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Volume 34, Number 2
MARCH/APRIL 2012
FREE
Continuing Nursing
Education
Page 4
Guest Editorial
The Nurse Education Imperative
Page 5
For Your Health
Page 6
Health Care Reform
Enhancing Quality and Safety
Nursing Competencies in
Ambulatory Care Practice
Page 14
Barbara Pacca
Most of us, when we hear hoof beats, think of horses. It’s so easy to look at a picture
and see what you most expect. As ambulatory nurses, we need to look for the unexpected – a zebra instead of a horse. The Immune Deficiency Foundation (IDF) would like us to
“Think Zebra.”
Primary immune deficiency disorders (PIDD) were once believed to occur rarely in the
general population. Historically they have been considered pediatric disorders because they
were thought to be diagnosed most often during childhood. According to the National
Institute of Child Health & Human Development (NICHD), “PI diseases were once thought
to be rare, mostly because only the more severe forms were recognized. Today physicians
realize that PIs are not uncommon. They are sometimes relatively mild, and they can occur
in teenagers and adults as often as in infants and children” (NICHD, 2011).
The 2007 National Patient Survey results published by the IDF conclude that diagnoses of PIDD are far more common than suggested in the literature. “The exact number
of persons with PI is not known. It is estimated that each year about 400 children are born
in the United States with a serious PI. The number of Americans now living with a primary
immunodeficiency is estimated to be between 25,000 and 50,000” (NICHD, 2011).
Survey findings indicate the prevalence of PIDD in the general population to be 1 in 1,200
persons (Boyle & Buckley, 2007). Findings also confirm that primary immune deficiency
disorders are no longer strictly a pediatric condition in the United States (IDF, 2007). More
than half of new patients surveyed were not diagnosed with PIDD until they were age 30
or older. The average length of time from onset of symptoms to diagnosis is 12.4 years
(IDF, 2007). Few of the patients participating in the survey reported a family history of
PIDD; however, 9 out of 10 patients reported they experienced repeated, serious, or
Telehealth Trials and
Triumphs
Attributes of an Excellent
Telephone Triage Nurse
Page 15
Nurses Wanted: Largest
Women’s Health Study
Seeks 100,000 Nurses
Page 16
AAACN News
Page 18
AAACN Membership
Speaks Out on Health Care
Reform
Page 19
Member Spotlight
continued on page 8
Contact hour instructions, objectives, and accreditation information may be found on page 13.
The Official Publication of the American Academy of Ambulatory Care Nursing
See Page 20
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Institute.
A
As I write my last message to you as the president of
AAACN, I am surprised and saddened at how fast the year
has passed. It has been an amazing experience for me. I cannot thank everyone enough for the support they have provided.
The board and I have worked to raise of our members’
awareness of the impact and opportunities afforded ambulatory care nurses through health care reform and the Institute
of Medicine (IOM) report on the Future of Nursing. The
enactment of the Affordable Care Act (March 2010), folLinda Brixey
lowed by release of the IOM report on the Future of Nursing
(October 2010), underscores nurses’ contribution and capacity to transform the
quality of care.
We have reached out to build collaborative relationships for AAACN and have
been rewarded with a growing number of opportunities to have member involvement providing the ambulatory perspective in external forums.
I have seen an increased willingness for our members to volunteer and am
always amazed at the enthusiasm and quality of the volunteers for the various opportunities. This has been key in our ability to strategically position AAACN for wider
recognition of the value of ambulatory care nurses. We are also receiving endorsements from other nursing organizations for our Position Statement on the Role of the
RN in Ambulatory Care. This is very exciting!
Policymakers, health care experts, and nurses are calling for nurses to optimize
their contribution to improve health care quality. With 3.1 million nurses in the
United States, we are the largest group of health care professionals. Corporate leadership needs more nursing involvement and to recognize the value nursing brings as
members of the care team, promoting improved health care outcomes. We need to
be involved in accreditation standard development and collaborative multidisciplinary work groups on legislative initiatives. We want to be full partners in providing
health care and to be recognized and rewarded for our expertise. We will continue
our conversations, working to develop synergies with other nursing organizations as
well as other multidisciplinary care team members.
There is a work group that is completing our position paper on the Role of the
RN in Ambulatory Care. This is exciting for us as an organization. Better recognition
of the role of the ambulatory care nurse in improving health care outcomes is not
our work alone. We must be in collaborative relationships with other nursing organizations, physicians, and legislative representatives.
We have convened a large and prestigious multidisciplinary team of members
and non-member affiliates to work on Care Coordination Competencies. We have
also invited the Academy of Medical-Surgical Nurses (AMSN) to join us in this
endeavor. We are expecting this to be a very important initiative.
Nursing can be instrumental in shaping the future of health care. Our professional organizations can help us influence public perception and policy decisions on
important issues that directly impact quality of care, access, and scope of practice.
All nurses need to be able to practice to the fullest extent of their education, training, and licensure. We need to be able to tell others how nursing improves patient
outcomes and to embrace the full value and power of our profession. Much of the
required change begins with us. Nursing has to participate in the transformational
changes that are needed. We can lead from where we are by being aware of the
quality measures that are used to evaluate patient outcomes and help management
recognize the nurse’s role in achieving these metrics. We must stay informed and
embrace the opportunities that support the expanded role for nurses.
2 ViewPoint MARCH/APRIL 2012
continued on page 13
Connect with Your Favorite Nurses Through Social Media
Want to be Friends?
Facebook is the hub of Internet social activity, and
AAACN is right in the middle with a Facebook page that
has over 700 fans. Nurses like you are connecting and
chatting, and we’re having a blast trying to make you
laugh while passing on news you need. So please visit the
page (www.facebook.com/aaacn), “Like” us, and get in
the loop! While you’re there, check out the new tabs for
certification, job openings, ambulatory resources, and telehealth tools. You can also view photos from past conferences and share your own.
Join Us for a Tweet
AAACN is also active on Twitter, where we have over 1,900 followers. Are you one of them? Send us a tweet at @AmbCareNursing and tell
us how we’re doing. We’d love to chat with you! Our Twitter feed broadcasts nursing news and updates on all things related to our specialty
organization. Check out our profile (www.twitter.com/ambcarenursing),
follow us, and add us to your favorite lists. We’ve got some handy Twitter
lists for you to follow as well, so you can read streamlined tweets in
focused areas such as pediatrics, veterans’ affairs, and patient education.
Can you help us make #AAACN a trending topic?
We took everything
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Welcome to the AAACN Career Center – your leading resource
for an ideal position or effective recruitment. Job seekers:
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And if you’re hiring, there’s something for you too. Because we’re
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Connect today!
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WWW.AAACN.ORG 3
The Nurse Education
Imperative
Nearly 18 months after the
release of the Institute of Medicine
(IOM) report “The Future of
Nursing:
Leading
Change,
Advancing Health,” it makes sense
to ask: what changes are occurring?
how can we make the most difference? and where can the report’s
recommendations take us toward
improving patient care?
Risa Lavizzo-Mourey
One of the report’s focal points,
and a priority for the Robert Wood Johnson Foundation, is
ensuring that nurses are educated and trained to excel as
21st century health care delivery becomes more complex
and extends beyond acute care settings. The Future of
Nursing report emphasizes that if nurses are to maintain
their effectiveness in providing high-quality patient care,
they will need to be better prepared. Specifically, the report
recommends creating a system that produces more nurses
educated at the bachelor of science (BSN) level and policies that allow nurses to transition seamlessly from an associate’s degree to the BSN or a higher degree. From the perspective of the IOM committee that developed the report,
increasing the percentage of the workforce holding a BSN
to 80% by 2020 is both an achievable goal and a necessary step to meet workforce competency and capacity
requirements (Institute of Medicine [IOM], 2011).
As a physician, I have seen the tremendous capabilities of
nurses–capabilities that are essential to meeting patient
needs. But to ensure that they maximize their contributions
to health and health care, nurses will need advanced skills
and expertise in care management, interdisciplinary teamwork, problem solving, and more. This makes higher levels of
education imperative. In addition, having a larger pool of
highly educated nurses will be necessary to expand the ranks
of nurse faculty, addressing the shortfall that now causes nursing schools to turn away thousands of qualified applicants
each year. These advanced degree nurses are also needed to
help ameliorate the worsening primary care shortage.
For numerous reasons, employers will benefit from
advancing levels of nurse education as well. For one, the
advent of value-based payment systems will place an even
greater imperative on having a highly trained health care
workforce. As payers increasingly focus on hospital readmission rates, nurse-sensitive quality measures, and care
coordination, nurses’ performance will be even more critical to the bottom line. More BSN-prepared nurses will
mean a bigger cadre of nurses prepared to fully participate
in interdisciplinary care teams and to take on leadership
roles at the staff and executive levels in a transformed
health care system.
In a recent survey conducted by AONE (Caramanica &
Thompson, 2012), 51% of nurse leaders said their organizations preferentially hire BSN nurses, although just 32%
pay BSN nurses more at the time of hire. Lack of access to
BSN nurses and lack of support from organizational leaders
were cited as the top barriers to such policies. Ninety-three
percent of survey respondents noted that their institutions
offer tuition benefits to support associate’s degree-to-BSN
advancement.
Some of the leading nurse employers favor advanced
degree nurses. The well-respected Johns Hopkins Hospital
has a stated preference for hiring BSN nurses and requires
nurses to obtain at least a BSN before going beyond a certain point on the career ladder. The for-profit Tenet Health
Care Corporation has adopted similar policies, and the
Veteran’s Health Administration also links education to career
advancement (Pittman, Horton, Keeton, & Herrera, 2011).
These policies can yield positive benefits, but monetizing the return on investment is challenging. We know that
turnover rates are sensitive to human resources policies,
including tuition reimbursement and career-ladder programs that provide growth opportunities (Pittman et al.,
2011). There is evidence that organizations that earn the
Magnet Recognition Program® credential for nursing excellence have lower turnover rates among nurses and thus have
improved clinical outcomes (Drenkard, 2010). In Magnetdesignated organizations, chief nursing officers and 75% of
nurse managers are required to have a BSN degree or higher (Frellick, 2011). An important consideration for employers
is that education progression policies may yield savings that
result from lower nurse turnover and vacancies, estimated to
cost from $22,000 to $64,000 per position (Strachota,
Normandin, O’Brien, Clary, & Krukow, 2003).
We cannot wait to take action; failing to grow a better
educated nursing workforce risks disastrous results. This is
particularly important in light of the aging nursing workforce as well as the coming expansion of health insurance
coverage in 2014. Although a recent study shows faster
growth in the supply of nurses than anticipated, its authors
caution that more progress is needed to meet our aging
population’s need for highly skilled nurses (Auerbach,
Buerhaus, & Staiger, 2011).
Around the country, educational institutions are finding creative ways of encouraging and facilitating progression to BSN and higher-level degrees. For example, the
Oregon Consortium for Nursing Education has created a
shared curriculum across 8 community colleges and the
Oregon Health & Science University School of Nursing,
which enables students to complete BSN coursework without leaving their home community. Graduates are trained
in clinical judgment, patient-centered care, systems thinking, leadership, and evidence-based practice. In New
Mexico, leaders will discard 24 separate curricula in favor
Note: Reprinted with permission from Elsevier. LavizzoMourey, R. (2012). The nurse education imperative.
Nursing Outlook. doi:10.1016/j.outlook.2011.12.001
of a uniform nursing curriculum and a shared faculty pool.
Florida is developing RN-to-BSN educational models,
including community college transition to state college
programs and community college transition to state university regional partnerships. Colorado is developing such
partnerships as well.
These are shining examples of the evolution that needs
to occur nationwide. To meet our nation’s health care
needs, we must strengthen the nursing profession at all
levels, from the front lines to the executive ranks. That is
precisely why we partnered with the IOM to develop the
report and why we are actively engaged in facilitating its
implementation through the Future of Nursing: Campaign
for Action.
Tackling the barriers to educational progression
requires a multifaceted approach. Far from being solvable
with a single action or within a single arena, realizing fullscale change will take the commitment of many in health
care, education, business, and other sectors. A key component of our effort is working with national stakeholders
through the Center to Champion Nursing in America, an
initiative of the AARP, the AARP Foundation, and the Robert
Wood Johnson Foundation.
Because nursing is so critical to improving health care,
it is a priority for our foundation and one to which we have
devoted more than $300 million over the last 10 years. At
the Robert Wood Johnson Foundation, the IOM report is
our blueprint for transforming the nursing profession to
help ensure that all patients receive the care they need and
deserve. We will continue to address its recommendations–and encourage many others to do the same–to fully
realize the Campaign for Action’s vision: a nation where all
have access to high-quality, patient-centered care in a
health care system in which nurses contribute as essential
partners in achieving success.
References
Auerbach, D.I., Buerhaus, P.I., & Staiger, D.O. (2011). Registered
nurse supply grows faster than projected amid surge in new
entrants ages 23-26. Health Affairs, 30(12), 2286-2292.
Caramanica, L., & Thompson, P.A. (2012, January). AONE survey:
Gauging hospitals’ use of preferential hiring policies for BSNprepared nurses. Voice of Nursing Leadership, 1, 17-18.
Drenkard, K. (2010). The business case for Magnet. Journal of
Nursing Administration, 40(6), 263-271.
Frellick, M. (2011). A path to nursing excellence. Trustee, 64, 201.
Retrieved from http://www.trusteemag.com/trusteemag_app/
jsp/articledisplay.jsp?dcrpath=TRUSTEEMAG/Article/data/03M
AR2011/1103TRU_FEA_PathToNursingExcellence&domain¼T
RUSTEEMAG
Institute of Medicine (IOM). (2011). The future of nursing: Leading
change, advancing heath. Atlanta, GA: The National Academies
Press.
Pittman P., Horton, K., Keeton, A., & Herrera, C. (2011, November).
Investing in nurse education: Is there a business case for employers? Manuscript in preparation.
Strachota, E., Normandin, P., O’Brien, N., Clary, M., & Krukow, B.
(2003). Reasons registered nurses leave or change employment
status. Journal of Nursing Administration, 33(2), 111-117.
Risa Lavizzo-Mourey, MD, MBA, is President and CEO, Robert
Wood Johnson Foundation, Princeton, NJ.
● March is colorectal cancer awareness month! For more
information to share with your patients on the signs and
symptoms and diagnostic tests available, check out this
information at the National Cancer Institute:
http://www.cancer.gov/cancertopics/pdq/prevention/
colorectal/Patient/page3
● Sleep disorders can affect health care staff as well as
patients. Check out this list of seven tips for better sleep:
http://www.mayoclinic.com/health/sleep/HQ01387
● Poison prevention is key in the spring! Call 1-800-2221222 and ask a Poison Control educator for stickers, magnets, brochures, or other poison prevention materials. If
you need information in a variety of foreign languages,
check out this site, The American Association of Poison
Control Centers: http://www.aapcc.org/dnn/Poisoning
Prevention/OrderPoisonPreventionMaterials.aspx
● Autism, pervasive developmental disorders, and Asperger’s
syndrome are becoming more prevalent. To direct your
patients to reliable information, have them access information
from
Autism
Speaks:
http://www.autism
speaks.org/family-services/resource-library
Carol Ann Attwood, MLS, AHIP, MPH, RN,C, is a Medical
Librarian, Patient Health and Education Library, Mayo Clinic
Arizona, Scottsdale, AZ, and a ViewPoint Editorial Board member.
She can be contacted at [email protected]
Cleveland LNG Raises Funds
To Help Children
The Cleveland local networking group (LNG) of the
Academy of Ambulatory Care Nursing raised donations for
the Providence House in Cleveland, OH. The Providence
House is one of the nation’s oldest operating crisis nurseries,
offering emergency shelter and care to children who are
actively at risk for abuse and neglect due to family crisis. The
Cleveland Academy of Ambulatory Care Nursing (CAACN)
raised $250 among its members, matched that with local
networking group funds, and was able to present $500 to
help with holiday needs for the children.
The Cleveland LNG has 25 formal members with an
additional 30-40 interested parties on our mailing list. We
meet monthly at a local restaurant, have speakers who provide continuing nursing education (CNE) offerings, and hold
discussion and networking after. We meet from September
until June, with the June meeting being a social/recruiting
event with appetizers provided. We have representatives
from 4 area hospitals/ambulatory clinics and have found
friends and colleagues through our common interests.
Submitted by Kitty Ribar, BSN, RN
WWW.AAACN.ORG 5
View health care reform resources online at:
www.aaacn.org/HCReform
Enhancing Quality and
Safety Nursing Competencies
In Ambulatory Care Practice
In the last issue of ViewPoint, the new Centers for
Medicare and Medicaid Services (CMS) “Never Events”
were presented and discussed, as well as how CMS considers these to be events that should never occur in ambulatory care settings (Haas, 2012). This ruling can have major
reimbursement consequences, but also requires that nurses and other providers in ambulatory care settings become
much more aware of quality and safety issues and ways to
prevent never events through evidence-based practice
(EBP) and use of the electronic health record (EHR). The
Institute of Medicine (IOM) has provided multiple reports
on the status of health care in the U.S. starting with To Error
is Human in 1999, where flawed systems were identified as
a major cause of error. In 2001, the IOM report Crossing the
Quality Chasm delineated issues with quality and safety and
recommended 6 aims for U.S. health care (see Figure 1).
There have been follow-up reports by the IOM (2003)
where the need for practitioners to gain expertise in the
areas of quality and safety are addressed. The Robert Wood
Johnson Foundation funded work by Cronenwett and colleagues (Cronenwett et al., 2007; Cronenwett, Sherwood,
& Gelmon, 2009a; Cronenwett, Sherwood, Pohl, et al.,
2009b) called Quality and Safety in Education in Nursing
(QSEN). The IOM’s six aims are the foundation for QSEN’s
six competencies.
Using the Institute of Medicine (2003) competencies
for nursing, QSEN faculty have defined pre-licensure and
graduate quality and safety competencies for nursing and
proposed targets for the knowledge, skills, and attitudes
(KSAs) to be developed in nursing pre-licensure and graduate programs for each competency (QSEN 2012a,
2012b):
• Patient Centered Care – Recognize the patient or
designee as the source of control and full partner in providing compassionate and coordinated care based on
respect for patient’s preferences, values, and needs.
• Quality – Use data to monitor the outcomes of care
processes and use improvement methods to design and
test changes to continuously improve the quality and
safety of health care systems.
• Teamwork and Collaboration – Function effectively
within nursing and inter-professional teams, fostering
open communication, mutual respect, and shared decision-making to achieve quality care.
• Safety – Minimizes risk of harm to patients and providers
through both system effectiveness and individual performance.
Figure 1.
IOM (2001) Six Aims for Improvement
• Safe: avoiding injuries to patients from the care that
is intended to help them.
• Effective: providing services based on scientific
knowledge to all who could benefit, and refraining
from providing services to those not likely to benefit.
• Patient-centered: providing care that is respectful of
and responsive to individual patient preferences,
needs, and values, and ensuring that patient values
guide all clinical decisions.
• Timely: reducing waits and sometimes harmful
delays for both those who receive and those who
give care.
• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: providing care that does not vary in quality because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic
status.
Source: IOM, 2001.
• Evidence-Based Practice – Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.
• Informatics – Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making.
These competencies, as defined above, provide the
KSAs that make up each competency. The QSEN competencies are now part of accreditation standards for prelicensure and graduate education and are content tested in
licensing and certification exams. Nursing students who
are now graduating will have had exposure to these competencies in theory, simulation, and clinical classes. Of concern is the fact that nurses currently practicing may not be
as familiar with the QSEN competencies. When and if new
graduate nurses move into ambulatory care, they will
expect to see EBP, Quality Councils, and EHR where nurses
document care processes and outcomes. If this is not the
norm for nursing in an ambulatory setting, retention of
nurses could be an issue, as well as poor patient and organization outcomes.
Concern regarding competency with quality and safety extends beyond nursing. The Lucian Leape Institute
issued a report in 2010 that was highly critical of the lack
of quality and safety content and experience in medical
student and residency programs. Prevention and management of potential never events in ambulatory settings
requires competencies in all six of the areas specified in
QSEN. However, this column will focus only on the EBP
and Informatics QSEN competencies because they are a
major focus of the health reform law. It is expected that
providers, nurses, physicians, and other health care professionals will use best evidence-based practices in the provision of care and that they will track evidence-based
processes and outcomes achieved. Tracking is where informatics comes into play. The Accountable Care law provides
funding for equipment to support the EHR, especially in
primary care practice. It is the expectation that the EHR will
enhance communication within the health care team and
across settings and decrease errors and costs due to duplication of testing, lost test results, etc. The EHR is also key to
tracking evidence-based processes of care and outcomes.
In addition to falls and pressure ulcers discussed as
potential never events in ambulatory care in our last
ViewPoint issue, surgical or invasive procedure events and
product or devise events in ambulatory care are also of
concern. The Joint Commission requires use of the
Universal Protocol in all accredited hospitals, ambulatory
care, and office-based surgical practices to prevent such
events and there is evidence that can be employed in EBP
protocols to prevent adverse surgical or device events.
So where do ambulatory nurse leaders start? The QSEN
Web site (http://www.qsen.org) is a great resource. It is
designed to assist in both nursing student and staff education, as well as education of the educator. You can search for
teaching strategies by indicating which QSEN competency
you want to work on, your learning setting, learner level,
and strategy type (such as simulation). There are also yearly QSEN conferences where those who are using QSEN
share strategies and methods. For the EBP competency,
there are free interdisciplinary Web-based modules
(http://www.ebbp.org). These interactive modules were
funded by a grant from the National Institutes of Health.
Another great resource funded by the Agency for
Healthcare Research and Quality is a text edited by Hughes
(2008) titled Patient Safety and Quality: An Evidence-Based
Handbook for Nurses. This 3-volume text is FREE to nurses on
CD-ROM from http://www.ahrq.gov/qual/nurseshdbk/.
Knowing that there are resources available to upgrade
and update ambulatory care nurses’ understanding of EBP
and use the EHR, the first step for ambulatory care nurse
leaders should be developing a strategic plan for prevention of never events in ambulatory care. Such a plan starts
with developing an understanding among leadership and
nurses and an appreciation of the issue of never events,
methods to identify potential for them in ambulatory care
settings, methods to develop or enhance understanding
and comfort with development of EBP protocols suited to
the ambulatory care setting, and knowledge and skills with
use of documentation formats in EHR to track EBP processes and outcomes.
Such a project may seem overwhelming, but leaders
need to look at one potential never event at a time. For
example, look at historical data on falls or operating room
errors so you can see where you should start. Begin with
work on the event that has the highest incidence and the
one that will have the greatest costs, both in poor patient
outcomes as well as financial, should it occur and thus the
greatest return on investments that will be made in EBP
and the EHR. Much of the cost is related to education time
for staff as well as development time needed for work on
EBP protocols and EHR documentation formats.
While there are financial incentives to EBP and the use
of EHR, there is a greater incentive that ambulatory nurses
will respond to – providing higher quality and safer care to
their patients.
References
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,
Mitchell, P., … Warren, J. (2007). Improving quality and safety
education. Nursing Outlook, 55(7), 122-131.
Cronenwett, L., Sherwood, G., & Gelmon, S., (2009). Improving
quality and safety education: The QSEN Learning Collaborative.
Nursing Outlook, 57(6), 304-312.
Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S.,
Sullivan, D., … Warren, J. (2009). Quality and safety education
for advanced nursing practice. Nursing Outlook, 57(6), 338-348.
Haas, S.A. (2012). Prevention and early detection of “never events”
within ambulatory settings to enhance quality and safety and
prevent financial losses. ViewPoint, 34(1), 6-8.
Hughes, R. (Ed.) (2008). Patient safety and quality: An evidence-based
handbook for nurses. Rockville, MD: Agency for Healthcare
Research and Quality. Retrieved from http://www.ahrq.gov/
qual/nurseshdbk/
Institute of Medicine (IOM). (1999). To err is human: Building a safer
health system. Washington, DC: National Academies Press.
Retrieved from http://www.iom.edu/Reports/1999/To-Err-isHuman-Building-A-Safer-Health-System.aspx
Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new
health system for the 21st century. Washington, DC: National
Academies Press. Retrieved from http://iom.edu/~/media/Files/
Report%20Files/2001/Crossing-the-QualityChasm/Quality
%20Chasm%202001%20%20report%20brief.pdf
Institute of Medicine (IOM). (2003). Health professions education: A
bridge to quality. Washington, DC: National Academies Press,
Quality and Safety in Nursing Education. Retrieved from
http://www.iom.edu/Reports/2003/Health-ProfessionsEducation-A-Bridge-to-Quality.aspx
Lucian Leape Institute. (2010). Unmet needs: Teaching physicians to provide safe patient care. Retrieved from http://www.
npsfstore.com/categories/publications
Quality and Safety Education for Nurses (QSEN). (2012a). Competency
KSAs (graduate). Retrieved from http://www.qsen.org/
ksas_graduate.php
Quality and Safety Education for Nurses (QSEN). (2012b). Competency
KSAs (pre-licensure). Retrieved from http://www.qsen.org/
ksas_prelicensure.php
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of
Nursing, Loyola University of Chicago, Chicago, IL. She can be contacted at [email protected]
WWW.AAACN.ORG 7
Think Zebra
continued from page 1
unusual infections prior to diagnosis (IDF, 2007). The goal
of this article is to raise awareness regarding PIDD in the
ambulatory nursing community.
Primary immune deficiency disorders are a group of
conditions in which the patient has an intrinsic immune
system defect in his or her immune system. There are currently more than 150 different diagnoses recognized by
the World Health Organization as PIDD (Boyle & Buckley,
2007). Making a PIDD diagnosis is challenging because
there aren’t any clearly recognizable or unique symptoms.
The patient frequently presents with symptoms of infections, which can be persistent and/or chronic. It is not
unusual in our practice to hear from a new patient and
family with a child who has been sick for a long period of
time – sometimes years. Often several different physicians
and specialists saw the child before there was a correct
diagnosis and appropriate referral for treatment. If the
patient, family, or health care provider does not look
beyond the individual episode requiring treatment, the
underlying cause may go undetected.
The Jeffrey Modell Foundation (2012) created the 10
Warning Signs of PIDD to help raise awareness of these disorders. The list for children is as follows (variations for
adults are noted):
1. Four or more new ear infections within one year (two
or more for adults)
2. Two or more serious sinus infections within one year
(in absence of allergy for adults)
3. Two or more months on antibiotics with little effect
4. Two or more pneumonias within one year (one or
more for adults)
5. Failure of an infant to gain weight or grow normally
6. Recurrent deep abscesses of the skin or internal organs
7. Recurrent need for intravenous antibiotics to clear
infections
8. Persistent thrush or fungal infection
9. Two or more deep-seated infections including septicemia (not noted in adult criteria)
10. A family history of PIDD
Also included in diagnosing an adult is an infection
with normally harmless tuberculosis-like bacteria and
chronic diarrhea with weight loss (Jeffrey Modell
Foundation, 2012). This information is available on the
Foundation Web site (www.info4pi.org).
Evaluation may include a detailed medical history,
thorough physical examination, blood tests, and vaccines
to test the immune response. A routine CBC with differential that shows a low lymphocyte count (especially if it persists in follow-up testing) may warrant closer examination
by an immunologist. Other lab tests frequently used in
diagnosis are IgG, IgA, IgM, and IgE levels, delayed-type
hypersensitivity skin tests, mitogen and antigen studies
that look at T cell response to stimuli, and CD19 and CD20
for B cell lymphocytes present in the circulation.
Frequently, patients are given vaccines (not live virus) followed by titers to check for the body’s response to those
vaccines. Patients with undiagnosed and untreated PIDD
are unable to produce antibodies sufficient to fight infection. Administration of live viruses to a patient with a compromised immune system can result in serious illness or
death. In addition, siblings and other household contacts
should not receive live virus vaccines due to the potential
for disease transmission (Winkelstein, 1996).
“PIDD vary in prevalence from relatively common to
very rare” (Burton, Murphy, & Riley, 2009, p. 6). Examples
of some of the better-known disorders are noted in Table 1
(see page 10). This table presents only basic information
regarding PIDD. The wide range of symptoms and variability among disorders makes it impossible to include details
for any one specific disorder in this format. It is worth special note that severe combined immune deficiency (SCID)
usually manifests in infancy, and without early diagnosis,
has poor outcomes for the patient. SCID is sometimes
known as “bubble boy disease.” When diagnosed at birth,
these patients receive a bone marrow transplant within the
first ten days of life. “In January of 2010, the Advisory
Committee on Heritable Disorders in Newborns and
Children voted to add screening for SCID to the core panel
of universal screening of newborns in the United States”
(Gill, 2010). To date, it is the only form of PIDD for which
routine screening has been established.
For many patients with PIDD, treatment includes IgG
replacement therapy given intravenously or subcutaneously. Intravenous infusions of immune globulin (IVIG) are usually given every 3-4 weeks and can be given in an infusion
center or at home through a home care agency. Home
IVIG infusions should be provided through a home care
agency with a nurse present during infusion. Subcutaneous
infusions are usually given weekly at home and administered by the patient or a family member following initial
training by a health care provider (Skoda-Smith, Torgerson,
& Ochs, 2010). Having options for the method of administration of IgG gives the patient some control over his or
her treatment options and lifestyle.
Stem cell transplants have been used for some patients
with PIDD with positive outcomes. “The primary immunodeficiency diseases for which HSCT (hemapoetic stem cell
transplant) is most commonly performed include those diseases that are characterized by deficient T-lymphocytes or
combined deficiencies of T-lymphocytes and B-lymphocytes. HSCT is most often used to treat SCID. HSCT has
also been used in some patients to treat other primary
immunodeficiency diseases such as the Wiskott-Aldrich
syndrome, hyper-IgM syndromes, and chronic granulomatous disease” (IDF, 2007). Clinical trials with gene therapy
are also being done with these same patient populations
with mixed results. Stem cell transplants and gene therapy
show tremendous potential for the treatment of T-lymphocyte disorders and combined T-lymphocyte and B-lymphocyte disorders, but more research is needed.
“Throughout adult life, patients remain stable in both
the management of their condition and the condition itself
by adhering to the chronic care management (CCM)
model” (Burton et al., 2009, p. 8). This model includes disease prevention, evidence-based interventions, along with
several other tenets of traditional care supported by
research and education. Burton and colleagues (2009) further discussed the new patient-centered PIDD CCM based
on the Expert Patient Program started in the United
Kingdom in 2002. The five core proficiencies identified as
necessary to becoming an expert patient are as follows:
• Problem-solving
• Decision-making
• Resource maximization
• Developing effective partnerships with health care
providers
• Appropriate interventions
“The focus of this new CCM for PIDD is enabling complete patient self-management from the patient’s perspective” (Burton et al., 2009, p. 8).
Assisting patients to be experts in their own care would
help to establish them as effective partners with their
health care providers. This type of health care
consumer/provider relationship is consistent with the
National Prevention Strategy (U.S. Department of Health
and Human Services, 2012) and would support the goals
of Health Care Reform. For patients with PIDD, being educated about their disorder and having the ability to advocate for their health care needs can make a significant difference in their ability to reach their optimal health
potential. “Effective management of chronic disease is the
key to both reducing health care expenses and improving
patients’ quality of life” (Burton et al., 2009, p. 5).
Resources for health care providers, patients, and families are available through the Internet or in print. The
Immune Deficiency Foundation (www.primaryimmune.org)
and the Jeffrey Modell Foundation (www.info4pi.org) are
both reliable sources of information. The IDF mission
includes PIDD research and patient advocacy among its
many offerings. Their “Think Zebra” campaign was established to promote awareness of PIDD. They have also published a handbook for patients and families as well as a nurses’ guide to IVIG. The handbook contains basic information
as well as a section dedicated to each of the most common
diagnoses. The IDF also sponsors an online continuing education course for nurses that includes detailed information
about PIDD. The course is free, provides 5 contact hour credits, and can be found on their Web site. IG Living magazine
(www.igliving.com) is a useful resource for patients and families receiving immune globulin therapy. It has been in publication for several years and is sponsored by several manufacturers of IVIG products. Subscriptions are free.
All of us, as ambulatory care nurses, are in a position to
listen to our patients’ stories, hear what they are saying,
and collaborate with them to look at the big picture. Early
diagnosis and treatment leads to the best possible outcomes for PIDD patients. So remember: The next time you
hear hoof beats, “Think Zebra!”
References
Boyle, J.M., & Buckley, R.H. (2007). Population prevalence of primary immunodeficiency diseases in the United States. Journal of
Clinical Immunology, 27(5), 497-502.
Burton, J., Murphy, E., & Riley, P. (2010). Primary immunodeficiency disease: A model for case management of chronic disease.
Professional Case Management, 15(1), 5-10.
Gill, J.D. (2010). Newborn screening for SCID – The time is now. IDF
Advocate, 63, 1-5. Retrieved from http://primaryimmune.org/
publication_s/newsletter/idf_newsletter63_spring10.pdf
Immune Deficiency Foundation (IDF). (2007). IDF national survey of
patients. Retrieved from http://primaryimmune.org/idf-surveyresearch-center/idf-surveys
Jeffrey Modell Foundation. (2012). National primary immunodeficiency resource center. Retrieved from http://info4pi.org/
National Institute of Child Health & Human Development (NICHD).
(2011). Primary immunodeficiency. Retrieved from http://
www.nichd.nih.gov/health/topics/Primary_Immunodeficiency.
cfm
Primary Immunodeficiency Resource Center. (2009). 10 warning
signs of primary immunodeficiency. Retrieved from
http://www.info4pi.org/aboutPI/index.cfm?section=aboutPI&
content=warningsigns
Skoda-Smith, S., Torgerson, T.R., & Ochs, H.D. (2010).
Subcutaneous immunoglobulin replacement therapy in the
treatment of patients with primary immunodeficiency.
Therapeutics and Clinical Risk Management, 6, 1-10.
U.S. Department of Health and Human Services. (2012). National
prevention strategy. Retrieved from http://www.healthcare.gov/
Winkelstein, M.L. (1996). Primary immune deficiency diseases: A
guide for nurses. Towson, MD: Immune Deficiency Foundation.
Suggested Reading
Burton, J., Murphy, E., & Riley, P. (2010). Primary immunodeficiency disease: A model for case management of chronic disease.
Professional Case Management, 15(1), 5-10.
Barbara Pacca, RN, BSN, CPN, HTPA, is a Clinical Nurse IV,
Children’s Hospital of Philadelphia, Philadelphia, PA.
AAACN Marketing Opportunities
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For more information, contact Marketing Director Tom
Greene at [email protected] or 856-256-2367.
WWW.AAACN.ORG 9
Table 1.
Examples of Primary Immune Deficiency Disorders
Age at Onset of
Symptoms or
Diagnoses
Characteristics
Inheritance
Common
Variable Immune
Deficiency
(CVID)
B-lymphocyte disorder
Most common form of PIDD
Low serum levels of immune
globulins
Symptoms vary in severity
Recurrent infections of ears,
sinuses, nose bronchi, and
lungs
Unclear genetic
nature
Affects males and
females
Variable
20% are less than
16 years of age
Some are diagnosed in the third
or fourth decade
of life
Prompt treatment of
infections
Antibiotic therapy
Immune globulin
replacement
Keep patient
infection free
Prevent development
of chronic lung
disease
X-linked
Agammaglobulinemia
(XLA)
Unable to produce antibodies
Have small tonsils and lymph
nodes on physical exam
Prone to infections in sinuses,
middle ear, eyes, and lungs
X-linked recessive Usually within the
Disease presents first few years of
in males; females life
can be carriers
Prompt treatment of
infections
Antibiotic therapy
Immune globulin
replacement
Extra attention
needed in
preventing/
treating infections
With treatment, a full
and active lifestyle is
possible
Selective IgA
Deficiency
None identified
Varies with severiOne of the most common
Affects males and ty of symptoms
PIDD, occurring in 1 in 500 females
people
Absence of IgA in serum and
secretions
Severity of symptoms varies
from relatively healthy to
significant illness; about 50%
have increased susceptibility
to infection
25-33% have autoimmune
disease
10-15% have
allergies/asthma
Considered to have increased
risk of anaphylaxis with blood
products including immune
globulin
Frequent assessment and
reevaluation by health
care provider to maintain
optimal health
Strong communication
between patient/family
and health care provider
to initiate treatment as
soon as disease process is
identified
Long-term outcomes
are unpredictable;
prognosis depends
on prognosis of
associated diseases
Severe
Combined
Immune
Deficiency
(SCID)
Combined B-lymphocyte and
T-lymphocyte disorder
Extreme susceptibility to
infection
Sometimes called “bubble
boy disease”
Bone marrow transplant
usually shortly after birth
Gene therapy
Supplemental treatment
can include immune
globulin replacement
therapy, frequent painful
procedures, and
hospitalizations
If blood or platelet
transfusion is necessary,
only irradiated, CMV
negative, leukocytedepleted products should
be used
Most serious form of
PIDD
Affected infants need
to be isolated from
others outside the
home
Without treatment,
risk of infection is
severe and can be
fatal
Several known
genetic causes
Most common is
X-linked recessive
(45%) affecting
males
Remainder are
autosomal
recessive affecting
males and
females
Can also be a
new mutation in
the affected infant
Can be diagnosed
in utero
Symptomatic at
or shortly after
birth
Treatment Options
Treatment Goals or
Life Expectancy
PIDD
Table 1.
(continued)
PIDD
Chronic
Granulomatous
Disease (CGD)
Characteristics
Phagocytic disorder
Susceptible to certain
bacterial and fungal
infections
Characteristic granuloma
formation at site of infection
or inflammation
Inheritance
Age at Onset of
Symptoms or
Diagnoses
Treatment Goals or
Life Expectancy
Early diagnosis of
infection
Aggressive antibiotic
therapy
Gamma interferon
May need recurrent
hospitalizations and
IV antibiotics to treat
infection
Can lead full,
productive lives into
adulthood
Wiskott-Aldrich
Combined B-lymphocyte and X-linked affecting Shortly after birth
Syndrome (WAS) T-lymphocyte disorder
males
or within the first
year of life
Low platelet count with
increased tendency for
bleeding
Recurrent bacterial, viral, or
fungal infections
Eczema
Increased incidence of
malignancy
Increased incidence of
autoimmune disease
Bone marrow transplant
Cord blood stem cell
transplant
Gene therapy
Supplemental treatment
can include appropriate
treatment of eczema,
immune globulin
replacement, antibiotic
therapy, and platelet
transfusion; when
absolutely necessary,
splenectomy can be
done for low platelet
counts
30 years ago, life
expectancy was 2-3
years of age
Currently the oldest
bone marrow
transplant recipients
are now 20-30 years
old and leading full,
productive lives
Hyper IgE
Affects the immune system,
Syndrome (HIES) bones, connective tissue, and
teeth
Characteristic skin boils
Also common to present with
rashes, upper respiratory
infections, recurrent
pneumonia, sinusitis, ear
infections, skeletal
abnormalities, characteristic
facial appearance, bone
fractures, or retention of
primary teeth
Very rare with approximately
200 published cases
Can be autosomal Usually within first
dominant or
few months of life
autosomal
recessive affecting
both genders
Appropriate skin care
Early treatment of
infection
Antibiotic therapy
(topical and oral)
Conflicting evidence to
support use of interferon,
immune globulin
replacement therapy,
G-CSF
Require constant
vigilance regarding
infection and chronic
lung disease
Can lead full,
productive lives into
adulthood
Hyper IgM
Syndrome
Can be X-linked First or second
recessive affecting year of life
males or
autosomal
recessive affecting
both genders
Immune globulin
replacement therapy
Antibiotic therapy
G-CSF for neutropenia
More recently, bone
marrow transplant or
cord blood stem cell
transplant have been
used
Can lead full,
productive lives
Immune system defects affect
the interaction between Blymphocytes and Tlymphocytes
Increased susceptibility to
infection
Approximately 50% develop
neutropenia
Frequently have enlarged
tonsils, big spleen and liver,
or enlarged lymph nodes
Usually X-linked
First few months
affecting males
to first few years
of life
Can also be
autosomal
recessive affecting
males and
females
Approximately
15% of CGD
patient are female
Treatment Options
WWW.AAACN.ORG 11
Table 1.
(continued)
PIDD
Characteristics
DiGeorge
Syndrome
Frequently associated with
22q11.2 deletion syndrome
Characteristic facial features
Parathyroid abnormalities
sometimes leading to
decreased serum calcium
levels and/or seizures
Cardiac defects
Thymus gland abnormalities
IgG Subclasses
Inheritance
Caused by
abnormal
migration and
development of
certain cells and
tissues during
growth and
differentiation of
the fetus
Age at Onset of
Symptoms or
Diagnoses
Treatment Options
Treatment Goals or
Life Expectancy
At birth or soon
after
Correction of defects in Dependent on the
organs and tissues; can
degree to which the
require painful
patient is affected
procedures, surgeries,
and possibly recurrent
hospitalization
Treatment of low calcium
levels
Treatment of any
allergies
Prophylactic antibiotics
Low levels of 1 or 2 IgG
No clear pattern
subclasses
of inheritance
Susceptible to certain
infections but not others
Frequently present with
recurrent infections of the
ear, sinuses, bronchi, and
lungs
Frequently unable to produce
adequate antibodies to
unconjugated polysaccharide
vaccines (pneumococcus or
haemophilus)
More common in children
than adults
Not specified
Immune globulin
replacement therapy
Antibiotic therapy
Periodic reevaluation of
immunoglobulin and IgG
subclass levels
Many children
outgrow their
deficiency as they get
older
Prognosis is generally
good
Ataxia
Telangectasia
Combined B-lymphocyte and
Present with neurological
abnormalities, unsteady gait,
or dilated blood vessels of the
eyes and skin
Increased susceptibility to
infection
Predisposition to certain
cancers
Autosomal
recessive affecting
males and
females
Initial onset of
symptoms is
often at 12-18
months
Diagnosis is frequently not made
until age 5-6
years, when
symptoms worsen
Treatment is primarily
supportive
Immune globulin
replacement
Antibiotic therapy
Physical and/or
occupational therapy
Learning support in
school
Disease course is
variable and
progressive
Recurrent lung
infections are
common
Complement
Deficiency
C1-4: C2 is most common,
occurring in 1 in 10,000 in
the general population
Prone to autoimmune
disorders
C5-9 deficiencies cause
increased susceptibility to
Neisseria family of bacteria
C1 inhibitor deficiency
Often have hereditary
angioedema (HAE),
presenting with swelling of
the tissue under the skin,
usually affecting hands, feet,
bowel, mouth, and airway
Most are
autosomal
recessive
C1Inhibitor is
autosomal
dominant
Not specified
Early and aggressive
treatment of symptoms
Prognosis is generally
good with patients
leading full,
productive lives
Source: Compiled from information obtained from the Patient & Family Handbook for Primary Immunodeficiency Diseases, Fourth Edition.
Copyright 2007 by Immune Deficiency Foundation (www.primaryimmune.org).
President’s Message
continued from page 2
Instructions for Continuing Nursing
Education Contact Hours
Think Zebra: Promoting Awareness of PIDD
Deadline for Submission: April 30, 2014
To Obtain CNE Contact Hours
1. For those wishing to obtain CNE contact hours, you must
read the article and complete the evaluation online in the
AAACN Online Library. ViewPoint contact hours are free to
AAACN members.
• Visit www.aaacn.org/library and log in using your
AAACN email address and password. (Use the same log
in and password for your AAACN Web site account and
Online Library account.)
• Click ViewPoint Articles in the left hand navigation bar.
• Read the ViewPoint article of your choosing, complete
the online evaluation for that article, and print your CNE
certificate. Certificates are always available under CNE
Transcript (left side of page).
2. Upon completion of the evaluation, a certificate for 1.0
contact hour(s) may be printed.
Fees
AAACN members: FREE
Objectives
Regular price: $20
The purpose of this continuing nursing education article is to
increase the awareness of primary immune deficiency disorders
(PIDD) in nurses and other health care professionals. After studying the information presented in this article, you will be able to:
1. Define primary immune deficiency disorders (PIDD).
2. Discuss the history of PIDD and how and when they are typically diagnosed.
3. Identify the 10 warning signs for PIDD.
4. Explain treatment options for PIDD.
The authors have not disclosed any affiliation or financial interest in
relation to this educational activity.
This educational activity has been co-provided by AAACN and
Anthony J. Jannetti, Inc.
Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses' Credentialing Center's
Commission on Accreditation (ANCC-COA).
AAACN is an approved provider of continuing nursing education by
the California Board of Registered Nursing, provider number CEP5366.
California licensees must retain this document for four years.
This article was reviewed and formatted for contact hour credit by
Rosemarie Marmion, MSN, RN-BC, NE-BC, Education Director.
Interested in Writing
for
?
Consider sharing your ambulatory
care or telehealth nursing expertise
by writing an article for ViewPoint!
Download author guidelines, copy
deadlines, and tips for authors at
www.aaacn.org/ViewPoint
As I look at our volunteerism, I reflect that each of
us is responsible for our own actions. We can choose to
be reactive, allowing others to define us, or we can
proactively take the lead, being involved during planning and development of initiatives that require nursing
expertise. The National Council of State Boards of
Nursing (NCSBN) has been promoting the Nurse
Licensure Compact to improve access to practice across
state lines. Many states have developed state action
coalitions that lobby for pro-nursing legislative initiatives. By supporting their activity, we promote nursing,
voice our concerns, and express the need for a more
consistent and better defined scope of practice for us all.
Laws governing our practice are made by legislators. If
we do not let them hear from us, they will hear from
others such as physician groups and hospital administrators. We must be present and participate to be heard.
We need to build and share our professional knowledge. The IOM recommends residency programs. As
they become a reality, ambulatory care needs to contribute to the planning and development. Residency
programs target new graduates. We should also look at
other opportunities such as transitional programming,
which may allow us to retain nurses who would otherwise leave the profession. Programs that support transitioning into another field of nursing through advanced
education and competence development are equally
important as the programs for new graduates. We have
included a reprint from Nursing Outlook in this issue of
ViewPoint (see page 4) related to the IOM’s nurse education imperative by Risa Lavizzo-Mourey, MD. Her article stresses the importance of our participation in meeting the requirement of our expanding role by ensuring
that nurses are educated and trained in the advanced
skills, expertise, and care coordination needed to excel.
Your membership in a professional nursing organization such as AAACN is an important way to leverage
the collective energy and resources of our larger body of
nurses. Nursing associations provide educational programs and tools for practice, support positive policy
changes, encourage research, and advocate on issues
important to the profession. Many times a professional
membership provides opportunities to participate in
workforce planning surveys and other data collection
opportunities. If we don’t use our voice, we will not be
heard and will be left behind.
Thank you again for the opportunity to serve as
your president. I truly appreciate all the work of our volunteers who have helped make this year a great success.
I hope to see you at our May 2-5 conference in Lake
Buena Vista, Florida!
Linda Brixey, RN, is Program Manager, Clinical Education, KelseySeybold Clinic, Houston, TX. She can be contacted at linda.brixey
@kelsey-seybold.com
See page 17 for a list of suggested topics.
WWW.AAACN.ORG 13
Attributes of an Excellent
Telephone Triage Nurse
Over the past year, I have been presenting telephone
triage seminars for Telephone Triage Consulting, Inc.
During and after presentations, I am often asked what
attributes a nurse should possess to be effective in triaging
a patient over the phone.
Ideally, every nurse in every area of nursing should possess all of these attributes. However, it is important for telephone triage nurses to possess all of them because of the
unique relationship they have with the patient. Nurse and
patient have a dialogue that lasts only several minutes.
During this brief encounter, the telephone triage nurse
assesses the patient through the patient’s self-assessment.
The plan of care is based on the nurse’s inquiry and discovery. Telephone triage nurses practice sophisticated nursing
and they have to be masters in the profession to do it effectively. If they possess the ten following characteristics, they
will be highly successful. Ironically, every characteristic
begins with the letter “c.”
Caring
A caring attitude is the most essential characteristic
that every nurse should possess. When you care for
patients, you watch over them and take responsibility for
their well-being. As a telephone triage nurse, you provide
advice that results in comfort and healing. You cannot provide care through your touch, but your patients will know
you care through your voice.
Compassionate
Compassion is concern for someone else’s suffering
and a desire to alleviate his or her suffering. Compassion
resides in the heart of a nurse. Practicing nursing without
compassion is like providing first aid without any feeling.
When caring for a patient over the phone, the nurse’s focus
and voice will relay the compassion the nurse feels in her
or his heart.
Critical Thinking
According to Yıldırım and Özkahraman (2011), critical
thinking is “the process of searching, obtaining, evaluating, analyzing, synthesizing, and conceptualizing information as a guide for developing one’s thinking with selfawareness, and the ability to use this information by
adding creativity and taking risks.”
The ability to critically think is essential as nurses collect
large volumes of patient-reported symptom information
and determine the appropriate level of care.
Common Sense
According to Cambridge Dictionary, common sense is
the “basic level of practical knowledge and judgment that
is needed to live in a reasonable and safe way.” In conversations with patients, it is essential that we execute our
common sense to help them also manage their situation
and symptoms in a reasonable and safe way.
A scenario that illustrates this is as follows: You triage a
patient at 3:00 a.m. According to his symptoms, you
advise that he is seen within four hours. The only area of
care available within the four-hour span is the emergency
room. If the patient waits until 8:00 a.m., he would be able
to be seen in the clinic with his primary care provider.
Common sense would allow you to recommend he be
seen by his own caregiver.
Competence
Being competent is having the knowledge, skill, and
experience to safely care for patients over the phone. How
is this accomplished? It is important to hire nurses who
have a minimum of five years experience and then provide
them with an organized and individualized orientation and
provide educational opportunities on a consistent basis.
You can ensure your own competence by attending conferences, reading nursing journals, and achieving nursing
specialty certification.
Confidence
As a telephone triage nurse, you need to be confident
with your decision-making ability. Even when patients are
vague, your ability to interview and clarify their situation
will lead to clear advice. If you are competent and you possess the ability to think critically, you can efficiently manage
a patient’s questions and symptoms. You will confidently
recommend the appropriate level of care. The patient will
sense your confidence and they will feel calmer and directed. They too will feel confident no matter what level of care
you recommend.
Courteous
Although courtesy is a basic customer service skill, it
can be forgotten when call volume is high and patients are
stressed. Yet being respectful and kind when you are talking to patients over the phone is essential to build a relationship of trust with your callers.
Excellent
Communication
Your patients cannot see you. You have to excel with
your ability to communicate. You need to get the information you need to formulate a plan that is realistic, safe, and
manageable. Communication involves a two-way flow of
information. It is not just about talking; it is also about listening to your patients. You need to ask open-ended questions, utilize reflective listening, relay empathy, and keep
the conversation focused. Utilizing effective communication strategies will lead to a trusting rapport between you
and your caller.
Curious
Being curious is not often mentioned as a valuable
attribute for a telephone triage nurse. However, it is curiosity that will lead you to act on your hunch. It is curiosity
that will compel you to ask about background noises. And
it is curiosity that will remind you to ask, “Is there anything
else that is going on?” And it may be that curious question
that will lead to the real reason for the patient’s call to you.
Curiosity may have killed the cat, but curiosity keeps the
telephone triage nurse vital.
Cautious
In the area of telephone triage nursing, you will often
hear that being cautious is a good thing. Without our ability to use all of our senses in our assessment, we have to be
more cautious. If we cannot build a picture of the patient
through the triage process, we have to recommend that
the patient be seen. We cannot take a risk when it involves
a patient’s well-being and life. We cannot afford to make a
mistake. Being cautious is a good thing.
Current
Keeping current on the latest research and best practices will keep your nursing practice at a high level. It is also
important to keep current with news, health trends, and
fads. Our callers are often getting much of their information from television and the Internet. We have to know
when there are behaviors that our callers are engaging in –
holistic and conventional.
One example of this is when there is an outbreak of
food poisoning from an identified offender. You may receive
calls about potential symptoms even if the incident has
occurred in another area of the country. Another example
is when callers see a commercial about new medication and
its side effects; they may want you to address these.
Hopefully you can identify most of these attributes in
yourself. If you are lacking in any area, there are opportunities for personal and professional growth. You can attend
conferences (such as the AAACN Annual Conference), read
journals, attain certification and self-reflect to develop your
attributes as a telephone triage nurse.
References
Cambridge Dictionary. (2011). Common sense. Retrieved from
http://dictionary.cambridge.org/dictionary/british/common-sense
Yıldırım, B., & Özkahraman, Ş. (2011). Critical thinking in nursing
process and education. International Journal of Humanities and
Social Science, 1(13), 257-262.
Kathryn Koehne, RNC-TNP, is a Nursing Systems Specialist,
Department of Nursing, Gundersen Lutheran Health Systems, and
a Professional Educator, Telephone Triage Consulting, Inc. She can
be contacted at [email protected]
LVM Systems, Inc.
4262 E. Florian Avenue, Mesa, AZ 85206
www.lvmsystems.com
Corporate members receive recognition in ViewPoint, on AAACN's Web site,
and in various conference-related publications, as well as priority booth placement at AAACN's Annual Conference. For more information about Corporate
Member benefits and fees, please contact Marketing Director Tom Greene at
[email protected] or 856-256-2367.
Nurses Wanted: Largest
Women’s Health Study Seeks
100,000 Nurses
Nurses’ Health Study Recruits “Next Generation”
From the dangers of tobacco and trans fats to the
benefits of physical activity and whole grains, much of
what we know about health today is thanks to the
Nurses’ Health Study.
Researchers are recruiting 100,000 nurses and nursing students to join the long-running Nurses’ Health
Study and expand its landmark research on women’s
health.
Female RNs, LPNs, and nursing students between
the ages of 20 and 46 who live in the U.S. or Canada are
eligible to join the study. More than 25,000 have signed
up already, and recruitment will stay open until the goal
of 100,000 participants is reached.
Researchers hope to engage a highly diverse group
of women in the “next generation” of the study. For the
first time, nursing students are eligible to enroll.
In order to make participation as convenient as possible for busy women, participants can join online and
complete the study’s surveys through a secure website,
http://www.nhs3.org/.
More than 250,000 nurses have participated in the
study since the 1970s. By completing confidential
lifestyle surveys, they have helped advance medical
knowledge about nutrition, exercise, cancer, heart disease, and many other conditions.
“Nurses were originally recruited for their expertise
in accurately reporting health data,” explains Dr. Walter
Willett, the study’s lead researcher and Chair of the
Nutrition Department at Harvard School of Public
Health in Boston, Mass. “Their involvement has been
invaluable, and their dedication is remarkable—an
astounding 90% of them are still enrolled, decades
later! The new group, NHS3, will allow us to understand
how today’s lifestyle and environment affect a woman’s
health in the future.”
Nurses enrolled in the earlier studies are encouraging their daughters and younger colleagues to join. “My
mom started filling out surveys when the study began,”
one nurse recently commented on the NHS3 Facebook
page (www.facebook.com/NHS3.org). “I am so proud
to be part of this study and see what it has done.”
Call for Member News
In the new "From Our Members" column, we welcome short
submissions and photos from members who wish to share their
nursing stories and experiences, practice innovations, and lessons learned. Submissions should be no more than 600 words
and emailed to [email protected] for consideration.
WWW.AAACN.ORG 15
Site Licenses Help Employers
Educate Groups of Nurses
Member Appointed as
HIMSS Representative
AAACN member Cynthia W.
Cyrus, RN, BSN, MBA, has been
appointed to serve as the
Organizational Affiliate representative to the Health Information and
Management Systems Society
(HIMSS). Cynthia is Project
Manager, Innovation Integration
Center at Vanderbilt Medical
Group, Nashville, TN. Cynthia will
Cynthia Cyrus
review information being disseminated by HIMSS and keep AAACN leadership and members apprised of the relevance to ambulatory care nursing.
Both the Ambulatory
Care Nursing Certification
Review Course and the
Telehealth Nursing Practice
Core Course (TNPCC) can
be offered to groups of 25
or more nurses through the
purchase of a site license. A
site license permits nurses
to take the course at their
own pace by accessing the course in the AAACN Online
Library. Once a nurse completes the course, she or he will
be awarded contact hour credit. The cost for up to 25 nurses is $2,000. The price increases based on the number of
users. Facilities that are promoting certification to groups
of nurses or have nurses new to telehealth who could benefit from the courses may wish to explore purchasing a site
license by contacting Pat Reichart at [email protected] or by
calling 800-262-6877.
Members Helped AAACN Grow in 2011
The 2011 Member-Get-a-Member campaign added 77 new members to our roster. Last year, 68 current members
recruited their colleagues by letting them know why they belong to AAACN and the benefits they enjoy. During the
campaign, a monthly winner was drawn each month and that recruiter received a $50 AAACN gift certificate. At the
end of the campaign, members Eileen Esposito and Carol Rutenberg had recruited three or more members, making
them eligible to win a $100 AAACN gift certificate. Bonnie Richter’s name was drawn as the winner of a free 2-year
membership renewal.
The winner of the top prize was Sharon McAllister from Saudi Arabia. She recruited five of her colleagues! Sharon
won complimentary registration to the 2012 conference.
AAACN welcomes these 77 new members and sends our special thanks to those members who did the recruiting:
Edhelpia Monje Agati
Flora May Alidon
Mary Anderson
Jermaine Antivola
Amy Aparicio
Leonida Ayangco
Amy Bacon
Rebecca Burke
Meredith Cotton
Christine Dailey
Mary Holfester Daly
Twila Darnell
Josephine Debnar
Susan Deering
Teresa Dijamco
Mattie Ely
Vanessa Flores
Mary Fortunato-Habib
Janet Fuchs
Linda Gemeiner
Julie Godfrey
Maryann Grottano
Annette Hamlin
Malinda Hanania
Jeannette Hausladen
Brenda Haynes
Katherine Herrmann
Mary Holmes
Carol Johnson
Jane Johnson
Barry Kandell
Kim Kish
Jennifer Laird
Linda Lawson
Ellie Leonard
Michele Lizzi
Deana Lovelace
Allison Lupo
Marion Marino
Lancelot Marr
Sylvia McKenzie
Marguerite Mignone
Mary Morin
Marilyn Morrisse
Kaitlin Mussomeli
Radhika Nandlal
Jerry O’Leary
Debora Oliver
Dawn Olmsted
Kiersten Osterchrist
Joyce Panacci
Cshalla Parker
Anja Peersen
Kate Piotrzkowski
Anthony Putney
Anita Reed
Heidi Regan
Bonnie Richter
Cynthia Rodrigues
Diane Rolf
June Rondinelli
Michele Rothman
Junghwa Ryoo
Catherine Scantlan
Renee Scott
Lori Sharp
Stephanie Skinner
Gloria Staley
Cynthia Standish
Susan Stirling
Karol Stirneman
Lisa Swerczek
Christine Torre
Cheryl Weimer
Mackenzie Williams
Theresa Wilmot
Mary Winkfield
The 2012 campaign kicks off April 1. Download a membership application from the Web site (www.aaacn.org),
fill in your name in the “Who referred you to AAACN?” section at the bottom, and distribute to colleagues. You can
also ask colleagues to insert your name in the “Referred By” section of the membership application if they join online.
You could be a winner of a certificate, a two-year membership, or complimentary registration to the 2013 conference in Las Vegas!
ViewPoint Article
“Wish List”
ViewPoint features articles on a variety of topics of
interest to ambulatory care and telehealth nurses. The
following “wish list” includes topics members have told
us they’d like to read more about, and now we’re hoping you can share your experience and knowledge with
other members!
• Ambulatory care staffing
ratios
• Ambulatory pediatrics
• Bariatrics
• Case management
• College health
• Disease management
• Immunizations
• Leadership in nursing
education
• Legal nurse consulting
• Magnet® process for
ambulatory
• Medical home model
• Metrics for ambulatory
care nursing
• Patient safety
• RN leadership
• Staff education
• Staffing/competencies in
specialty clinics
• Travel medicine
If you or someone you know would like to write an article
on a “wish list” topic, complete the Author Interest Form at
www.aaacn.org (click Publications > ViewPoint).
Virtually Attend AAACN’s
37th Annual Conference
If you are unable to attend the Orlando conference, you can still learn from the fantastic sessions.
The audio recordings and handouts from all sessions offered at the conference will be available for
purchase in early June in the AAACN Online Library
at www.prolibraries.com/aaacn. You may purchase
individual sessions or a package that includes all
sessions. Each session you purchase includes the
accompanying contact hours. Once you make a
purchase, you have permanent access to those sessions. Past conferences, ViewPoint articles, and
webinars are also in the library. We encourage you
to browse the Online Library for topics of interest to
you. If you know someone who attended the conference, ask if they will share their content with you!
Conference attendees can each offer access to the
conference sessions to two colleagues for free.
WWW.AAACN.ORG 17
AAACN Membership Speaks Out on Health Care Reform
An objective under Goal 1 of the
AAACN Strategic Plan, Serve our
Members, is to inform and engage
members about health care reform
(HCR). In November 2011, members of AAACN were given the
opportunity to respond to a survey
on the impact of HCR. The elevenquestion survey was sent out to
members via SurveyMonkey. The
intent of the survey was threefold:
to understand the level of impact
HCR has on our members, identify
the elements of HCR in which members are currently involved and their
willingness to share experience, and
evaluate how well members feel
AAACN is supporting their HCR
needs.
The survey, sent to 2,302 members, had a response rate of 6.8%,
with 156 members starting the survey and 132 members completing.
Below is a summary of the
responses to 11 survey questions.
One What effect does health care
reform have on practice? Fifty-three
percent of those who answered said
that HCR is having a moderate
impact on their practice.
Two In what elements of HCR are
members’ institutions or facilities
involved? Seventy-eight percent of
respondents are involved in
Meaningful Use, 71% in Patient
Centered Medical Home, 71.7% in
Care Coordination, 57.5% in
Readmissions, and 41.6% in
Accountable Care Organizations.
Three Would members feel they
would benefit from participation
dedicated to HCR via discussion
board? Approximately 50% of those
responding showed interest.
Four What HCR topics would be of
interest for the discussion board?
Patient Centered Medical Home, RN
Role, Care Coordination, Accountable Care Organizations, EMR, Readmissions, Military/Veterans issues,
and Reimbursement were mentioned
with the most frequency. About half
of those responding said they would
participate in online discussion of relevant health care reform topics.
Five Have you visited the HCR page
on the AAACN Web site (http://
www.aaacn.org/hcrforum) that was
added in July 2010? According to
the survey, only 27.1% of respondents were aware that this robust
member resource existed.
Six Is the content on the HCR Web
site valuable? Fifty-five percent
found the content to be very valuable and 44% percent found it to be
moderately valuable.
Seven Why haven’t you been taking advantage of the HCR online
content? Most respondents said
they were either unaware that the
Web page existed or that time limitations kept them from accessing
this information.
Eight Any suggestions for other
resources for the AAACN Web site?
Nine individuals responded to this
question. Their suggestions were:
National Database of Nursing
Quality Indicators (NDNQI), Patient
Centered Medical Home Updates,
healthleaders.com, AIDS administration, and any positive impact of HCR
for patients.
Nine If you’re currently implementing change, would you be willing to
share your expertise and if so, in
what way? Twenty-three members
indicated they would be interested
in participating.
Ten Please provide contact information so you can be reached to discuss your experience and/or expertise. Thirty-eight members provided
their contact information. Many also
provided AAACN with ways in
which they would be willing to
share, such as webinars, ViewPoint
articles, and participation on a HCR
Expert Panel.
About half of the respondents
said they would participate in online
discussion of relevant health care
reform topics. The main HCR concerns of our members are medical
home, the role of the RN, reimbursement, care coordination, and
issues affecting military personnel.
Eleven How can AAACN enhance
the learning needs of members? The
majority of those responding to the
survey encouraged AAACN to continue to provide information on HCR
through annual conference, Web
site, ViewPoint, e-newsletters, and
webinars.
In an effort to swiftly respond to
the results of HCR survey, AAACN
Post Your Health Care Reform
Comments and Questions
Member Jan Fuchs, MBA, MSN, NEA-BC,
recently accepted the responsibility to monitor
posts in the online Health Care Reform Forum
(http://www.aaacn.org/hcrforum). Jan completed
her Health Care MBA and is fascinated by health
care policy. She has been actively involved in legislation in Ohio and is part of a group working to
remove barriers to health care delivery. Members
are encouraged to post their comments and questions via the Forum. The Forum is another way
AAACN is providing networking opportunities to assist you with implementing the required changes related to health care reform.
Visit the online forum today!
http://www.aaacn.org/hcrforum
has taken action. The Health Care Reform Forum, part
of the HCR site (http://www.aaacn.org/hcrforum), provides members with the opportunity to post their
thoughts and ideas on HCR. Recently, a volunteer
opportunity to monitor this discussion was sent out to
members. Janet Fuchs, MBA, MSN, NEA-BC, Senior
Director of Ambulatory Nursing with Cleveland Clinic,
has recently been appointed to this volunteer role.
Secondly, the association has already begun to contact
those willing to share expertise to discuss plans to share
their expertise with their colleagues. Finally, because so
many respondents were unaware of the HCR page on
the AAACN site, we want to be sure you know the page
is accessible through a link reading “HC Reform,” which
is located on the blue banner at the top of the AAACN
home page. In just one click, you will be able to access
the Health Care Reform Forum and many other HCR
resources.
Thank you for providing thoughtful feedback. From
the survey, we know many of our members are actively
involved in health care reform initiatives and have experiences they would like to share with their colleagues.
Your responses also validate the need for your professional organization to continue to inform and engage
members about health care reform. AAACN is committed to serving our members and will continue to follow
through with this very relevant strategic plan objective!
Suzanne N. Wells, BSN, RN, is Manager, Answer Line, St. Louis
Children's Hospital, St. Louis, MO, and American Academy of
Ambulatory Care Nursing President-Elect. She can be contacted at
[email protected]
Col. Carol Andrews, USAF, NC, MA, RN-BC, NE-BC, CCP, is
Director, MAJCOM-AFMOA Team for Requirements and
Information X-fer (MATRIX), United States Air Force, San Antonio,
TX, and American Academy of Ambulatory Care Nursing Director.
She can be contacted at [email protected]
Coming soon in
Educational offerings:
• Lyme Disease: The Great Imitator
• 37th Annual Conference Photo Highlights
Plus these favorite columns:
• Telehealth Trials and Triumphs
• Health Care Reform
• For Your Health
• Member Spotlight
• From Our Members
Patricia M. Grady, BSN, RN, CRNS,
FABC, is currently the Associate Chief
Nursing Officer and Executive Director of
Lahey Clinic Medical Center, North
Shore Ambulatory Practice and
Ambulatory Operations, Peabody, MA.
Her dynamic role supports the advancement of organizational strategic requirements for clinical quality and safety practices, patient satisfaction, employee engagement to research,
development and execution of outcome-oriented health care
product lines, business plan development, and project management. She also achieved the status of an Advisory Board
Company Fellow in Business.
When “Pattie” was selected as Administrator of a
standalone ambulatory care center, she was tasked with
transforming the culture to an updated clinical practice
with an integrated model of care. It was during the $40
million design and building project for a new ambulatory
care center that Pattie first recognized the need to join
AAACN. Her desire was to support the advancement of evidence-based ambulatory clinical practice; however, it was
the multitude of AAACN resources that she had access to
as a member which helped her achieve her goals of successful practice outcomes. Her leadership team, staff, and
providers were competent and happy.
The most valuable aspect of AAACN membership to
Pattie is her ability to network with fellow leaders in
advancing the integrated model of the ambulatory care
practice. The majority of Pattie’s practice and leadership
experiences have been in the ambulatory care sector. She’s
had the opportunity to truly advance ambulatory nursingled strategies to create positive quality outcomes for
patients, families, health care organizations, and the health
insurance industry. According to Pattie, “The heart of all I
focus on every day is ensuring the delivery of the highest
quality and safety of patient and family-centered care at
the lowest cost.” Currently, Pattie supports the research of
the AAACN Care Coordination Literature Review Team in
developing national care coordination competencies for
the ambulatory care nurse.
Pattie wants everyone to know that she is the proud
mother of two fabulous sons, Mark and Matthew, and very
fortunate to be married 29 years to her wonderful husband, Mark. On a career-focused note, she is currently
leading the research and development of the Nurse Care
Coordinator role with aligned evidence-based tools as
Lahey Clinic rolls out their Patient Centered Medical Home
program.
While Pattie is still developing her future career plans,
she encourages all of us to share the benefits of AAACN
membership with ambulatory care nurses everywhere.
Deborah A. Smith, RN, DNP, is an Associate Professor, Georgia
Health Sciences University, College of Nursing, Augusta, GA, and
Editor of the Member Spotlight column. If you would like to be featured in Member Spotlight, contact Deborah at dsmith@georgia
health.edu
WWW.AAACN.ORG 19
CHANGE SERVICE REQUESTED
East Holly Avenue, Box 56
Pitman, NJ 08071-0056
Presorted Standard
U.S. Postage
PAID
Deptford, NJ
Permit #142
Volume 34, Number 2
ViewPoint is published by the
American Academy of Ambulatory
Care Nursing (AAACN)
AAACN Board of Directors
President
Linda Brixey, RN
President-Elect
Suzanne (Suzi) N. Wells, BSN, RN
Immediate Past President
Traci Haynes, MSN, RN, BA, CEN
Director/Secretary
Mary Vinson, DNP, RN-BC, CMPE
Director/Treasurer
Susan M. Paschke, MSN, RN-BC, NEA-BC
AAACN is a welcoming, unifying community for registered nurses in all ambulatory care settings.
Our mission is to advance the art and science of ambulatory care nursing.
Directors
Col. Carol Andrews, MS, RN-C, BC, CNA
Judy Dawson-Jones, MPH, BSN, RN
Barbara Pacca, BSN, RN, CPN
Executive Director
Cynthia Nowicki Hnatiuk, EdD, RN, CAE
Call for Abstracts for 2013 Conference
Director, Association Services
Patricia Reichart
AAACN ViewPoint
www.aaacn.org
Editor
Kitty M. Shulman, MSN, RN-BC
Issue Editor
Patricia (Tricia) Chambers, BHScN, DC, RN
Editorial Board
Carol Ann Attwood, MLS, AHIP, MPH, RN,C
Virginia Forbes, MSN, RN, NE-C, BC
Liz Greenberg, PhD, RNC
Jerry A. Mansfield, PhD, RN
Laura Morano, RN, CPN, MA
Susan M. Paschke, MSN, RN-BC, NEA-BC
Ginger H. Whitlock, RN, MSN, CNA
Manuscript Review Panel
Irene Berg, MSN, RN-BC
Patricia L. Jensen, MSN, RN
Vannesia D. Morgan-Smith, MGA, RN, NE-BC
Becky Pyle, MS, RN
Janice Tuxbury, DNP, FNP-BC
Managing Editor
Katie R. Brownlow, ELS
Editorial Coordinator
Joe Tonzelli
Layout Designer
Bob Taylor
Education Director
Rosemarie Marmion, MSN, RN-BC, NE-BC
Marketing Director
Tom Greene
www.facebook.com/AAACN
www.twitter.com/AmbCareNursing
AJJ-0412-V-2M
© Copyright 2012 by AAACN
We
invite you to submit
an oral or poster
abstract for the 38th Annual
AAACN Conference, April 2326, 2013, at the Las Vegas
Hotel and Casino. Share your
expertise, new practice initiatives or techniques, best practices, or research with colleagues. Presenters receive
$100 off their registration fee.
Oral presenters receive an honorarium. The deadline for oral
presentations is May 15, 2012,
the poster deadline is
December 15, 2012. Obtain
the oral and poster criteria
from the Events section of the
Web site at www.aaacn.org.

ViewPoint_MA12_Layout 1 - American Academy of Ambulatory

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