95% confidence interval [CI] = 1.5, 8.2); oncology and administration nurses were twice as likely to engage in binge drinking; and psychiatric nurses were most likely to smoke (OR = 2.4; 95% CI = 1.6, 3.8). No specialty differences appeared for prescription-type drug use. CONCLUSIONS: Certain nursing specialties were more likely than others to be associated with substance use. The differences were not explained by demographic characteristics. Inasmuch as a comparison of these results for nurses with prior work on physicians found considerable agreement by specialty, preventive initiatives should consider inter-disciplinary approaches to substance use education.

Professional needs of palliative care nurses in New South Wales.

A survey of 108 palliative care nurses practising in New South Wales, Australia, was undertaken to explore their professional needs and clinical knowledge. Opportunity for improved training was the most frequently nominated professional need. Only 12% of the sample had postgraduate qualifications in palliative care and fewer than 20% were currently undertaking postgraduate training. Sixty-three per cent of nurses indicated that a lack of opportunity for formal study was a problem for them. The results of the knowledge survey revealed a need for additional training. Many nurses did not have the clinical knowledge identified as minimal by an expert committee. Those nurses who had a postgraduate qualification in oncology scored more highly on the knowledge questionnaire than did those whose general nursing training was undertaken outside Australia. The implications of these findings for training and other professional support are discussed.

Burn-out in hospital nurses: a comparison of acquired immunodeficiency syndrome, oncology, general medical, and intensive care unit nurse samples.

Previous research has shown that job-related stress and burn-out are associated with high levels of demand placed on the worker, especially in situations where influence is low. This study examined burn-out among nurses working on acquired immunodeficiency syndrome (AIDS) special care units (SCUs), oncology SCUs, medical intensive care units (ICUs) and general medical units to measure the extent to which delivery method (SCU, ICU, and general unit), patient diagnosis, or other key personal and work-related characteristics were associated with the level of distress in these nurses. A sample of 237 nurses from 18 units in seven hospitals were surveyed using the Maslach Burnout Inventory. This study showed no significant differences in burn-out scores across nurse samples representing variations in patient diagnosis and delivery method. Specifically, nurses on AIDS SCUs, oncology SCUs, medical ICUs, and general medical nursing units reported similar levels of distress on the burn-out subscales. There was one exception: medical ICU nurses scored significantly lower on the Personal Accomplishment subscale (P < .001). Regression analyses for the Emotional Exhaustion and Personal Accomplishment subscales indicated that greater job influence had a significant protective effect on emotional exhaustion and enhanced personal accomplishment (P < .05). As expected, job tension was a key predictor of exhaustion (P < .001), and being white was associated with greater feelings of accomplishment (P < .002). Working in a medical ICU continued to show a negative impact on accomplishment when race and other important covariates were controlled for (P < .05), and working on an AIDS SCU was predictive of exhaustion in a multivariate context (P < .05).

Current Procedural Terminology (CPT) coded services provided by nurse specialists.

In this exploratory study, a random sample of nurses from nine nursing specialties was surveyed to identify which Current Procedural Terminology (CPT) coded procedures they perform and how frequently they perform them. CPT codes are used universally to file claims for physician payment. The sample included 74 school nurses, 67 enterostomal nurses, 53 family nurse practitioners, 43 critical care nurses, 43 oncology nurses, 40 rehabilitation nurses, 39 orthopaedic nurses, 34 nephrology nurses and 25 nurse-midwives. Specific questionnaires were developed for each specialty with codes identified by expert panels. The number of CPT codes ranged from 233 for family nurse practitioners to 58 for school nurses. The mean number of coded services performed by individual respondents ranged from 79 (FNP) to 18 (school nurses); individual respondents performed 0-162 codes. Supervision by physicians was very infrequent. Charges to Medicare in 1988 for the coded services included in the survey were $22,793,427.34 (aggregate allowable charges). The study provides some documentation of the degree to which nurses perform the same services and procedures for which physicians are being paid. If policy makers are serious about reaching innovative solutions to the problems of quality, access and cost, everything must be "on the table," including the contributions of nurses.