Patient acuity has increased due to more complex patient ... · Patient acuity has increased due to more complex patient populations. This objective, quantitative tool is used to

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OFFICIAL NEWSLETTER

Volume 23 – Number 2March/April 2014

Patient acuity has increased due to more complex patient populations. This objective,quantitative tool is used to assign acuity ratings, adjust staffing ratios, assignappropriate skill mix, and balance workload to maximize safe, effective care.

A 148-bed community hospital, which is part of a large academic health system, has seenphysician specialists admit more complex patient cases to a 36-bed medical-surgical unitover the past few years. The usual census in the past included patients who had experiencedan appendectomy, hysterectomy, or cholecystectomy. Many of these patients are now dis-charged from the outpatient surgery service. Today, the population on this unit includespatients who have undergone a thoracotomy with placement of multiple chest tubes, multi-level spinal fusion, and laminectomy, patients recovering from cranio-neurosurgical proce-dures, and patients of prostatectomy and urologic reconstruction surgeries. The “overnightobservation” patients are now bariatric surgery patients with precise regimens to follow orbilateral mastectomy patients.

The nurses on this medical-surgical unit began to feel the impact of the increase inpatient acuity while their staffing ratios remained the same. They also felt an imbalance inworkload among the team at times when the assignments did not accurately reflect patientacuity nor balance the skill mix of the staff.

Charge nurses, who made the nurse-patient assignments for each 12-hour shift,attempted to balance the workload by using a subjective evaluation of patient acuity and theunit’s nursing skill mix. Assignments were often made under time-pressure and with limitedinformation. The staff nurses requested a more objective and equitable way of defining acu-ity ratings to promote safer patient care. The unit’s Clinical Nurse Specialist and NurseManager were supportive and felt it important to advocate for the nurses and their patients.

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INSIDE THIS ISSUE

Nutrition to Improve Outcomes: Healthy to Undernourished: Post-Hospital Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Nursing Management of Constipation in the Medical-Surgical Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Strategies for Nurse Educators: Restructuring the New Nurse Orientation Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Drug Update: NSAIDs: Is Naproxen the Safest Choice? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

CNE

Molly McClelland

Thoughts from

the EditorVolume 23 – Number 2

March/April 2014

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© Copyright 2014 by AMSN. All rights reserved.Reproduction in whole or part, electronic ormechanical without written permission of the pub-lisher is prohibited. The opinions expressed inMedSurg Matters! are those of the contributors,authors and/or advertisers, and do not necessarilyreflect the views of AMSN, MedSurg Matters!, or itseditorial staff.

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“Just a Nurse”I recently had an experience that is unfortunately all too familiar. I’ve been par-

ticipating in multidisciplinary discussions with other university professors to developa collaborative program encouraging disadvantaged youth to pursue biomedical sci-ence degrees including social, behavioral, and clinical professions. When I was askedto sit on the committee, I thought my expertise and background in nursing sciencewould be a valued addition. However, a professor from biology assumed those seek-ing biomedical degrees would most likely want to pursue only chemistry or biology– certainly not nursing. The physics professor on the committee asked why nursingstudents would need to take a chemistry course at all.A professor representing psy-chology seemed to appreciate the clinical portion of nursing, but was also unclearabout why youth with biomedical interests would choose nursing. My response wassimilar to every other time I’ve encountered these types of assumptions. I taughtthe group what nurses do, what they know, how smart they are, and the extensivescientific education they all have in order to do their jobs well.

I don’t like feeling so defensive about being a nurse. When I’m around othernurses, there is a sense that we all know exactly how much science, intelligence, andknowledge it took for each of us to become a registered nurse. Ours is not a newprofession, so why is it that so many non-medical people have no idea what we door what it takes to do what we do…and do it well? The phrase “just a nurse” impliesthat anyone with a few minimal skills could perform the role of a nurse.

Nursing is unique in that it combines a plethora of sciences. Nurses are trainedto understand the chemical reactions of numerous pharmacological therapies.Biological knowledge is essential for understanding human physiology and howpatients will react to thousands of different variables. In addition, because nursescare for people in vulnerable situations, knowledge of ethics, therapeutic communi-cation, mental health, psychology, and astute assessment skills are also imperative.

Nurses must combine the hard sciences with the complexities of the humanexperience in an effort to heal, improve health, or provide for a comfortable death.The ability to perform extremely complex tasks – such as proper nutrition assess-ments, sage nurse-patient assignments, or assessing the cause of recurrent constipa-tion and using evidence-based practices to prevent reoccurrence – all while educat-ing and caring for the people affected by these issues takes the intelligence, knowl-edge, skills, kindness, compassion, and expertise unique to nurses.

To understand and navigate the evolving health care coverage, manage globaland natural disasters, practice in advanced roles, implement good nutritionstrategies, and meet the health care needs of individuals, families, and communi-ties takes much more than just having an understanding of chemistry or biology.To effectively do all that, it takes a scientifically well-trained nurse knowledgeablein all the sciences (chemistry, biology, physiology, mathematics, psychology, soci-ology, and nursing). It takes “just” a nurse.

Molly McClelland, PhD, MSN, RN, CMSRN, ACNS-BCMedSurg Matters! Editor

Healthy to Undernourished:Post-Hospital Syndrome

Bob was a 62-year-old man who weighed 180 poundsand was 5 feet, 10 inches tall. He was a very active man whoplayed on a golf team two days a week. Bob was admitted tothe hospital for elective abdominal and inguinal herniarepairs. Bob’s surgery went well, and he was discharged threedays later. When Bob arrived home, he could barely make itup the stairs to his bedroom. He was exhausted. He felt weakand unstable. What went wrong?

Like many hospitalized patients, Bob’s body was stressedduring the hospitalization. He underwent surgery. He wasNPO the night prior to surgery, didn’t have any nutrition theday of surgery, and was nauseated postoperatively. All ofthese factors limited his intake of nutrients. Furthermore, hisabdominal pain limited his mobility during the hospitalizationand prevented him from sleeping well. Bob was undernour-ished and deconditioned when he returned home.

Dr. Krumholz (2013) terms this familiar condition Post-Hospital Syndrome, the temporary condition of weaknessacquired during hospitalization that places patients at risk forpost-discharge complications. During a hospitalization, thefocus is often placed on the patient’s immediate care needs.Effectively caring for a patient involves managing his or herimmediate care needs related to hospitalization, but alsoaddressing the essential elements of nutrition, mobility, andsleep. Unfortunately, these essential elements are oftenunder-emphasized.

What if Bob’s nurse identified his inadequate nutrientintake on post-operative day 1 and collaborated with hisphysician and dietician to establish a clear plan? Bob couldhave received anti-emetics prior to each meal to reduce thenausea and increase the likelihood of eating. Bob might havereceived a bland food tray that may have been more palatablein face of the nausea. Perhaps, Bob could have been asked toidentify foods that he preferred and wanted to eat. Bob’senvironment could have been optimized to make it moreconducive to eating. His bedside table might have beencleaned off prior to the tray delivery. He also could have beenassisted to brush his teeth and wash hands to create a moresupportive mealtime environment. He might have beenhelped out of bed and into a chair to facilitate eating and pro-mote mobility.

Moreover, Bob could have received a nutrition plan totake home. Often, patients are told to return to a ‘regular’

home diet. Yet without fully understanding the patient’s homenutrition regimen, the ‘regular’ home diet may be inadequate.Bob might have benefited from a prescriptive home nutritionplan to increase his stamina, aid his healing, and prevent com-plications. Bob also could have been given a prescription foranti-emetics to facilitate nutritional intake at home.

Looking to the future of health care, patients like Bobneed comprehensive nutrition plans. Nutrition that is priori-tized during hospitalization and transitioned to home pro-vides our patients with the best chances for success.Providing quality nutrition care is a key element in reducingPost-Hospital Syndrome and rapidly returning patients to afunctional life.

ReferenceKrumholz, H.M. (2013). Post-Hospital Syndrome – An acquired, tran-

sient condition of generalized risk. New England Journal of Medicine,368(2), 100-102. doi:10.1056/NEJMp1212324

Beth Quatrara, DNP, RN, CMSRN, ACNS-BC, is aClinical Nurse Specialist – Advanced Practice Nurse 3, andDirector of PNSO Nursing Research Program, University ofVirginia Health System, Charlottesville, VA. She is the “Nutritionto Improve Outcomes” Column Editor and the AMSN ClinicalRepresentative to the Alliance to Advance Patient Nutrition.

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Volume 23 – Number 2

NutritionTO IMPROVE OUTCOMES

If you have any questions or comments regarding the "Nutrition to Improve Outcomes" column, or if you are interested in writing, pleasecontact Column Editor Beth Quatrara at [email protected].

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Nursing Management ofConstipation in the

Medical-Surgical Setting

Deadline for Submission: April 30, 2016

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ObjectivesThe purpose of this continuing nursing educationarticle is to increase nurses’ and other health careprofessionals’ awareness of prevention and treat-ment of constipation on the medical-surgical unit.After studying the information presented in this arti-cle, you will be able to:1. Discuss the prevalence of constipation in

hospitalized patients and the role of nurses inassessment.

2. Describe each of the three categories ofconstipation.

3. Identify the types of laxatives that can be used torelieve constipation, and explain the indicationsand response of each.

4. Provide non-pharmacologic resolutions forconstipation.

Note: The author, editor, editorial board, andeducation director reported no actual or potentialconflict of interest in relation to this continuingnursing education article.

This educational activity has been co-provided byAnthony J. Jannetti, Inc. and AMSN.

Anthony J. Jannetti, Inc. is accredited as a providerof continuing nursing education by the AmericanNurses Credentialing Center’s Commission onAccreditation.

Anthony J. Jannetti, Inc. is a provider approved bythe California Board of Registered Nursing, providernumber CEP 5387. Licensees in the state of CA mustretain this certificate for four years after the CNE activ-ity is completed.

CNECONTINUING

NURSINGEDUCATION

Nursing Management ofConstipation in the Medical-Surgical Setting

Robert Hunter

2011). Clinicians generally define con-stipation quantitatively and based onfrequency of stools, typically consider-ing less than three bowel movements aweek abnormal (Leung, Riutta, Kotecha,& Rosser, 2011). The Rome diagnosticcriteria in Table 1 attempts to standard-ize the definition of constipation(Longstreth et al., 2006).

Categories of ConstipationConstipation can be broadly

divided into three categories: normaltransit constipation (functional), slowtransit constipation, and outlet consti-pation.Normal Transit Constipation

In normal transit constipation,stool transit time and frequency doesnot change; patients often complain ofabdominal pain, bloating, difficult pas-sage of stools, and hard stools(Gallagher, O’Mahony, & Quigley, 2008).Many providers consider normal transitconstipation a component of constipa-tion-predominant irritable bowel syn-drome rather than a category of consti-pation (Gallagher et al., 2008).Slow Transit Constipation

Slow transit constipation resultsfrom decreased peristalsis in the colon,causing longer intestinal transit timebefore stool reaches the rectum.As thestool remains in the colon, water con-tinues to be reabsorbed, leading to ahard and dry stool. With slow transitconstipation, individuals will complainof infrequent bowel movements. Theetiology of slow transit constipation ispoorly understood. Postulated causesof slow transit constipation include lackof fiber, neuropathy, and disorders ofthe enteric nervous system andendocrine system (Frattini & Nogueras,2008).

Constipation is a common lower gas-trointestinal disorder that is often over-looked in acute care services. Nursescan have a significant impact in pre-vention and treatment of constipationthrough comprehensive nursing assess-ment, timely interventions, and patientadvocacy.

Constipation, a common conditionthat is negatively associated with qualityof life (Belsey, Greenfield, Candy, &Geraint, 2010), results in a significantcost to the United States health caresystem. As of 2001, the total cost oftreating constipation in the UnitedStates was $253 million per year, withinpatient care accounting for 55% ofthe total cost (Martin, Barghout, &Cerulli, 2006). Further studies areneeded to evaluate the current cost ofconstipation on the United Stateshealth care system.

Nurses play a key role in prevent-ing and treating constipation throughcomprehensive nursing assessment,timely interventions, and patient advo-cacy. As a part of patient advocacy, it iscritical that nurses understand consti-pation, articulate assessment findings toproviders, and collaborate on evidence-based treatment options so that appro-priate medical therapies are adminis-tered when indicated. By doing so,nurses may decrease the psychologicaland physiological stress associated withconstipation and the patient is lesslikely to have a delayed discharge.

DefinitionMedical professionals and patients

define constipation in many differentways. Patients tend to define constipa-tion qualitatively, based upon theirsymptoms, such as straining to passfecal material, unsatisfactory defecation,infrequent passage of stools, andabdominal bloating (Lindberg et al.,

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Outlet ConstipationOutlet constipation (also known as

pelvic floor dysfunction, rectal outletdelay, obstructive defecation, or pelvicfloor dyssynergia) occurs when there isdifficulty evacuating stool (Kyle, 2011a;Marples, 2011). Inadequate anal relax-ation, paradoxical anal contraction, andimpaired rectal contraction are thoughtto be the primary causes of outlet con-stipation (Rao & Go, 2009). Patientsmay report feelings of incomplete defe-cation or the need to strain with defe-cation. Anatomical problems of recto-cele or rectal wall prolapse can inhibitnormal functions of the pelvic floor

muscles and contribute to outlet con-stipation (Leung et al., 2011). Otherconditions leading to outlet obstruc-tion include impaired rectal sensation,organic causes (e.g., tumor), and anis-mus that occurs when the external analsphincter muscle contracts rather thanrelaxes during defecation (Norton,2006; Tack et al., 2011).

Nursing AssessmentEffective nursing assessment and

diagnosis are essential for the preven-tion and management of constipation.Neglecting a gastrointestinal assess-ment can lead to failed prevention or

treatment of constipation, resulting inan extended length of stay in the hospi-tal. Providers may be reluctant to dis-charge a patient until bowel function isrestored. Due to the multi-factorialnature of constipation, identifying con-tributing factors can be challenging (seeTables 2 and 3). In addition to physicalcauses, constipation may also beaffected by psychological, emotional,and environmental factors. Presentingsymptoms should be considered inrelation to relevant medical history(Kyle, 2011b). For example, a patientmay complain of new-onset constipa-tion with sleep deprivation, perhapsrelated to underlying depression. It isessential that on admission to a unit,nurses assess for constipation and riskfactors beyond the patient’s primarydiagnosis. During patient admission, thenurse should collaborate with theadmitting provider regarding currentbowel function and the need for laxa-tives or enemas, if constipation has notalready been addressed. Continuedassessment and collaboration withproviders throughout the patient’s stayis essential for proper management ofconstipation.

The nursing assessment shouldencompass the following subjective andobjective information:

• Patient’s description of constipa-tion symptoms including excessivestraining during defecation, natureof stools, sensation of obstructionor incomplete evacuation, abdomi-nal pain, abdominal tenderness ordiscomfort, nausea, vomiting, orrectal pain on defecation.

• Last bowel movement, number ofstools per week, or changes inbowel habits.

• Examination of the abdomenincluding auscultation of the fourquadrants, palpation for firmnessor tenderness, and general appear-ance.

• Assessment of bowel managementat home including laxative use,dietary habits, and exercise regi-men.

• Contributing medications or med-ical history (see Table 2).

Table 1.Rome Criteria III to Diagnose Constipation

1) Patient must experience two or more of the following:

A. Straining ≥ 25% of defecationsB. Lumpy or hard stools ≥ 25% of defecationsC. Sensation of incomplete evacuation ≥ 25% of defectionsD. Manual maneuvers to facilitate ≥ 25% of defecations (e.g., digital evacuation)E. Fewer than three defecations every week

2) Stool rarely loose without use of laxatives

3) Criteria insufficient to indicate irritable bowel syndrome

Source: Longstreth et al., 2006.

Category Description

Medications Antacids, anticholinergics (tricyclic antidepressants,antihistamines, antipsychotics, antispasmodics),antiepileptics, anti-Parkinsonian drugs, calcium channelantagonists, calcium supplements, iron supplements,diuretics, opioids

Cardiac Disorders Congestive heart failure

Endocrine and MetabolicDisorders

Diabetes mellitus, chronic renal disease, hyperthyroidism,hypothyroidism

Gastrointestinal Disorders Anal fissure, colorectal tumor, diverticular disease,hemorrhoids, irritable bowel syndrome, megacolon,strictures, rectal prolapse, volvulus

Myopathic Disorders Amyloidosis, dermatomyositis, systemic sclerosis

Neurological Disorders Autonomic neuropathy, cerebrovascular disease, dementia,depression, multiple sclerosis, spinal cord lesion,Parkinson’s disease

Table 2.Medications and Medical Disorders Associated with Constipation

Source: Gallagher et al., 2008; Kyle, 2011b; Rao & Go, 2010.

Academy of Medical-Surgical Nurses www.amsn.org

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• Assessment of the perineal areafor hemorrhoids, rectal prolapse,tears, bleeding, excoriation, lesions,and fecal soiling (Kyle, 2011a).

• Digital rectal exam if the clinician istrained and competent to do theprocedure. Many facilities requirenurses to obtain an order from aprovider to perform digital rectalexams. The clinician should assessfor the presence and consistencyof fecal matter in the rectum andits consistency, masses, or irregularsurface contours and anal sphinc-ter function and tone. Weak restingtone may contribute to fecalincontinence, whereas increasedtone may reveal a potential causeof constipation. This assessmentmay help determine the need for asuppository or manual evacuationof feces in severe cases (Kyle,2011a).

Complications ofConstipation

Patients with a history of chronicconstipation bear a higher risk than thegeneral population for specific compli-cations. Although complications arerarely life threatening, nurses need tobe familiar with the potential complica-tions in order to promptly initiatetreatment. Complications include fecalincontinence, hemorrhoids, anal fissure,organ prolapse (i.e., uterus, rectum,bladder, and vagina), fecal impaction andbowel obstruction (Leung et al., 2011).Stercoral perforation (perforation ofthe bowel due to fecal mass) is a rarebut potentially life threatening compli-cation (Sakharpe, Lee, Park, & Dy, 2012).Persistent straining causes increasedintra-abdominal and intrathoracic pres-sure, putting the patient at risk for her-nias, worsening gastric reflux, hemor-rhoids, syncope as a result of vasovagalresponse, and less commonly, transientischemic attacks (Kyle, 2011c; Gallagheret al., 2008).

PharmacologicalManagement of Constipation

Providers often prescribe a widevariety of treatments for constipation,despite a lack of robust research tosupport specific medical therapies

(Leung et al., 2011). Through the admis-sion medication reconciliation processor specific physician inpatient orders,patients will often have scheduled and“as needed” (PRN) laxatives available.Nurses frequently need to select whichlaxative(s) to administer among severalPRN options. By understanding the dif-ferent classes of laxatives and themechanism of action, nurses can usetheir assessment findings to administerthe appropriate laxative(s). Severalcommonly used classes of laxativesinclude bulk-forming, osmotic, stimu-lant, enemas and suppositories, stoolsofteners, and peripheral opioid antago-nists. Less frequently used laxativeswithin the inpatient setting – such asLubiprostone (Amitiza®), Tegaserod(Zelnorm®), and Linaclotide (Linzess®)– go beyond the scope of this article.Fiber and Bulk-Forming Laxatives

Fiber and bulk-forming laxativescause increased water absorbency andstool weight, which results in increasedperistalsis. Bulk-forming laxatives arethe least harmful class of laxatives, butthey may take up to three days to beeffective (see Table 4) (Kyle, 2011a).Commonly used over-the-counterbulk-forming laxatives include psyllium(Metamucil®), bran, and methylcellulose.Bulk-forming laxatives are inappropri-ate for patients on fluid restrictionsbecause limited fluid intake may result

in mechanical obstruction. Bloating,abdominal pain, and flatulence are themost common adverse effects. Fiberand bulk-forming laxatives are consid-ered first-line treatments for preventingand treating chronic constipation(Lindberg et al., 2011). In the acute caresetting, faster acting and more effectivetherapies may be needed to treat acuteconstipation.Osmotic Laxatives

Osmotic laxatives draw water intothe intestinal lumen, resulting in softerstool and improved propulsion of stool.Osmotic laxatives include polyethyleneglycol (PEG 3350), lactulose, saline laxa-tives (magnesium salts), and sorbitol.Because osmotic laxatives function inthe colon and not systemically, they aregenerally considered safe for mostpatients. However, several severeadverse effects may occur with osmoticlaxatives including electrolyte abnor-malities, hypovolemia, and diarrhea(Gallagher et al., 2008). Patient popula-tions with renal insufficiency or renalfailure are prone to electrolyte abnor-malities; therefore it may be prudent toconsider alternative therapies. Adverseeffects of PEG 3350, lactulose, and sor-bitol include abdominal cramping, bloat-ing, and flatulence (Johanson, 2007;Leung et al., 2011). PEG 3350 and lactu-lose are both strongly supported bysystematic reviews as treatment modal-

Category Description

Fiber Intake Fiber deficiency is associated with constipation

Functional Deficits Factors: reduced privacy, inaccessible toileting, reliance onothers for toileting needs, communication difficulties

Inactivity Immobility or sedative lifestyle is associated withconstipation

Increasing Age Constipation is associated with increasing age, but is not aphysiological consequence of normal aging

Low Calorie Intake Low calorie intake is associated with constipation

Female Sex Higher incidence of self-reported constipation with females

Depression Depression is associated with constipation

Table 3.Factors Associated with Constipation

Source: Gallagher et al., 2008; Lindberg et al., 2011.

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ities for constipation; however, a recentCochrane article found PEG 3350superior to lactulose in terms of stoolfrequency per week, relief of abdominalpain, and stool softness (Lee-Robichaud, Thomas, Morgan, & Nelson,2010). The use of saline laxatives is notstrongly supported by research(Gallagher et al., 2008).Stimulant Laxatives

Stimulant laxatives cause increasedintestinal peristalsis, resulting inimproved mucus secretion and intes-tinal motility. The two commonly usedclasses of stimulant laxatives areanthraquinone (e.g., senna and cascara)and diphenylmethane derivatives (e.g.,bisacodyl). Stimulant laxatives takeeffect 6-12 hours post administration(see Table 4) and therefore should begiven at bedtime. There is inadequatedata supporting the long-term use ofstimulant laxatives, but given the typicalshort length of inpatient stay, stimulantlaxatives are appropriate to use in anacute care setting. Due to the increasedintestinal motility, a common side effectis abdominal cramping (Tack & Müller-Lissner, 2009).Enemas and Suppositories

Enemas and suppositories, usedalone or in conjunction with oral laxa-tives, work rapidly to clear the rectumof stool and restore normal bowelfunction when oral laxatives are unsuc-cessful. After the rectum is cleared,patients typically start a bowel manage-

ment program, which includes dietmodification and may also include med-ical management. The mechanisms ofaction for the different types of suppos-itories and enemas include carbon-dioxide releasing (potassium bitartrateand sodium bicarbonate), hyperosmotic(e.g., glycerin and sodium phosphates),lubricant (e.g., mineral oil and glycerin),stimulants (e.g., bisacodyl and senna),and stool softeners (e.g., docusate)(Mayo Clinic, 2011).

Enemas play an important role inpreventing fecal impaction (Gallagher etal., 2008). Types of enemas include tapwater, normal-saline, vegetable oil, andsoap. Tap water enemas are consideredmild enemas with few side effects; how-ever, repeated use in a short time framecan cause electrolyte abnormalities as aresult of water absorption in the rec-tum and colon (Nepal, Atreja, &Lashner, 2012). Soap suds enemas arethought to be more effective than tapwater enemas but may result in rectalor colon inflammation (Cassagnol, Saad,Ebtesam, & Ezzo, 2010; Rao & Go,2010).

Sodium phosphate and sodium cit-rate enemas are commonly used inpractice. Serious complications areinfrequent for low risk patients. Higherrisk patients may experience life threat-ening adverse effects as a result ofsodium phosphate or sodium citrateenema administration. The adverseeffects of phosphate enemas includefluid and electrolyte imbalances such as

hyperphosphatemia, hypernatremia,hypocalcemia, and metabolic acidosis(Mendoza, Legido, Rubio, & Gisbert,2007). Because of the high salt content,sodium citrate enemas may exacerbateedema in patients with end-stage heartfailure and thus should be used withcaution in this patient population (Kyle,2011a). Risk factors for the adverseevents include patients with chronicrenal failure, elderly patients, andpatients with decreased intestinalmotility (Mendoza et al., 2007).A recentstudy recommends sodium phosphateenemas be limited only to low riskpatients due to severe complicationsexperienced by elderly patients whoreceived sodium phosphate enemas(Ori et al., 2012). In the study, complica-tions that patients experienced fromsodium phosphate enema administra-tion included acute renal failure,hypotension with volume depletion,extreme hyperphosphatemia, severehypocalemia, hypernatremia, andhypokalemia (Ori et al., 2012). In light ofthis new evidence, current guidelinesare likely to be revised to recommendwarm water enemas of 30-60mL untilfurther data is published.Stool Softeners

Stool softeners allow water and fatto penetrate feces by lowering surfacetension on the stool. Docusate sodiumand docusate calcium are commonlyused in practice. Stool softeners are nolonger recommended to treat constipa-tion because of the limited supportingevidence and questionable efficacy(Gallagher et al., 2008).Peripheral Acting µ-OpioidReceptor Antagonists (PeripheralOpioid Antagonists)

Alvimopan and methylnaltrexonecan be used for treatment of opioid-induced constipation and act peripher-ally so that pain relief is not affected.With a 5 mg dose of methylnaltrexone,50% of patients had a bowel movementwithin four hours of administration(Portenoy et al., 2008). Peripheral opi-oid antagonists also show promise inalleviating opioid-induced side effectssuch as nausea, post-operative ileus, uri-nary retention, and pruritus (Rao & Go,2010). As an additional note, due to the

Class Common Laxatives Onset Time(Hours)

Bulk-Forming andFiber

Bulk Forming: Psyllium, bran, andmethylcellulose

48-72

Osmotic Polyethylene glycol (PEG), lactulose, salinelaxatives (magnesium salts) (e.g., milk ofmagnesia, sodium biphoshate, and sorbitol)

Saline 0.5-3Others 24-48

Stimulant Senna and bisacodyl 6-12

Stools Softeners Docusate sodium and docusate calcium 24-48

Peripheral OpioidAntagonists

Alvimopan and methylnaltrexone Within 8 hours

Table 4.Laxative Effectiveness Time

Source: Gallagher et al., 2008; Rao, 2009.

Academy of Medical-Surgical Nurses www.amsn.org

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constipating effects of opioids, anypatient consistently receiving opioidsshould also receive laxative treatment.

Discharge Education andConsiderations

Nurses play an instrumental role inproviding education at discharge tohelp patients prevent and manage con-stipation at home. Nurses should edu-cate patients on non-pharmacologicmanagement of constipation and pro-vide medication teaching on any pre-scribed laxative.Non-Pharmacologic Management

Lifestyle modifications such as diet,exercise, and increasing fiber intake canbe sufficient in preventing constipationwithout the use of laxatives, dependingon the severity of the constipation.Increasing fluid intake is commonly rec-ommended as a means to prevent ormanage constipation (Leung et al.,2011). However, there is conflicting evi-dence about whether increasing fluidintake is an effective intervention. Forinactive individuals, exercise positivelycorrelates with bowel function (Kyle,2011a). The nurse should assess whichactivities the patient is willing to do forexercise and encourage these activitiesif not contraindicated. Dietary assess-ment prior to discharge is necessary todetermine if fiber deficiency may beresponsible for constipation. Increasingfiber intake to 25 grams a day can helpprevent fiber deficiency constipation(Lindberg, et al., 2011). Nurses shouldeducate patients about the types offood with high fiber content as well asother foods that may be constipating oract as pro-motility agents. An alterna-tive therapy for patients experiencingoutlet constipation is biofeedback, alearned strategy for behavior modifica-tion. Patients are taught diaphragmaticbreathing and synchronizing abdominalpush efforts with anal relaxation while arectal probe measures pressure read-ings (Rao & Go, 2010). Biofeedback issupported by randomized controlledtrials and improves bowel function byincreasing control and sensation of thepelvic floor muscles and anorectum,eliminating paradoxical contractions(Leung et al., 2011).

Collaboration at Discharge Prior to discharge, the nurse needs

to be cognizant if a patient has a historyof chronic constipation, risk factors forconstipation, or new interventionsfrom the hospital course that mayrequire constipation prophylaxis. Thenurse should then collaborate with thedischarge provider to determine if aprescription is necessary to preventconstipation or if non-pharmacologicalmanagement is sufficient. For example,when a patient is prescribed opioids atdischarge, there needs to be considera-tion for laxative prescription as well. If apatient resides in a long-term care facil-ity or has a home caregiver, these par-ties should be notified of any necessarychanges to diet, exercise, or medicalmanagement.

ConclusionPatients in a hospital setting are at

high risk for presenting with or devel-oping constipation. Nursing profession-als play a crucial role in identifying andmanaging constipation for patients.Prompt recognition and treatment ofconstipation are paramount to decreas-ing cost and improving patient wellbeing. Nurses should advocate forpatient’s needs through collaborationwith providers. Sharing nursing assess-ment findings, as well as appropriateevidence-based treatment options, canmake a difference for the patient inmanaging constipation.

ReferencesBelsey, J.J., Greenfield, S., Candy, D., & Geraint,

S. (2010). Systematic review: Impact ofconstipation on quality of life in adultsand children. Alimentary Pharmacology andTherapeutics, 31(9), 938-949.

Cassagnol, M., Saad, M., Ebtesam, A., & Ezzo, D.(2010). Review of current chronic con-stipation guidelines. U.S. Pharmacist,35(12), 74-85.

Frattini, J., & Nogueras, J. (2008). Slow transitconstipation: A review of a colonic func-tional disorder. Clinics in Colon and RectalSurgery, 21(2), 146-152.

Gallagher, P.F., O’Mahony, D., & Quigley, E.M.(2008). Management of chronic constipa-tion in the elderly. Drugs & Aging, 25(10),807-821.

Johanson, J. (2007). Review of the treatmentoptions for chronic constipation.Medscape General Medicine, 9(2), 25.

Kyle, G. (2011a). Managing constipation in

adult patients. Nurse Prescribing, 9(10),482-490.

Kyle, G. (2011b). Risk assessment and manage-ment tools for constipation. BritishJournal of Community Nursing, 16(5), 224-230.

Kyle, G. (2011c). The importance of assessingconstipation. Practice Nursing, 22(10),544-548.

Lee-Robichaud, H., Thomas, K., Morgan, J., &Nelson, R.L. (2010). Lactulose versuspolyethylene glycol for chronic constipa-tion. Cochrane Database SystematicReview, 7(7). doi:10.1002/14651858.CD007570.pub2

Leung, L., Riutta, T., Kotecha, J., & Rosser, W.(2011). Chronic constipation: An evi-dence-based review. Journal of theAmerican Board of Family Medicine, 24(4),436-451.

Lindberg, G., Hamid, S.S., Malfertheiner, P.,Thomsen, O.O., Fernandez, L.B., Garisch,J., … Lemair, A. (2011). World gastroen-terology organisation global guidelineconstipation: A global perspective. Journalof Clinical Gastroenterology, 45(6), 483-487.

Longstreth, G.F., Thompson, W.G., Chey, W.D.,Houghton, L.A., Fermin, M., & Spiller, R.C.(2006). Functional bowel disorders.Gastroenterology, 130(5), 1480-1491.

Marples, G. (2011). Diagnosis and managementof slow transit constipation in adults.Nursing Standard, 26(8), 41-48.

Martin, B.C., Barghout V., & Cerulli, A. (2006).Direct medical costs of constipation inthe United States. Managed CareInterface, 19(12), 43-49.

Mayo Clinic. (2011, November 1). Laxative (rectalroute). Retrieved from http://www.mayoclinic.com/health/drug-information/DR602369

Mendoza, J., Legido, J., Rubio, S., & Gisbert, J.P.(2007). Systematic review: The adverseeffects of sodium phosphate enema.Alimentary Pharmacology and Therapeutics,26(1), 9-20.

Nepal, S., Atreja, A., & Lashner, B. (2012).Strategies for optimal colonoscopy bowelpreparation. European Gastroenterology &Hepatology Review, 8(1), 65-70.

Norton, C. (2006). Constipation in olderpatients: Effects on quality of life. BritishJournal of Nursing, 15(4), 188-192.

Ori, Y., Rozen-Zyi, B., Chagnac, A., Herman, M.,Zingerman, B., Atar, E., … Korzets, A.(2012). Fatalities and severe metabolicdisorders associated with the use ofsodium phosphate enemas: A single cen-ter’s experience. Archives of InternalMedicine, 172(3), 263-265.

Portenoy, R.K., Thomas, J., Moehl Boatwright,M.L., Tran, D., Galasso, F.L., Stambler, N.,… Israel, R.J. (2008). Subcutaneousmethylnaltrexone for treatment of opi-oid-induced constipation in patients withadvanced illness: A double-blind, random-

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ized, parallel group, dose-ranging study.Journal of Pain and Symptom Management,35(5), 458-468.

Rao, S. (2009). Constipation: Evaluation andtreatment of colonic and anorectalmotility disorders. GastrointestinalEndoscopy Clinics of North America, 19(1)117-139.

Rao, S.S., & Go, J.T. (2009). Treating pelvic floordisorders of defecation: Management orcure? Current Gastroenterology Report,11(4), 278-287.

Rao, S.S., & Go, J.T. (2010). Update on the man-agement of constipation in the elderly:New treatment options. ClinicalInterventions in Aging, 5, 163-171.

Sakharpe, A., Lee, Y., Park G., & Dy, V. (2012).Stercoral perforation requiring subtotalcolectomy in a patient on methadonemaintenance therapy. Case Reports inSurgery. doi:10.1155/2012/176143

Tack, J., & Müller-Lissner, S. (2009). Treatmentof chronic constipation: Current phar-macologic approaches and future direc-tions. Clinical Gastroenterology andHepatology, 7(5), 502-508.

Tack, J., Müller-Lissner, S., Stanghellini, V.,Boeckxstaens, G., Kamm, M., Simren, M.,… Fried, M. (2011). Diagnosis and treat-ment of chronic constipation – AEuropean perspective. Neurogastro-enterology & Motility, 23(8), 697-710.

Additional ReadingHiggins, D. (2006). How to administer an

enema. Nursing Times, 102(20), 24.

Robert Hunter, MSN, RN, is aRegistered Nurse, Medical-Telemetry, St.Joseph Medical Center, Tacoma, WA.

Literature ReviewA literature search completed in

CINAHL® used the search termspatient classification, clinical assess-ment, and acuity score for the year2004 and forward. Articles were exam-ined for relevance to our setting andresources. For instance, methods usingproprietary software were reviewedfor concepts but not considered forimplementation.

Twigg and Duffield (2009) agreedthat nurse workload is difficult todefine and measure, yet necessary toensure adequate staffing for safe patientcare. They reviewed methods of deter-mining nursing workload that have beenused historically and agreed that itremains a complex process.

Brennan and Daly (2009) citedtools that have been used to determinepatient acuity, yet agreed that there isinconsistency in how acuity is definedand measured. They agreed that meas-urement of patient acuity should incor-porate patient severity of illness andnursing workload factors.

Figure 1.Original 20 Categories and Final 10 Categories

Tamburro, West, Piercy, Towner,and Fang (2004) found that the nursingacuity score for pediatric oncologyintensive care patients predicted sur-vival and affirmed the insight of thebedside nurse in assessing severity ofillness. Although their patient popula-tion was different, the acuity systemthey developed that used both clinicalseverity and nursing workload indica-tors provided guidance in the develop-ment of our tool. Friese, Earle, Silber,and Aiken (2010) related certain clinicalseverity scores to patient mortality.Brewer (2006) combined and refinedover 30 variables into 16 acuity charac-teristics. Our tool incorporated patientcharacteristics used by Brewer, such asrespiratory and cardiac management,isolation status, activities of daily living,and wound management. Brewer’smethodology of consolidating variableswas used to influence the design of ouracuity tool.

Rauhala and Fagerström (2004)discussed the RAFAELA system, amnemonic they created, comparingpatient acuity with nurse resources. TheRAFAELA system assigns points based

Patient Acuity Toolcontinued from page 1

Special Issue ofMedSurg Matters! toFocus on Education

The July/August issue ofMedSurg Matters! will have anemphasis on nursing education.Explored topics will include: educa-tion initiatives based on the Instituteof Medicine's Future of Nursingreport, collaborative learning andthe professional growth of studentnurses, and emerging roles fornurses after health care reform.Keep an eye on your mailbox thissummer for this exciting themeissue.

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on care intensity for patient needs anduses the Professional Assessment ofOptimal Nursing Care Intensity Level(PAONCIL) tool, which establishesoptimal nursing intensity per caregiver.The RAFAELA system – used primarilyin Finland for outpatient departments,psychiatric nursing care, primary healthcare, and long-term or home care –was complicated to use and not appli-cable to our patient population.

DeLisle (2009) found that using anacuity tool representative of patientstatus and clinical intensity could beused to assist in equitable distributionof nursing workload. The acuity toolrated patients a Level I-V based onnursing time required to administerchemotherapy in an outpatient ambula-tory oncology unit. Although this wasnot our patient population, this infor-mation was helpful in considering clini-cal severity and nursing workload indi-

cators in determining acuity and makingpatient assignments.

The literature was helpful in stimu-lating discussion about how to defineacuity, but a specific patient acuityassessment tool appropriate for ourmedical-surgical patient population wasnot found.

Using input from staff nurses, theauthors set out to develop a compre-hensive acuity assessment tool thatcould be used objectively and consis-tently by the staff. The intention was toutilize this tool to make appropriatepatient assignments and balance theunit workload to maximize safe, effec-tive patient care.

MethodThe authors held roundtable dis-

cussions that were open to all staff onthe unit over a period of severalmonths. Discussions included “what

defines acuity” and “how to differenti-ate levels of acuity.” The team talkedabout what “counts” – illness of thepatient or how much nursing time isrequired to care for them or both.What about the psychological “work”of dealing with an anxious, upset, orconfused patient?

At first, the proposed acuity toolhad 20 categories (see Figure 1). Thenumber of categories and descriptorswere refined over a period of eightweeks by the researchers with inputfrom the nurses and manager. Throughdiscussions and continual assessment ofthe patient population, the team wasable to refine descriptors that identifieddifferent levels of acuity. After ten revi-sions, the final tool consisted of 10 cat-egories – six related to patient clinicalseverity and four related to nurseworkload (see Figure 2).

Figure 2.Final Acuity Tool

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866-877-2676 Volume 23 – Number 2

Using the tool, a typical, uncompli-cated postoperative patient was rated a2.A complex surgical patient with moreextensive care needs was a 3, and apatient at high risk for a decline in sta-tus or requiring frequent nursing careor assessment would have a 4 rating.Patients were rated a 2, 3, or 4 in eachof the ten categories. For example, inthe respiratory category, a stablelaparoscopic cholecystectomy patientmight need oxygen per nasal cannula at2 liters per minute (lpm) for the first 24hours due to the carbon dioxide gas

used to inflate the abdomen during theprocedure and would be identified as a2. A patient requiring oxygen supportabove 2 lpm per nasal cannula, perhapsdue to cardiac status would be a 3. Apatient with decompensating respira-tory status requiring a full-face oxygenmask would have a 4 rating.

ResultsContent validity was verified using

the input of the nursing staff and man-ager during the ten design and revisionmeetings. The resulting acuity tool waspiloted and validated for usability and

Figure 3.Results – Subjective, Validation, and Implementation

feasibility on all shifts at varying timesand days of the week. During thisphase, a total of 40 nurses assessed 183patients. Patients were scored in eachof the ten categories. Initially, rawscores were used and converted to anoverall acuity rating of 2, 3, or 4.Refinement of the tool showed that ascore of 3 for any category gave thepatient a final 3 acuity rating, and a 4score in any category gave a final 4 rat-ing. This refinement eliminated the needto perform mathematical calculationsand greatly reduced the complexity ofuse. Acuity ratings using the tool werethen compared to ratings assigned bycharge nurses using their traditional,subjective method.During the trial period, the chargenurses rated 51% of patients as 2 and49% of patients as 3 (none of thepatients received a 4). When nursesused the new tool for the samepatients concurrently, 32% of patientswere a 2, 53% were a 3, and 15%were a 4 rating (see Figure 3). Theseratings reflected the nurses’ percep-tions of their patients’ acuity. Therewas agreement among managementand the researchers that nurses werenot overstating the number of high-acuity patients.

ImplementationThe next phase was to implement

the new acuity tool. Beginning July 18,2011, each nurse rated his or herpatients’ acuity using the tool. Duringthis phase, 43 nurses rated 488patients. Data revealed that 51% of thepatients received an acuity rating of 2,38% received a 3 rating, and 12%received a 4 rating (see Figure 3). Datacollected using the objective toolshowed that our previous subjectivemethod failed to identify high-acuitypatients.

Acuity indicators were analyzed todetermine frequencies of occurrence(see Figure 4). The most frequentlyoccurring driver for a patient rating of4 was activities of daily living and isola-tion (for example, the care required fora paraplegic and a quadraplegic postop-erative patient due to nursing work-load). The second most common driverfor a 4 was wound/ostomy (for exam-

Figure 4.Drivers of Acuity by Category

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Figure 5.Sample Unit Assignment Based on Patient Acuity and Nurse Experience

ple, a high-output ileostomy patientrequiring frequent monitoring of out-put volume, site leakage, and fluid/elec-trolyte imbalance). The top drivers foran acuity rating of 3 were activities ofdaily living, patient’s isolation status, andadmit/discharge/transfer.

The acuity ratings completed bynurses are now given to charge nursesto make the assignment for the oncom-ing shift. The typical nurse-patient ratioof 5:1 is adjusted to 4:1 if a nurse has apatient with a rating of 4. Novice nursesare assigned patients with acuity ratingsof 2 or 3, and assignments are balancedto distribute the unit workload (seeFigure 5).

DiscussionThis tool incorporates clinical

severity and nurse workload indicatorsto determine acuity and is used tomake patient assignments in alignmentwith appropriate skill mix and staffingratios. Nurses supported having anobjective tool to use in assessingpatient acuity to provide safe care,adjust staffing ratios, and balance unitworkload. Experienced nurses wereassigned higher acuity patients. Thechief nursing officer, operation adminis-trators, and nurse manager supportusing the new acuity tool to adjust

staffing ratios each shift according topatient needs.

The advantages of the tool aresimplicity, cost, and customization. Thetool does not require complex docu-mentation (i.e., any 4 is a 4) andrequires about ten seconds per patientper shift to complete. It does notrequire expensive information technol-ogy support. Finally, the tool is easilyadapted to the unique needs of anypatient population.

ConclusionsOur experience illustrates that the

use of the collaboration process bymanagement and staff nurses can leadto the development of an objective,quantitative acuity tool to assign patientacuity to medical-surgical patients. Thisunit used this tool to effectively deter-mine nurse-patient ratios and develop asafer nursing workload. Currently, theauthors are mentoring other units atour hospital to facilitate the develop-ment of an acuity tool for their patientpopulations.

ReferencesBrennan, C.W., & Daly, B.J. (2009). Patient acu-

ity: A concept analysis. Journal of AdvancedNursing, 65, 1114-1126.

Brewer, B.B. (2006). Is patient acuity a proxyfor patient characteristics of the AACNSynergy Model for Patient Care? NursingAdministration Quarterly, 30(4), 351-357.

DeLisle, J. (2009). Designing an acuity tool foran ambulatory oncology setting. ClinicalJournal of Oncology Nursing, 13(1), 45-50.

Friese, C.R., Earle, C.C., Silber, J.H., & Aiken,L.H. (2010). Hospital characteristics, clin-ical severity, and outcomes for surgicaloncology patients. Surgery, 147(5), 602-609. doi:10.1016/j.surg.2009.03.014

Rauhala, A., & Fagerström, L. (2004).Determining optimal nursing intensity:The RAFAELA method. Journal ofAdvanced Nursing, 45(4), 351-359.

Tamburro, R.F., West, N.K., Piercy, J., Towner, G.,& Fang, H. (2004). Use of the nursing acu-ity score in children admitted to a pedi-atric oncology intensive care unit.Pediatric Critical Care Medicine, 5(1), 35-39.

Twigg, D., & Duffield, C. (2009). A review ofworkload measures: A context for a newstaffing methodology in WesternAustralia. International Journal of NursingStudies, 46, 132-140.

Kathy Chiulli, MSN, RN, CMSRN,was a Medical-Surgical Clinical NurseSpecialist, Inpatient Medical-SurgicalUnits, Duke Raleigh Hospital, Raleigh, NC,at the time this article was written.Jackie Thompson, MSN, RN,CMSRN, was a Stroke Coordinator,Duke Raleigh Hospital, Raleigh, NC, at thetime this article was written.Kristi L. Reguin-Hartman, BSN,RN, was an Education ResourceSpecialist, WakeMed Hospital, Raleigh,NC, at the time this article was written.

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Volume 23 – Number 2

Recognizing the need to better assist the new graduatenurses in their transition period, a medical-surgical depart-mental on-boarding program was implemented in January2010. In the on-boarding program, the medical-surgical clini-cal director and educator met with the new graduate nursesevery three months at pre-scheduled times throughout thefirst year of employment. During these pre-planned meetings,the director and educator provided encouragement andestablished trusting relationships with the new graduates.According to IUHB’s Human Resource Department, thisprogram was successful in decreasing first-year graduatenurse turnover from 45% to 18% from the January 1, 2010,implementation. Turnover rates again increased in 2011 to29% when a change in medical-surgical leadership occurred.Sustainability of the program’s success was not maintained.

PlanningThe Clinical Education and Practice Department was

eager to make changes to the current two-week centralizedorientation program provided to new nurses entering theorganization. It was essential to provide an approach that wasthoughtful, evidence-based, and built on the American NursesAssociation’s (ANA) Professional Practice Standards and theNational Nursing Staff Development Organization (NNSDO)standards of learning (ANA, 2012; NNSDO, 2009).

The centralized two-week orientation consisted of anumber of presenters and slideshow presentations. Eighty-sixwritten evaluations at the end of this centralized orientationfound new nurses to be overwhelmed with the amount of

Restructuring the New NurseOrientation Program:

Making It Meaningful, Relevant, Engaging,and Pertinent to Quality Patient Outcomes

High turnover rates are reported among new nurses within their firstyear of work following graduation (Bullock, Paris, & Terhaar, 2011;Hippeli, 2009). Restructuring new graduate nurse orientation shouldbe explored to assist the novice nurses during their time of transitionfrom student to practice.

Evidence demonstrates that the first year of employ-ment for a new graduate nurse can be quite stressful and ten-uous at best, and turnover rates can be as high as 60%(Bullock et al., 2011; Hippeli, 2009). This high turnover ratecan result in lower nurse satisfaction while also negativelyimpacting patient care and the financial well-being of organi-zations. The rollout of newer nurses into nursing practiceskews the level of experience, knowledge, and critical-thinking capabilities on nursing units. It is estimated to cost$50,000 to recruit and train one new nurse (Kowalski &Cross, 2010).

Transitioning from the classroom to the real world ofhealth care for a new nurse graduate can be overwhelming.Hospitals have shown initial success in facilitating a smoothtransition through residency programs and structured pre-ceptor programs (Hillman & Foster, 2011). While the successof transitioning to the real world is multi-faceted – includingthe implementation of a residency program and a defined pre-ceptor program – the foundation of transition success beginson the first day the new nurse graduate enters the facility.

BackgroundIndiana University Health Bloomington (IUHB) became

a Magnet® facility in 2010 with an impressive overall turnoverpercentage of 9.73% in 2009 and 7.68% in 2010. However, theIUHB Human Resource Department reported the first-yearnew graduate nurse turnover rate for the two medical-surgical units, where the majority of new graduate nursesbegin their careers at IUHB, was 45% in 2009 and 18% in2010. Hippeli (2009) and Bullock and colleagues (2011)reported first-year new graduate nurse turnover ratesranges between 27% and 60%. The 18% turnover rateachieved at IUHB in 2010 was significant in relation to the2009 turnover rate, as well as in comparison to reportednew graduate turnover rates.

Strategies forNURSE EDUCATORS

If you have any questions or comments regarding the "Strategies for Nurse Educators" column, or if you are interested in writing, pleasecontact Column Editor Janet Knisley at [email protected].

Academy of Medical-Surgical Nurses www.amsn.org

14

information presented. The participants expressed boredomwith content and teaching techniques, and commented theydid not value the learning methodology of orientation.

With this knowledge, the clinical educators and managerbegan an eight-month journey to restructure new nurse orien-tation. Pesut and Hermann’s (1999) methodology of having agoal and working backward to achieve that goal was used as amodel for restructuring the orientation program. The main goalfor change was to make centralized orientation meaningful, rel-evant, engaging, and pertinent to quality patient outcomes.

New graduate nurse orientation evaluations of the cur-rent orientation program identified that the majority oflearning occurred while performing patient care. To berespectful of this feedback, the planning group decided tostreamline the two-week centralized orientation program toone week, allowing the new graduate nurses to begin on thenursing units one week sooner. The centralized orientationprogram content was trimmed down to only two topics:organizational patient quality outcomes and The JointCommission’s National Patient Safety Goals (2014).

While this new program was designed with the new grad-uate nurse in mind, IUHB disseminated the new centralized ori-entation program to include all new nursing personnel hires,including both new graduate nurses and newly hired experi-enced registered nurses (RNs) as well as newly hired PatientCare Technicians (PCTs), the unlicensed assistive nursing per-sonnel. IUHB as an organization values teamwork, and it wasimportant for the orientation program to highlight this.

Historically, PCT, new graduate nurse, and newly hired experi-enced RN orientation had been separate orientation programs.

Patient care scenarios are the core of the new central-ized orientation program and are presented and discussed toallow for intradisciplinary learning among PCTs, new gradu-ate nurses, and experienced nurses. Learning in a safe envi-ronment with the assistance of both low and high fidelitysimulation methods is now the primary learning modality uti-lized in the centralized orientation program.

ImplementationThe new centralized orientation program was imple-

mented in January 2012. The program implementers recognizedthat flexibility and adaptability are essential to success. Each ori-entation week may have different numbers of PCTs and nurses.Adapting the scenarios to best accommodate the varying num-ber of orientees attending orientation has been necessary.

Furthermore, reviewing the centralized orientation pro-gram evaluations to continuously strive to optimize orienteelearning also necessitates flexibility and adaptability. Orienteefeedback continues to drive the centralized orientation pro-gram, and the program is adapted at times as necessary.

The Clinical Education and Practice (CEP) team devel-oped a structured yearlong timeline that each clinical educa-tor follows with each orientee. This timeline focuses on skillsacquisition, clinical documentation, and collaborative rela-tionship building. A yearlong residency program is beingdeveloped with plans to provide discussion groups with the

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866-877-2676 Volume 23 – Number 2

new graduate nurses at three-, six-, nine-, and twelve-monthpost-hire intervals.

Evaluation Although still relatively new in this implementation, the

feedback received thus far is overwhelmingly positive as evi-denced by comments received on the written evaluations.

One of the experienced RNs, who had been through theprevious orientation program a couple of years ago and wasnow a rehire at IUHB stated, “This new orientation was somuch more meaningful because you got rid of all that extrastuff. I could focus on what is important.”

A new graduate nurse stated, “Wow, to know there isthis team of people dedicated to my learning is incredible. Ifeel like I’m the most important person here.”

While it is too early in the program implementation tomeasure success, data derived from patient outcomes suchas patient satisfaction, pressure ulcers, falls, pain control, andhospital-acquired infections will be monitored monthly. Asimple ten-question pre-/post-test to evaluate the effective-ness of the new centralized orientation program has beendeveloped. Qualitative data obtained from the learners’debriefing sessions will also be used to evaluate and contin-ually adapt the program. Ongoing monitoring of RN turnoverrates, especially the first-year rates, will optimally be the keyto whether or not this program has contributed to a bettertransition for the new nurses.

Health Care Reform: A Call for Manuscripts

MedSurg Matters! includes an ongoing column – “HealthCare Reform” – which addresses the impact of the AffordableCare Act (2010) as well as the Institute of Medicine (IOM)Future of Nursing recommendations on health care and nursing.

Authors are needed for future columns, in particular toaddress IOM recommendations for nursing education.Manuscripts are sought on these topics:

• Life-Long Learning• BSN Preparation• MSN Preparation• DNP and PhD Preparation• Funding Sources for Advancing Your EducationThe following are minimal areas to include when address-

ing education preparation for nursing: overview of the IOM rec-ommendation for nursing education for the specific degree,benefits of attaining an advanced degree (professional, personal,and effect on patient outcomes), core courses, online versustraditional programs, and a list of the top 10 programs.

Queries regarding these and other related topics shouldbe sent to [email protected]. Suggested manuscript length is3-5 double-spaced, typewritten pages (1-2 newsletter pages).

Download the Author Guidelines at www.amsn.org/newsletter and get started today!

ConclusionWhile the orientation program in and of itself is not the

sole factor to address first-year new graduate nurse gradua-tion turnover rates, the IUHB education team believes orien-tation can positively affect the turn rates.Any opportunity tobetter prepare new graduate nurses to the realities of nurs-ing practice will help with the transition from student nurseto professional nurse.

ReferencesAmerican Nurses Association (ANA). (2012). Professional practice standards.

Retrieved from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards.aspx

Bullock, L., Paris, L., & Terhaar, M. (2011). Designing an outcome-focusedmodel for orienting new graduate nurses. Journal for Nurses in StaffDevelopment, 27(6), 252-258.

Hillman, L., & Foster, R. (2011). The impact of a nursing transitionsprogramme on retention and cost savings. Journal of NursingManagement, 19, 50-56.

Hippeli, F. (2009). Nursing: Does it still eat its young, or have weprogressed beyond this? Nursing Forum, 44(3), 186-188.

Joint Commission, The. (2014). National patient safety goals. Retrieved fromhttp://www.jointcommission.org/standards_information/npsgs.aspx

Kowalski, S., & Cross, C. (2010). Preliminary outcomes of a local residencyprogramme for new graduate registered nurses. Journal of NursingManagement, 18, 96-104.

National Nursing Staff Development Organization (NNSDO). (2009).Core curriculum for staff development (3rd ed.). Pensacola, FL: Author.

Pesut, D., & Hermann, J. (1999). Clinical reasoning: The art and science ofcritical and creative thinking. Albany, NY: Delmar Publishers.

Pam Adams, MSN, RN, is a Clinical Manager, Clinical Education andPractice, Indiana University Health Bloomington, Bloomington, IN.Lillian Bartlett, BSN, RN, is a Clinical Educator of SurgicalServices, Indiana University Health Bloomington, Bloomington, IN.David Blasdel, CHUC, is a Clinical Educator, Unlicensed AssistivePersonnel, Indiana University Health Bloomington, Bloomington, IN.Jason Giesler, BSN, RN, is a Clinical Educator, Critical Care andCentral Telemetry, Indiana University Health Bloomington,Bloomington, IN.Barb Haley, BSN, RN, is a Clinical Educator, Oncology and FloatPool, Indiana University Health Bloomington, Bloomington, IN.Ronda Hendricks, BSN, RN, is a Clinical Educator, Women andChildren Services, Indiana University Health Bloomington,Bloomington, IN.Diana Hensley, BSN, RN, is a Clinical Educator, Ortho/Neuroand Acute Rehab, Indiana University Health Bloomington,Bloomington, IN.Cheryl Jacobs, BSN, RN, is a Clinical Educator, Women andChildren Services, Indiana University Health Bloomington,Bloomington, IN.Peggy Lee, BSN, RN, is a Clinical Educator, CardiovascularServices, Indiana University Health Bloomington, Bloomington, IN.Courtney Moore, BSN, RN, is a Clinical Educator, BehavioralHealth, Indiana University Health Bloomington, Bloomington, IN.Reagan Norman, BSN, RN, is a Simulation Specialist, IndianaUniversity Health Bloomington, Bloomington, IN.Mary Anne Proctor-Holmes, BSN, RN, is a Clinical Educator,Medical/Surgical, Indiana University Health Bloomington,Bloomington, IN.

AMSN BOARD OF DIRECTORS

PresidentKathleen Lattavo, MSN, RN, CNS-MS, CMSRN,

RN-BC, ACNS-BCPresident-Elect

Jill Arzouman, MS, RN, CMSRN, ACNS, BCTreasurer

Jane E. Lacovara, MSN, RN, CMSRN, CNS-BCSecretary

Robin Hertel, MSN, RN, CMSRNDirector

Dee A. Eldardiri, MS, RN-BC, CMSRNDirector

Gloria J. Hurst, BSN, RN, CMSRNDirector

Michele George, MBA, BSN, RNDirector

Cynthia C. Barrere, PhD, RN, AHN-BC, RCNSExecutive Director

Cynthia Hnatiuk, EdD, RN, CAE, FAANDirector, Association Services

Suzanne Stott, BS

MedSurg Matters!

EditorMolly McClelland, PhD, MSN, RN, CMSRN, ACNS-BC

Editorial CommitteeMillicent G. De Jesus, MSN, RN-BC

Deidra B. Dudley, MN, MS, RN-BC, NEA-BCMichael M. Evans, MSN, MSEd, RN, ACNS, CMSRN, CNE

Dianne J. Gibbs, MSN, RNBarbara Chamberlain, PhD, APRN, MBA, CCRN, WCC

Perry C. Goldstein, MSN, RN, CMSRN, PCCNStephanie Huckaby, MSN, RN-BC

Elizabeth Miller, DNP, RN, CMSRN, CCMSally S. Russell, MN, RN, CMSRNCatherine A. Santori, RN, CMSRN

Elizabeth Thomas, MSN, RN, ACNS-BC

Managing EditorKatie R. Brownlow, ELS

Editorial AssistantJamie Curran

Layout and Design SpecialistRobert Taylor

Education DirectorRosemarie Marmion, MSN, RN-BC, NE-BC

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Volume 23 – Number 2 • March/April 2014

NSAIDs: Is Naproxen the Safest Choice?Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly

taken over-the-counter and prescribed medications in the United States. NSAIDs areused to reduce inflammation and pain. Leading medications in this class include: ibupro-fen (Motrin®, Advil®), naproxen (Alleve®, Naprosyn®), ketoprofen (Ketofen®, Ostofen®),celecoxib (Celebrex®) and aspirin (Bayer®). Nonetheless, despite their widespread useand effectiveness, serious complications are associated with this class of drugs. NSAIDshave been found to cause peptic ulcer disease, gastrointestinal bleeding, kidney disease,heart attack, and stroke – especially when overused or in combination with other thingslike alcohol and tobacco.

Recently, the medication naproxen, which is manufactured by several leading phar-maceutical companies, was reported to be safer than other NSAIDs relating to cardio-vascular complications. In a report published by CBS News (http://www.cbsnews.com/news/aleve-may-be-safer-on-heart-than-other-anti-inflammatory-drugs/) on January 28,2014, data suggested that the cardiovascular risks associated with taking naproxen werelower compared to the other NSAIDs. The results of the new data could have signifi-cant financial implications for the companies producing naproxen. Considerations toremove the warning labels from naproxen packaging were being discussed.

The Federal Drug Administration (FDA) met in March 2014 to review the newnaproxen findings and to determine if cardiovascular warning labels could be removedfrom packaging. However, in a 16-9 vote, the FDA panel decided against removing thewarning labels from naproxen packaging, claiming the initial data was biased and limitedin validity. Therefore, nurses should continue to teach patients that all NSAIDs (includ-ing naproxen products) do carry cardiovascular risks in addition to the aforementionedpotential complications to watch for when taking NSAIDs.

More information on the results of the FDA decision can be found at:http://www.healio.com/cardiology/vascular-medicine/news/print/cardiology-today/%7B4f5f075f-9662-4e1d-9f84-f6f31501abfc%7D/fda-advisers-data-do-not-support-lower-cv-risk-with-naproxen

Drug Update