AMERICAN NURSE O FFICIAL J OURNAL An Publication March 2020 Volume 15 • Number 3 MyAmericanNurse.com CNE Avoiding antipsychotics for nursing home residents with dementia Adults with chronic kidney disease The changing face of cystic fibrosisMyAmericanNurse.com March 2020 American Nurse Journal 1 Editor-in-Chief Lillee Smith Gelinas, MSN, RN, CPPS, FAAN Senior Fellow and Nurse Executive, Institute for Patient Safety University of North Texas Health Science Center, Fort Worth, Tex. Editorial Board AMERICAN NURSE O FFICIAL J OURNAL Editorial mission: American Nurse Journal is dedicated to integrating the art and science of nursing. It provides a voice for today’s nurses in all specialties and practice settings. As the official journal of the American Nurses Associ- ation, it serves as an important and influential voice for nurses across the country. The journal is committed to de- livering authoritative research translated into practical, evidence-based literature and relevant content to keep nurses up-to-date on best practices, help them maximize patient outcomes, advance their careers, and enhance their pro- fessional and personal growth and fulfillment. E DITOR E MERITUS Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN Research Associate Professor Sadie Heath Cabaniss Professor and Dean University of Virginia School of Nursing Charlottesville, VA Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN President (2018-2020), Case Management Society of America 12th President (2012-2014), National Association of Hispanic Nurses Director, Care Management, UC Irvine Health Orange, CA Danielle (Dani) Bowie, DNP, RN, NE-BC Vice President of Nursing Workforce Development Bon Secours Mercy Health Cincinnati, OH Thomas R. Clancy, PhD, MBA, RN, FAAN Clinical Professor, School of Nursing University of Minnesota Minneapolis Danette Culver, MSN, APRN, ACNS-BC, CCRN-K, RN-BC Clinical Nurse Specialist Norton Healthcare Louisville, KY Amina Dubuisson, MSN, RN, MBA/HCM, LNHA Regional Director of Clinical Operations Greystone Health Tampa, FL Michael L. Evans, PhD, RN, NEA-BC, FACHE, FAAN Dean and Professor Texas Tech University Health Sciences Center School of Nursing Lubbock, TX Margaret A. Fitzgerald, DNP, APRN, BC, NP-C, FAANP, CSP President, Fitzgerald Health Education Associates, Inc. North Andover, Mass. FNP, Adjunct Faculty, Family Practice Residency Greater Lawrence Family Health Center, Inc. Greater Lawrence, MA Melissa A. Fitzpatrick, MSN, RN, FAAN Chief Operating Officer Kirby Bates Associates Chapel Hill, NC Christine Hedges, PhD, RN, NE-BC Director of Nursing Quality and Research University of North Carolina Hospitals Chapel Hill, NC Tiffany Kelley, PhD, MBA, RN-BC DeLuca Foundation Visiting Professor for Innovation & New Knowledge UCONN School of Nursing Storrs, CT Founder/CEO Nightingale Apps & iCare Nursing Solutions Boston, MA Linda J. Knodel MHA, MSN, NE-BC, CPHQ, FACHE, FAAN Senior Vice President/Chief Nurse Executive Kaiser Permanente Oakland, CA Eileen T. Lake, PhD, RN, FAAN Jessie M. Scott Endowed Term Chair in Nursing and Health Policy Professor of Nursing and Sociology Associate Director, Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Philadelphia Norma M. Lang, PhD, RN, FRCN, FAAN Professor and Dean Emeritus School of Nursing University of Pennsylvania, Philadelphia Wisconsin Regent Distinguished Professor and Aurora Professor of Health Care Quality and Informatics Professor Emerita College of Nursing University of Wisconsin, Milwaukee Tina Marrelli, MSN, MA, RN, FAAN Marrelli and Associates, Inc. Health Care Consultants and Publishers e-Caregiving Solutions Venice, FL Bernadette Mazurek Melnyk, PhD, RN, CRNP, FAANP, FNAP, FAAN Vice President for Health Promotion University Chief Wellness Officer Dean and Professor, College of Nursing Professor of Pediatrics & Psychiatry, College of Medicine The Ohio State University Columbus Sally Miller, PhD, APRN, FNP-BC, AGACNP-BC, AGPCNP- BC, PMHNP-BC, FAANP Associate Professor, Associate Dean for Graduate Affairs University of Nevada Las Vegas Las Vegas, NV Jack Needleman, PhD, FAAN Fred W. and Pamela K. Wasserman Professor Chair, Department of Health Policy and Management UCLA Fielding School of Public Health Los Angeles Christine Pabico, MSN, RN, NE-BC Director, Pathway to Excellence Program American Nurses Credentialing Center Silver Spring, MD Rebecca M. Patton, DNP, RN, CNOR, FAAN Former President, American Nurses Association Lucy Jo Atkinson Professorship in Perioperative Nursing Frances Payne Bolton School of Nursing at Case Western Reserve University Cleveland, OH Mark Pelletier MS, RN Chief Operating Officer Chief Nurse Executive The Joint Commission Oakbrook Terrace, IL Joseph Potts, MSN, RN Assistant Nurse Manager, Resource Pool Northeast Georgia Medical Center Gainesville, GA Staci Reynolds PhD, RN, ACNS-BC, CCRN, CNRN, SCRN Assistant Clinical Professor/DANCE Coordinator Duke University School of Nursing Infection Prevention Clinical Nurse Specialist Duke University Hospital Durham, NC Stephanie Schulte, MLIS Associate Professor, Health Sciences Library The Ohio State University, Health Sciences Library Columbus Franklin A. Shaffer, EdD, RN, FAAN Chief Executive Officer CGFNS International Philadelphia, PA Roy L. Simpson, DNP, RN, DPNAP, FAAN, FACMI Clinical Professor, Assistant Dean for Technology Management Nell Hodgson Woodruff School of Nursing Emory University Atlanta, GA Marla J. Weston, PhD, RN, FAAN CEO Weston Consulting, LLC Washington, DC March 2020 • Volume 15 • Number 3 MyAmericanNurse.com Editorial Staff Editor-in-Chief Lillee Smith Gelinas, MSN, RN, FAAN Executive Editor, Professional Outreach Leah Curtin, RN, ScD(h), FAAN Editorial Director Cynthia Saver, MS, RN Managing Editor Julie Cullen Copy Editor Jane Benner Publishing Staff Group Publisher Gregory P. Osborne Executive Vice President Steve Ennen Director of Professional Partnerships Tyra London Associate Publisher John J. 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Kim Audience Engagement Manager Michelle Welliver Database Administrator Parvathi Bellamkonda American Nurse Journal is the official journal of the American Nurses Association, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910-3492; 800-274-4ANA. The journal is owned and published by HealthCom Media. American Nurse Journal is peer reviewed. The views and opinions expressed in the editorial and advertising material in this issue are those of the authors and advertisers and do not necessarily reflect the opinions or recommendations of the ANA, the Editorial Advi- sory Board members, or the Publisher, Editors, and staff of American Nurse Journal. American Nurse Journal attempts to select authors who are knowledgeable in their fields. However, it does not warrant the expertise of any author, nor is it responsible for any statements made by any author. Certain statements about the uses, dosages, efficacy, and characteristics of some drugs mentioned here reflect the opinions or investigational experience of the au- thors. Nurses should not use any procedures, medications, or other courses of diagnosis or treatment discussed or suggested by authors without evaluating the patient’s conditions and pos- sible contraindications or dangers in use, reviewing any appli- cable manufacturer’s prescribing or usage information, and comparing these with recommendations of other authorities. Edited, designed, & printed in the USA AMERICAN NURSE O FFICIAL J OURNAL 2 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com 4 Editorial By Lillee Gelinas, Editor-in-Chief Our moods can change with the seasons. Understanding our winter moods can help us better cope with them. 6 Avoiding antipsychotic medication use in nursing home residents with dementia By Kelly O’Neill, Marilyn Reierson, Kaylie Doyle, Angel Davis, and Jane Pederson Nurses are critical to reducing unnecessary use of antipsychotics and advocating for other options. 16 CNE Adults with chronic kidney disease: Overview and nursing care goals By Jennifer Chicca Learn about the management of chronic kidney disease so you can care for patients more confidently. 28 The changing face of cystic fibrosis By Paula H. Lomas and Quynh T. Tran Because of new treatment options, more people with CF are living into adulthood. That means you’ll be caring for these patients in a variety of care settings. R APID R ESPONSE 23 Supraventricular tachycardia By Elizabeth Avis and Lois Grant Recognizing changes in a patient’s clinical status ensures a good outcome. W EB EXCLUSIVE ! Drugs and devices today Access an update of drug news, including alerts, approvals, and removals, at myamericannurse.com/ article-type/drugs-and-devices/ . 15 Nurses and the public’s trust By Ernest J. Grant Nurses can help create a world where racism, discrimination, and prejudice are not tolerated. 42 2019 ANA Innovation Award winners update The award winners have had an exciting year. Find out what’s been happening with their innovations F ROM W HERE I S TAND 48 Why CNOs care about compliance By Leah Curtin Compliance isn’t just a matter of following the rules. It’s also about ethics. W EB EXCLUSIVE ! What works: Equitable nurse-patient assignments using a workload tool By Amanda L. O’Connell, Rita M. Nettleton, Dawn R. Bunting, and Susan Eichar This med-surg unit used collaboration, patience, trust, respect, and open communication to develop and implement a workload tool that’s improved patient care and nurse satisfaction. myamericannurse.com/?p=65141 W EB EXCLUSIVE ! Take note Access a round-up of clinical and practice news and alerts at myamericannurse.com/article-type/take-note- practice-updates/. American Nurse Journal (ISSN 1930-5583 [print], ISSN 2162-8629 [online]) is published monthly by HealthCom Media, Lantern Hill Business Park, 259 Veterans Lane, Suite 201, Doylestown, PA 18901. Printed in the U.S.A. Copyright © 2020 by HealthCom Media. All rights re- served. No part of this publication may be reproduced, stored, or transmitted in any form or by any means, elec- tronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without per- mission in writing from the copyright holder. Periodicals Postage paid at Doylestown, PA and additional offices. Postmaster: Send address changes to American Nurse Journal, Lantern Hill Business Park, 259 Veterans Lane, Suite 201, Doylestown, PA 18901. Subscription information: Annual subscriptions: $49.00 U.S.; $59.00 Canada; $71.00 outside U.S./Canada. Single copies: $7 U.S.; $15 outside U.S. Institutional subscriptions available by request. Digital-only subscription: $14.97. Reprints and back issues: Contact Chris Evans Gartley (Pro- duction Director) at 215-489-7000 or production@healthcom media.com. Availability may be limited. March 2020 • Volume 15 • Number 3 MyAmericanNurse.com STRICTLY CLINICAL PRACTICE MATTERS FEATURES EDITORIAL 33 Learn about the top issues facing ANA member nurses, how ANA is working for you, and what ANA is doing to advance nursing. F EATURE ARTICLE : Federal legislative agenda 44 Frequently asked questions about the Nurse Licensure Compact By Rebecca Fotsch Find out how the compact affects your practice. 24 The perils of perfectionism in nursing By Rose O. Sherman Perfectionism is a weakness masquerading as a strength. Learn how to dial back this trait so you don’t derail your career. 26 Year of the Nurse 2020 By Oriana Beaudet Make 2020 the year you tap into your inner innovator. 10 Build resilient teams to tackle nursing burnout By Teresa M. Stephens With purpose, priorities, perspective, and personal responsibility, you and your colleagues can build teams ready to face any challenge successfully. W EB EXCLUSIVE ! Advanced care of patients with cognitive impairment By Mullane Harrington Patients with cognitive impairment may act violently because they’re unable to communicate. This organization developed a strategy to manage these patients’ unique needs. myamericannurse.com/?p=65143 MyAmericanNurse.com March 2020 American Nurse Journal 3 Subscription Questions? Christian Evans Gartley, Production Director 215.489.7004 cevansgartley@healthcommedia.com Change in Mailing Information? To change your subscription information online, send re- quest to Christian Evans Gartley, Production Director, at cevansgartley@healthcommedia.com Indexing American Nurse Journal is indexed in the Cumulative Index to Nursing and Allied Health Literature. Submit an Article Please email Cynthia Saver, MS, RN, at csaver@health commedia.com . In the email, describe the topic of your proposed article and why it would be of interest to the readers of American Nurse Journal; include your name, credentials, employer, and phone number. We’ll let you know if we’re interested in the article you’ve proposed and can advise you on how to focus it. For more infor- mation, please refer to the Author Guidelines (MyAmerican Nurse.com/author-guidelines). Send a Letter to the Editor Your input is vital in assuring that American Nurse Journal is a valuable resource to your practice. You can email a Letter to the Editor at MyAmericanNurse.com/ send-letter-editor . March 2020 American Nurse Journal 33 ANA ON THE FRONTLINE NEWS FROM THE AMERICAN NURSES ASSOCIATION nn Nurses make their voices heard C OMING NEXT MONTH •What nurses need to know about neuraxial anesthesia •Complications after acute myocardial infarction •Cannabinoid hyperemesis syndrome explained •Updated CDC guidelines on infection prevention ANA ON THE FRONTLINE LIFE AT WORK LEADING THE WAY HEALTHY NURSEMarch madness Understanding our winter moods can help us and our teams cope with stress. I T ’ S THAT TIME AGAIN . “March Madness” is an expression that’s been linked to basketball since 1908, but March also has been associ- ated with another kind of madness. Begin- ning in the mid-1900s, people began using the term to refer to “a form of madness or uncharacteristic behavior said to affect peo- ple in March.” The inclement weather and shorter days with less sunlight that winter brings may have led to the expression. While much of the country is preoccupied with college basketball March Madness, nurs- es focus on the demands of patients, which can seem magnified this time of year. The feelings you or someone you care about might be experiencing aren’t unusual, but are they really “March madness”? Is there really such a thing as “winter brain”? Did you know that late winter and early spring are the busiest times in psychiatry? Just when the stress of the holidays is over, many people feel overwhelmed and can’t figure out why. During a recent meeting, staff and pro - viders raised concerns about behaviors or remarks being observed that could signal depression, fatigue, or burn out. We’re pay- ing close attention to these types of com- ments because of our organization-wide fo- cus on understanding colleagues’ emotional intelligence and improving their health and well-being. I immediately thought about March Madness and how our winter moods might be impacting our ability to build a healthly workplace. Have you heard the phrase “beware the Ides of March”? In ancient Rome, the year be- gan in spring, not the middle of winter, and the Ides of March (the ides being halfway through the month in the Roman calendar) corresponded with the first full moon of the year. It used to be a celebration of spring but became famous for the date when Julius Cae- sar was assassinated in 44 BC. According to our organization’s chief of psychiatry, mental health difficulties at this time of year have nothing to do with the moon, and everything to do with changes in sunlight. As spring ap- proaches, more energy, light, insomnia, and mania (or mixed emotional states) are just waiting to happen. Understanding that seasonal changes in brain chemicals can lead to mood fluctua- tions is important, especially if you’re trying to improve your ability to handle stress or, like me, trying to enhance team performance through resiliency training and avoiding trig- gers (such as overcommitting and perfection- ism) that can cause the blues. (See “The per- ils of perfectionism” on page 24.) “March madness” has an entirely different context for me now as a symptom, not as a sporting event. Healthy nurses and healthy teams are vital to ensuring optimal outcomes. Understanding how to recognize and effec- tively deal with the “winter brain” can opti- mize your own coping strategies. Lillee Gelinas, MSN, RN, CPPS, FAAN Editor-in-Chief EDITORIAL 4 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com6 American Nurse Journal Volume 15, Number 3 MyAmericanNurse.com Avoiding antipsychotic medication use in nursing home residents with dementia Nurses are critical to improved resident well-being. W E PERCEIVE the world around us by combin- ing information from what we see, hear, touch, taste, and smell. Standing in a hallway, we hear the elevator ding and someone singing gospel in a hushed voice, feel the flat carpet below our shoes, and detect a faint scent of lavender mingling with fresh-baked cookies. Our minds instantly interpret these sensory messages based on our memory and experience, compressing information into meaning. We respond in a consistent and pre- dictable way. We look to see who’s stepping off the elevator or who might want to enter it. Many people living in nursing homes have impaired senses, such as vision or hearing loss. They also may have disorders such as demen- tia that make interpreting information less pre- dictable and more inconsistent with others’ general perceptions. Picture Joe*, an 82-year- old man living with dementia, standing near us in that same hallway. He perceives and processes the same sensory information we re- ceived differently. His mind misinterprets many of the signals. He hears the same elevator ding and appears to be ready to fight. Unless you know about Joe’s past experience as a boxer, you might not understand that the elevator bell triggers his memory and his defensive posture. Individuals with dementia frequently have difficulty explaining what they’re feeling or ex- periencing, and we’re left to interpret observed behavioral expressions. These behaviors can sometimes appear as fear, anger, or aggression, and that may be how the resident communicates an unmet need, such as discomfort in a current position or location, a need to move or for time alone, environmental noises, or pain. In nursing homes, the interprofessional team is charged with assessing these behaviors and determining the most appropriate care. All too frequently the answer has been to medicate to calm or chemi- cally restrain with antipsychotics, without un- derstanding the true cause of the behavior. Why focus on antipsychotics? In the U.S. healthcare system and Ameri can By Kelly O’Neill, BSN, MPA, RN, CPHQ; Marilyn Reierson, MS; Kaylie Doyle, MBA; Angel Davis, MBA, MS, BSN, RN; and Jane Pederson, MD, MS MyAmericanNurse.com March 2020 American Nurse Journal 7 culture, medications are held in high regard as a way to manage symptoms of illness, re- duce distress, and manage physical and men- tal health problems. Antipsychotics (such as quetiapine, risperidone, and hal operidol) some- times have been viewed as the antidote to expressions of fear, anger, and aggression as- sociated with dementia. Antipsychotics have been used to treat people with dementia when they exhibit be- haviors (agitation, aggression, delusions) sim- ilar to those seen in people with psychotic ill- nesses such as schizophrenia. This is despite the black box warning of increased mortality for elderly patients with dementia-related psychosis. According to the U.S. Food and Drug Administration (FDA), these patients are at a 1.6 to 1.7 times increased risk for death; most of the deaths seem to be related to car- diovascular (heart failure, sudden death) or infection (pneumonia) issues. Antipsychotics also are associated with significant side ef- fects, such as increased risk of cerebrovascu- lar accident, involuntary or disabling move- ment (gait changes, extrapyramidal signs, tardive dyskinesia), orthostatic hypotension, edema, weight gain, sedation, confusion, de - lirium, cognitive impairment, and metabolic changes (increased glucose and triglycerides). The FDA states that “antipsychotics are not in- dicated for the treatment of dementia-related psychosis” except in cases of the development (and documentation) of delirium. The Centers for Medicare & Medicaid Serv- ices (CMS) recognized the need to enhance the quality of life and care for individuals living with dementia and launched the National Part- nership to Improve Dementia Care in Nursing Homes in 2012. The partnership’s goal is to re- duce the use of antipsychotic medications and encourage nonpharmacologic approaches and person-centered dementia care. Under the di- rection of CMS, Quality Improvement Organi- zations (QIOs)—composed of health quality experts, clinicians, and consumers—work to improve healthcare quality. They support the National Partnership to Improve Dementia Care in Nursing Homes at local levels in collab- oration with organizations such as nursing home trade associations, state survey agencies, and professional organizations. Some nursing home residents may require antipsychotic medications as a last resort. However, given what we know about the risks of using them to address behavioral ex- pressions associated with dementia, alterna- tive strategies to support residents should be used first. Lead the change Nurses are vital to reducing inappropriate use of antipsychotic medications and improving nursing home resident well-being. The good news is that the national prevalence of long- stay nursing home residents (those who have stayed more than 100 cumulative days) receiv- ing antipsychotics has decreased from 38.9% in 2011 to 14.6% in 2018. Nurses who work in long-term care have been instrumental in that success. Staying on message, understanding antipsychotic use, and setting goals will help you participate in this continuing effort. Stay on message Take the lead in conveying a consistent mes- sage about using nonpharmacologic ap- proaches to support residents with dementia. Talk with providers about the work you’re do- ing to avoid initiating antipsychotics or mini- mizing their dosage and duration. This is one of the most effective actions you can take to help the whole care team (including medical directors, nurse practitioners, nurses, and nursing assistants) stay committed to improv- ing care and decreasing antipsychotic use. Link your message about reducing antipsy- chotics to your nursing home’s priorities and values (quality, compassionate care and im- proving resident quality of life). Offer re- sources to help staff, residents, and families develop a shared understanding of the risks of antipsychotics. (See Share information.) Understand antipsychotic use Approach antipsychotic use reduction like any other quality assurance/performance improve- ment initiative. Start by learning about the cur- rent use of antipsychotics for residents with dementia, then ask probing questions to un- derstand when, why, and how often they’re prescribed, duration of use, therapeutic goals, and how goals are identified and monitored. As you examine your residents’ medical records and other data sources, document your findings and look for patterns of use. You might identify that nurses are requesting antipsychotic medications before completing resident assessments, or that some providers The national prevalence of long-stay nursing home residents receiving antipsychotics has decreased from 38.9% in 2011 to 14.6% in 2018.Next >